Mental health consumers' perspectives of physical health interventions: An integrative review

Abstract Consumers of mental health services experience poor physical health compared to the general population, leading to long‐term physical illness and premature death. Current research and policy activity prioritizes the physical health of consumers yet few of these recommendations have translated to practice. This implementation gap may be influenced by the paucity of literature exploring consumer perceptions and experiences with physical healthcare and treatment. As a result, little is understood about the views and attitudes of consumers towards interventions designed to improve their physical health. This integrative review aims to explore the literature regarding consumer perspectives of physical healthcare and, interventions to improve their physical health. A systematic search was undertaken using (i) CINAHL, (ii) MEDLINE, (iii) PsycINFO, (iv) Scopus, and (v) Google Scholar between September and December 2021. Sixty‐one papers comprising 3828 consumer participants met the inclusion criteria. This review found that consumers provide invaluable insights into the barriers and enablers of physical healthcare and interventions. When consumers are authentically involved in physical healthcare evaluation, constructive and relevant recommendations to improve physical healthcare services, policy, and future research directions are produced. Consumer evaluation is the cornerstone required to successfully implement tailored physical health services.


BACKGROUND
An estimated 20% of the global population is diagnosed with a mental illness (MI) (Steel et al. 2014;World Health Organization 2001) such as anxiety, depression, substance use disorder, bipolar disorder, or schizophrenia. MI is defined as diagnosable mental, behavioural, or emotional disorders resulting in substantial impairment of social, emotional, and occupational functioning (Center for Behavioral Health Statistics & Quality 2018) and each disorder varies in severity (RANZCP 2016). For the purpose of this review, and consistent with the language of Australian mental health policy, the term 'consumer' will be used to reference any person diagnosed with a clinically defined high or low prevalence disorder MI (Lyon & Mortimer-Jones 2020). Moreover, reflecting the inclusivity of differing perspectives regarding the diagnosis of MI in policy and for consumers, this review will collectively refer to all people diagnosed with a MI rather than a specific diagnosis (Perkins et al. 2018). People diagnosed with MI are at greater risk of experiencing adverse physical health outcomes such as higher morbidity and premature mortality up to 30 years compared to the general population (De Hert et al. 2011;Department of Health 2017;Dickerson et al. 2018;Firth et al. 2019;Lawrence et al. 2013). Although 17% of this early mortality can be attributed to suicide, the majority of premature deaths are consistently attributed to poor physical health (De Hert et al. 2011;Dickerson et al. 2018;Firth et al. 2019). Within the Australian context, up to three-quarters of premature deaths for people diagnosed with a MI were attributed to physical comorbidities (De Hert et al. 2011;Edmunds 2018;Lawrence et al. 2013;Oakley et al. 2018).
Prevalent physical health comorbidities such as cardiovascular disease (CVD) (29.9%), respiratory disease (23.6%), and cancer (13.5%) (Dickerson et al. 2018;Lawrence et al. 2013) have consistently been reported as contributors to premature mortality. Metabolic syndrome; the clustering of cardiometabolic risk factors such as hypertension, elevated triglyceride levels, and central adiposity (Alberti et al. 2009;Oakley et al. 2018), account for 50% of the physical health comorbidities present in people diagnosed with MI, specifically schizophrenia (Edmunds 2018). Multimorbidity (the presence of multiple cardiovascular risk factors) is strongly associated with modifiable lifestyle-related factors including obesity, cigarette smoking, physical inactivity, nutritional inadequacies, and side effects related to pharmacological treatment (De Hert et al. 2011;Morgan et al. 2014;Oakley et al. 2018;Vancampfort et al. 2015).
Complicating the risk factors for developing physical comorbidities are the negative or deficit symptoms of the MI, and adverse drug reactions (ADRs) (Curtis et al. 2012;Department of Health 2017;Firth et al. 2019;Morgan et al. 2012Morgan et al. , 2014Oakley et al. 2018). Negative symptoms deteriorate the consumers' social, occupational, and emotional functioning capacity and impede the physical and mental health recovery process (Department of Health 2017; Morgan et al. 2014). Cardiometabolic, endocrine, and neuromotor complications such as weight gain, hyperprolactinaemia, and extrapyramidal side effects can arise from ADRs (Firth et al. 2019). In combination, the severity of illness and ADRs associated with antipsychotic medications increase the risk of physical health morbidity and early mortality (Edmunds 2018;Firth et al. 2019;Oakley et al. 2018).
Efforts to minimize antipsychotic medication-related ADRs and modifiable risk factors for metabolic syndrome led to the development of a positive cardiometabolic health algorithm (Curtis et al. 2012). The framework provides a guideline for metabolic screening, prevention, and early interventions, prompting review, and rationalization of polypharmacy, and implementation of healthy lifestyle behaviours to curb weight gain (Curtis et al. 2012). Despite growing evidence supporting the regular physical health monitoring and assessment of people diagnosed with a MI, implementation of these guidelines remains problematic (Clancy et al. 2019;Happell et al. 2013;McKenna et al. 2014;RANZCP 2015RANZCP , 2016Taylor & Shiers 2016) and growing concerns remain regarding the projected twofold increase in cardiometabolic risk factors for people diagnosed with MI (Charlson et al. 2018;Firth et al. 2019;Morgan et al. 2014;Oakley et al. 2018).
Compounding the effects of lifestyle factors and ADRs are systemic inadequacies in health service provision directed to improve physical healthcare. Stigma from health professionals, and diagnostic overshadowing contributes to the dismissal of reported physical health concerns as somatic complaints, which potentially leads to the increased withdrawal from accessing services for physical health issues (Duggan et al. 2020;Edmunds 2018;McCloughen et al. 2016). Diagnostic overshadowing occurs when a consumers' diagnosis of MI is prioritized despite presenting with a physical health concern Nash 2013;Oakley et al. 2018). Moreover, a lack of clear allocation of roles and responsibilities among healthcare professionals results in inadequate physical healthcare practices and hinders quality care necessary to address physical health issues for consumers (Clancy et al. 2019;Ewart et al. 2016;Happell et al. 2016aHappell et al. , 2016bHappell et al. , 2016cMorgan et al. 2012;Oakley et al. 2018). These shortcomings in service provision mean people diagnosed with a MI, such as schizophrenia, experience a disparity in physical healthcare that borders on a violation of human rights (Edmunds 2018).
The physical health of consumers and the healthcare disparities they face is prioritized in current research and policy activity (Clancy et al. 2019;Department of Health 2017;Ewart et al. 2016). Studies consistently suggest the need to move beyond defining the problem to implementing high standard evidence-based physical healthcare (Clancy et al. 2019;Ewart et al. 2016;McCloughen et al. 2016). To date, few of these recommendations have translated to practice, partly due to the paucity of literature exploring consumer perceptions of the physical healthcare they receive Morse et al. 2019).
Previous reviews synthesized the scarce literature exploring consumer perspectives about their physical health and perceived barriers to optimal physical health and healthcare (Chadwick et al. 2012;Happell et al. 2012aHappell et al. , 2012b. These reviews have provided insight into the barriers consumers experience. For example, consumers reported diagnostic overshadowing, inconsistent approaches to screening or addressing their physical health needs, and poor or stigmatizing attitudes from health professionals (Chadwick et al. 2012;Happell et al. 2012aHappell et al. , 2012b. Understanding the consumers' views on barriers to accessing physical healthcare services, reveals the individual and systemic issues health services need to address. Less still is understood about the views and attitudes of consumers towards physical health interventions targeted to improve their physical health. It is nearly 10 years since the reviews of Chadwick et al. (2012), Happell et al. (2012a), and Happell et al. (2012b) have been published. Since then, it appears no reviews have been conducted to explore consumers' perceptions about physical health or the physical healthcare they receive. Attention needs to be placed on consumer views about the physical healthcare they receive to enable consumer autonomy, supported decision making and tailoring of services to their needs. Urgent calls to conduct more research providing consumers a voice to generate strategies to improve services and outcomes is warranted (Department of Health 2017; Ewart et al. 2016;Morse et al. 2019;Small et al. 2017).

Aim
This integrative review aims to explore how consumers view their physical health and experience of the physical healthcare they receive by questioning: What are the perspectives of mental health consumers regarding: • physical health; and • interventions to improve their physical health?
Findings from this review will contribute to the growing knowledge about consumers' perception of physical healthcare and produce results that will inform the development of consumer centred physical healthcare services, policy, and research directions.

Literature review method
The Cochrane, Joanna Briggs Institute (JBI) and Prospero databases were searched to identify whether similar reviews regarding consumer views and attitudes on physical health and physical health interventions existed. Three reviews synthesizing literature pre-2012 were found, however, they only explored the consumer view regarding physical health (Chadwick et al. 2012;Happell et al. 2012aHappell et al. , 2012b. Since 2012, no reviews exploring the consumer perspectives of physical healthcare were identified. Therefore, to the best of our knowledge, this will be the first integrative review to summarize the literature on this topic. An integrative approach was considered appropriate because it allows for the consolidation and comparison of diverse primary research methods (Whittemore & Knafl 2005). Integrative reviews provide a comprehensive understanding of a phenomenon through the critical appraisal and analysis of past experimental and nonexperimental research, and theoretical literature (Hopia et al. 2016;Whittemore & Knafl 2005). Guided by methods described by Cooper (1998), the present integrative review (i) formulated a research question, (ii) searched the literature, (iii) evaluated the data, (iv) analysed and integrated the outcomes of the studies, and (v) presents the results (Hopia et al. 2016;Whittemore & Knafl 2005).

Search strategy
The review scope primarily explored the views and attitudes of consumers. However, carers and clinicians were included in the search. Studies on the physical health of people diagnosed with MI tend to explore the views of multiple populations or focus on clinicians with an addition of the consumer and carer population. For this reason, a threefold literature search strategy was developed to ensure consumer views were extracted from studies where they may not be the primary focus. A Population, Intervention, Comparator, and Outcome (PICO) structure was implemented where the Population comprised consumers, carers, and health professionals; the Intervention included any physical health-related intervention; the Comparator was any or no intervention; and the Outcome was the experience or perception of the included population.
The search was conducted using the following five databases: (i) CINAHL, (ii) MEDLINE, (iii) Psy-cINFO, (iv) Scopus, and (v) Google Scholar, using keywords and MESH terms, combined using Boolean operators. The search strategy is shown in Table 1. The reference lists of the included studies were handsearched for additional relevant studies. The search was conducted between September and December 2021 and date-limited to include studies published since 2005 because physical healthcare for consumers was increasingly being prioritized in research (Fogarty & Happell 2005;Happell et al. 2012aHappell et al. , 2012bOakley et al. 2018). Therefore, to ensure the integrity of this review, studies since 2005 were thoroughly searched and reviewed for inclusion. Search terms were guided by previous literature reviews on physical health and current literature on physical healthcare for people diagnosed with MI.

Inclusion and exclusion criteria
Studies were screened if they met the following inclusion criteria: (i) studies exploring physical healthrelated interventions for any mental health consumer in a primary, secondary or tertiary settings, (ii) published in the English language, (iii) peer-reviewed between 2005 and present, and (iv) published original research exploring the perspectives and experiences of consumers. Studies that met the above inclusion criteria were eligible for inclusion in the review. The review excluded publications not written in English, focusing on clinicians or carers only, theoretical and non-peerreviewed literature.

Study quality appraisal
Extracting specific methodological features of primary studies is recommended to evaluate overall study quality (Whittemore & Knafl 2005). Depending on the research design, different criteria are applied to report study quality. Eligible qualitative studies were assessed using the Critical Appraisal Skills Programme (CASP) qualitative tool (see Table 2). The CASP qualitative tool was used because it is a commonly used tool that offers a comprehensive 10-item checklist for assessing the methodological quality of a qualitative study. This comprehensive appraisal enables the reviewer to determine the relevance of including a paper in the review (Critical Appraisal Skills Programme; Hopia et al. 2016). Descriptive quantitative and mixed-method studies were appraised using the Mixed Methods Appraisal Tool (MMAT) (see Table 3). Historically, appraising the quality of studies of a different design has been challenging (Hong et al. 2018); however, the MMAT offers the flexibility and algorithmic assistance to choose the set(s) of quality criteria to use for multiple study designs (Hong et al. 2019). Mixed methods and quantitative descriptive study criteria were chosen to appraise the quality of quantitative and mixedmethod studies of various designs (Hong et al. 2018).
A diverse presentation of primary studies may require quality assessment using various appraisal tools with different criteria. A 2-point scale (low and high) to indicate the quality of a study and a discussion of the methodological limitations and strengths are recommended (Whittemore & Knafl 2005). During the quality appraisal, no studies were identified to be of low quality thus posing a challenge to determine moderate from high-quality studies. Consistent with other flexible integrative review approaches to quality scoring, this review will use a 3-point scale to distinguish moderate and high-quality studies (Hopia et al. 2016).

Data extraction and analysis
The creation of a data matrix enables structured analysis of primary sources and supports the writing of a

Study characteristics
The literature search resulted in the inclusion of 61 papers comprising 3828 consumer participants (see Fig. 1). From the 61 papers, 46 focused on the consumer voice whilst 15 explored the dual perspectives of  Bartlem et al. (2018) + + n/a n/a n/a n/a n/a + + + + n/a n/a n/a n/a n/a + + n/a n/a n/a n/a n/a + +

Edmonds and Bremner (2007)
+ + n/a n/a n/a n/a n/a + U Furness et al. Happell et al. (2014aHappell et al. ( , 2014bHappell et al. ( , 2014c -+ n/a n/a n/a n/a n/a + + Henning Cruickshank et al. (2020) + + n/a n/a n/a n/a n/a + + + + n/a n/a n/a n/a n/a + + Wheeler et al.

Study design, quality and synthesis
Most papers (n = 47) were qualitative studies, using exploratory, descriptive, and phenomenological approaches. Quantitative (n = 8) and mixed-methods papers (n = 6) mainly comprised cross-sectional surveys. Mostly high-quality papers (n = 57) were included in this review, with only four papers assessed as moderate quality. Methodological strengths for all studies included clear articulation of research aims, methodology, and findings. Common omissions included lacking discussion regarding non-response bias (n = 10), confounders (n = 9), relationship bias Are the measurements appropriate?
Is the risk of nonresponse bias low?
Is the statistical analysis appropriate to answer the research question?
Is there an adequate rationale for using a mixedmethods design to address the research question?
Are the different components of the study effectively integrated to answer the research question?
Are the outputs of the integration of qualitative and quantitative components adequately interpreted?
Are divergences and inconsistencies between quantitative and qualitative results adequately addressed?
Do the different components of the study adhere to the quality criteria of each tradition of the methods involved?
Quality rating + + + n/a n/a n/a n/a n/a High n/a n/a n/a n/a n/a High n/a n/a n/a n/a n/a High n/a n/a n/a n/a n/a High + + + + + + + + High + -U n/a n/a n/a n/a n/a Moderate + U + n/a n/a n/a n/a n/a High n/a n/a n/a n/a n/a High + U + n/a n/a n/a n/a n/a High (n = 17), justification of recruitment strategy (n = 5), and information about the representativeness of included samples (n = 5). Despite these limitations and except for two qualitative studies, one cross-sectional survey and a mixed-methods study that were assessed as moderate quality, the overall quality of studies chosen for this integrative review was high. Table 4 presents a summary of the studies reviewed, the country and region where the study took place, study focus, setting, research design, sample characteristics, quality rating, and findings. Aligning with the review question, studies outlined in Table 4 were categorized according to their main focus which resulted in three main themes, reflecting the consumers: (i) attitude towards physical health, (ii) perception of physical healthcare, and (iii) experiences with a physical health intervention. Within the main themes, sub-themes were identified and speak to the common perceptions and experiences of consumers regarding physical health and interventions to improve their physical health.

Attitudes towards physical health
Perceived physical health status The need to explore the consumers' views on physical health and related care is crucial to gain invaluable data that can generate quality improvement strategies . Consumers define physical wellbeing as a holistic concept that includes a sense of normality, interconnectedness, and well-being in the domains of physical, mental, nutritional, spiritual, social, and economic health (Graham et al. 2013;Owens et al. 2010;Verhaeghe et al. 2013). Mobility,

CONSUMER VIEWS OF PHYSICAL HEALTH INTERVENTIONS
the absence of physical disease, injury, or pain, and the ability to function and participate in life are considered optimal physical health indicators by consumers (Happell et al. 2016a(Happell et al. , 2016b(Happell et al. , 2016c. Few consumers perceived themselves to be physically active (Browne et al. 2016), fit and healthy (Chee et al. 2019), or rated their quality of life as 'very good' (Happell et al. 2014a(Happell et al. , 2014b(Happell et al. , 2014c. Though consumers define and desire optimal physical health, this is sometimes perceived as unattainable because of the challenges they face (McCloughen et al. 2016).

Concern for poor physical health
Consumers are aware and express concern about the number and severity of the physical health issues they encounter (Brunero & Lamont 2009;Ewart et al. 2016;Verhaeghe et al. 2013). For instance, consumers commonly report experiencing physical health comorbidities such as weight gain, hypertension, CVD, heart disease, and diabetes (Blanner Kristiansen et al. 2015;Fraser et al. 2015;Happell et al. 2016aHappell et al. , 2016bHappell et al. , 2016cRollins et al. 2017). Concerns about weight gain, primarily resulting from medication side-effects, are reported by consumers as frequently ignored by the clinical team ( (Wheeler et al. 2018), compound the challenge of addressing these physical comorbidities. Consumers recognize the impact of physical comorbidities on their overall health therefore consider changing their health behaviours an important step.

Impact of physical ill-health
Physical comorbidities impact all aspects of the consumers' life and are perceived by consumers to endanger the quality of life they desire (Carson et al. 2016). A study interviewing consumers diagnosed with firstepisode psychosis, noted their concerns regarding the experience of physical changes to their outward appearance (McCloughen et al. 2016). Despite these concerns, personal barriers such as amotivation, lowered confidence, and low levels of health literacy make it challenging for consumers to actively address their physical health concerns (Chee et al. 2019;McCloughen et al. 2016;Vazin et al. 2016;Wheeler et al. 2018). Consequently, these experiences result in consumers questioning what is at stake for them in their lives. Consumer reports of experiencing existential loss, loss of agency, and capacity to work (Carson et al. 2016) indicated the impact on their community participation (Patel et al. 2018). Consumers recognize the challenge of combatting the personal barriers to physical well-being hence seek support from healthcare systems to achieve their ideal quality of life.

Perception of physical healthcare
healthcare systems Consumers report seeking diverse services to support their physical well-being (Happell et al. 2019). Perceptions of physical healthcare vary, with some consumers reporting instances of being asked about or screened for their physical health (Butler et al. 2020;Young et al. 2017), and the healthcare system facilitating the disability pension application process (Gedik et al. 2020). Others reported experiencing scarce or unresponsive physical healthcare systems Happell et al. 2016aHappell et al. , 2016bHappell et al. , 2016c. Unresponsive healthcare systems are characterized by perceived lack of communication about the side effects of medications, negative staff attitudes (Ewart et al. 2017), low prioritization of physical health (Gray & Brown 2017), and dismissal of and failure to address physical health concerns (Happell et al. 2016a(Happell et al. , 2016b(Happell et al. , 2016c. Perceived unresponsive health professionals and systems (Blanner Kristiansen et al. 2015;Ewart et al. 2016;Happell et al. 2016aHappell et al. , 2016bHappell et al. , 2016c) saw some consumers attempting to self-manage their physical comorbidities (Katakura et al. 2013;Rollins et al. 2017). Over-reliance on the consumer to self-manage their physical comorbidities can cause stress (Katakura et al. 2013) and the recurrence of psychological symptoms. Hence, consumers require support from health services in addition to their social support mechanisms (Bartlem et al. 2018;Young et al. 2017).

Systemic barriers
Systemic barriers to physical healthcare such as access to healthcare services, diagnostic overshadowing, and negative interpersonal skills, results in worsening physical health (Ewart et al. , 2017Gedik et al. 2020;Matthews et al. 2021;McCloughen et al. 2016;

19)
High Physical health problems included weight issues; cardiovascular and metabolic diseases, poor physical shape, liver diseases, lung diseases, and dental issues Causes: lifestyle, mental illness and organizational issues Consumers were often very specific about the strategies to prevent and treat certain problems and causes to their poor health Clinicians were broader  Consumers (n =

9)
High Consumers recognizes physical health benefits but experience barriers that impede exercise participation, e.g., motivation and safety Walking viewed as the most accessible and favourable form of exercise and identified the potential benefits of exercising in a group for socialization by consumers and clinicians Clients identified enjoyment, positive impact on mood, alleviating symptoms, and associated health benefits as primary reasons for engaging in exercise Questionnaire response: most consumers perceived themselves as physically active compared to clinicians who did not perceive them as active (Continued)

6)
High Needs of consumers differ from the general population therefore it is necessary to tailor their healthcare to their specific needs Barriers: the sense of inferiority, most of them experience stress before and during the consultation, and while waiting for the results of laboratory assessments, lack of or non-systematic collaboration between professionals, nil discussion of physical health by the mental healthcare team Suggestions: systematic professional collaboration and clarification of roles, flexible approach from GP, e.g., reassurance and paying attention to mental health, individualized support, monitoring, and supporting a healthy lifestyle (Continued)

4)
High Physical health aided mental health recovery, e.g., improved self-esteem, renewed sense of hope, improved mood, and increased motivation) Staff interactions were viewed as important, e.g., support and encouragement via goal setting, metabolic screening Peer support, interaction, and activities led to a reduction in social isolation, shared learning, and reduction in stigma Participants believed that they now had the knowledge to live a healthy lifestyle, that the changes they had made could be sustained, and that their capacity to make lifestyle changes in the future was enhanced (Continued)  2014). Limited accessibility to physical healthcare has been reported by consumers in the community Matthews et al. 2021). In an Australian sample, most consumers (90%) reported experiencing challenges with accessing physical healthcare. Mental health services were relied on to assist with access to physical healthcare and for some consumers, they only considered their physical health when prompted by their psychiatrist (Young et al. 2017). Barriers such as cost of care, prioritization of mental healthcare, diagnostic overshadowing, stigma, separate mental and physical health services, and negative interpersonal skills Gedik et al. 2020;Graham et al. 2013;Gray & Brown 2017;Hemmings & Soundy 2020;Ince & G€ un€ us ßen 2018;McCloughen et al. 2016;Roberts & Bailey 2013), disempower consumers and negatively affect engagement with mental health services (Young et al. 2017).

Suggestions for improved physical healthcare
Being told what to do and focusing on adherence with national recommendations for physical health, is perceived as a narrow concept of health that undermines the individual's autonomy (Owens et al. 2010). Education programs designed to raise consumer awareness of physical health problems and self-management strategies (Verhaeghe et al. 2013) are not enough to effect changes in health behaviours (Brunero & Lamont 2009) if they do not consider consumer input. Consideration should be taken to co-produce physical healthcare (Bocking et al. 2018) that aligns with the preferences of consumers who seek support to improve health behaviour risks such as smoking and dietary inadequacies (Bartlem et al. 2018;Ehrlich & Dannapfel 2017;Ince et al. 2019). Consumers suggest small changes over time are more motivating and easier to adhere to (Wardig et al. 2015). Involving consumers in their physical healthcare increases their sense of autonomy thus influencing the level of engagement with health behaviour change (Ehrlich & Dannapfel 2017). Consumers prefer collaborative and integrated care planning, person-centred support, and positive interpersonal interactions with staff (Happell et al. 2019;Hemmings & Soundy 2020;Rollins et al. 2017). For instance, autonomy and supported decision-making for physical healthcare is valued (Wright-Berryman & Cremering 2017) and perceived to be a general care planning requirement (Small et al. 2017). Collaborative care planning also involves centring the consumers' needs and integrating mental and physical health to coordinate and provide holistic care (Happell et al. 2019;Wheeler et al. 2018). One study suggested the segregation of physical health support services because peer workers were perceived to provide practical steps to access and maximize the benefit of physical health information and advocacy for consumers (Bocking et al. 2018). The attractiveness of this option results from perceived benefits that consumers will not encounter discrimination will experience flexibility and have the opportunity to segue into mainstream options (Bocking et al. 2018;Graham et al. 2013). Nonetheless, integrated services are preferred by consumers for their convenience, and ability to improve information sharing, communication, and resources (Happell et al. 2019;Rollins et al. 2017).
Communication and the therapeutic relationship are considered important because of their influence on the engagement. Healthcare professionals are perceived by consumers, as potentially proactive and encouraging, contribute to the reported feelings of ease, motivation, and continued engagement with physical health practices (Hassan et al. 2020a(Hassan et al. , 2020bHemmings & Soundy 2020;Watkins et al. 2020). Moreover, consumers prefer healthcare professionals to possess interpersonal and professional qualities including trustworthiness, friendliness, flexibility, being knowledgeable, and informative, and having the ability to offer practical support and professionally collaborate. (Nash 2014;Rollins et al. 2017;Small et al. 2017). The interpersonal and professional qualities listed, influence consumers' engagement with their physical healthcare and in turn, health outcomes (van Hasselt et al. 2013). Positive therapeutic relationships with consumers enable healthcare professionals and systems to play a role in improving their physical health outcomes.
Experiences with physical health interventions Types of physical health interventions. Consumers recognize a need to support people to provide routine and structured care to assist them with achieving a state of physical well-being (Bartlem et al. 2018;R€ onngren et al. 2014). The present review identified 19 studies exploring consumer experiences with a physical health intervention. Interventions include: (i) a physical deterioration screening tool (Brimblecombe et al. (Edmunds 2018), and (iii) discipline-specific interventions led by mental health nurses (Furness et al. 2020;Hassan et al. 2020aHassan et al. , 2020bR€ onngren et al. 2018) and a physiotherapist (Hemmings & Soundy 2020). These studies provided consumers with the opportunity to evaluate the impact of these interventions and inform future direction. For instance, consumer feedback regarding the novel implementation of an electronic National Early Warning Score (eNEWS) system in six mental health inpatient wards, designed to promptly detect and respond to physical deterioration, led to an amendment of the project plan (Brimblecombe et al. 2019). The amended project plan included educating staff members on the importance of providing results of the physical observations and leaflets for consumers explaining the eNEWS system, particularly issues around confidentiality (Brimblecombe et al. 2019).
Impact of physical health interventions. Physical health interventions were viewed to be helpful if they not only improved the consumers' physical health but also other areas of their life such as their mental health and social connection. Indicators for improved physical health included improved fitness, physical capacity in daily activities, and appearance, where weight loss (Furness et al. 2020;Kern et al. 2020;Roberts & Bailey 2013) fitting into clothes (Vazin et al. 2016) and shifting self-image (Pickard et al. 2017), cardiovascular and strength endurance (Fogarty & Happell 2005;Vazin et al. 2016) were reported as measures of the interventions' benefits. Equally valued, building and improving social relationships (Crone 2007;Furness et al. 2020;Matthews et al. 2021;R€ onngren et al. 2018;Wardig et al. 2015;Watkins et al. 2020), acquiring physical health and lifestyle knowledge (Crone 2007;Roberts & Bailey 2013;R€ onngren et al. 2018;Wardig et al. 2015;Watkins et al. 2020), and improving selfesteem and efficacy (Vazin et al. 2016;Watkins et al. 2020) were perceived as benefits of engaging with physical health interventions. Some consumers attributed the success of the interventions to the flexible person-centred approach to intervention delivery (Edmunds 2018;Fogarty & Happell 2005;Hassan et al. 2020aHassan et al. , 2020b, accessibility to the intervention (Edmunds 2018;Hassan et al. 2020aHassan et al. , 2020b, and peer and health professional support (Fogarty & Happell 2005;Furness et al. 2020;Park et al. 2017;Roberts & Bailey 2013;R€ onngren et al. 2014;Wardig et al. 2015;Watkins et al. 2020).
The therapeutic relationship with health professionals was highly valued because it influenced the consumers' experience and engagement with an intervention (Edmunds 2018;Furness et al. 2020;Hassan et al. 2020aHassan et al. , 2020bMatthews et al. 2021;Watkins et al. 2020). Positive experiences with healthcare professionals could be attributed to their effective interpersonal skills when working with consumers, their useful and personalized health promotion advice and supportive approach (Edmunds 2018;Furness et al. 2020;Matthews et al. 2021;Watkins et al. 2020). Additionally, these positive experiences with healthcare professionals enhanced motivation and enabled consumers' perseverance with an intervention (Hassan et al. 2020a(Hassan et al. , 2020bWatkins et al. 2020). One study detailed how the perceived negative staffing attitudes towards consumer eating habits, subsequently influenced consumers to become despondent with the educational lifestyle program (Roberts & Bailey 2013).
Consumers reported experiencing barriers to some of the lifestyle interventions, specifically related to symptomology and systemic issues. Sedentary lifestyle, amotivation, and physical comorbidities such as weight gain, attributed to the MI and antipsychotic medications were reported to impact consumers' ability to partake in physical activity (Hemmings & Soundy 2020;Matthews et al. 2021;Pickard et al. 2017;Roberts & Bailey 2013;Vazin et al. 2016). For example, consumers and healthcare professionals from a mental health rehabilitation and recovery facility both acknowledged sedentary lifestyles as being normalized and challenging to shift in their environment (Matthews et al. 2021). Physical activity in this example is advocated for in conceptual terms but restricted in practice because of perceived conflict by staff and consumers' experience of limited access to physical activity resources (Matthews et al. 2021). Access to physical activity programs or facilities were considered barrier because consumers either relied on transportation from healthcare professionals to access facilities for physical activity or faced stigma when having to seek permission to engage in physical activity (Matthews et al. 2021). The siloing of physical and mental health services potentially results in stigmatization for consumers. Some consumers who perceived physiotherapy as a beneficial intervention also reported poor experiences where their mental health was disregarded as a factor in missing an appointment and consequently were discharged from the service (Hemmings & Soundy 2020). Consumers from another study reported stigma potentially being reduced through positive interactions with peers during physical activity and therapeutic relationships with healthcare professionals (Watkins et al. 2020).
Healthcare professionals, such as mental health nurses, physiotherapists, and peer support workers are well-positioned to support and integrate physical and mental healthcare (Bocking et al. 2018;Furness et al. 2020;Hassan et al. 2020aHassan et al. , 2020bHemmings & Soundy 2020;R€ onngren et al. 2018). Physical health interventions delivered by mental health nurses have been reported by consumers as positive, helpful, and valuable (Furness et al. 2020;Hassan et al. 2020aHassan et al. , 2020bR€ onngren et al. 2018). The mental health nurse practitioner candidate (NPC) role coordinating physical and mental healthcare for consumers, was regarded as useful. The health promotion advice and support provided for adopting healthy lifestyle behaviours enabled observable physical and mental health improvements such as weight loss and increased energy (Furness et al. 2020). Similarly, consumers accessing a physiotherapy service suggested service enhancement will occur when there is consideration and integration of their physical and mental health needs (Hemmings & Soundy 2020). Consumers from a study exploring the potential use of peer support workers as an intervention to improve physical health questioned whether segregation of physical health supports for consumers was an option (Bocking et al. 2018). Consumers recognized the benefits of partaking in segregated physical activities such as little to no encounters of discrimination, and the accessibility and flexibility of the peer-led program (Bocking et al. 2018). Mainstream physical activities were still favoured because of the potential to be multifunctional in the provision of physical and mental healthcare, and to broaden social connections with the wider community (Bocking et al. 2018). Integrated physical and mental health services are preferred by consumers regardless of the discipline delivering a physical health intervention.
Previous literature has cited systemic inadequacies such as unclear roles and local procedures detailing responsibilities, as ongoing issues that contribute to disparities in physical healthcare (Chadwick et al. 2012;Happell et al. 2012aHappell et al. , 2012bNash 2014). Continuing to define barriers that have long been understood detracts from efforts required to explore, develop, and evaluate different, collaborative, and sustainable solutions. In a pursuit to sustainably develop and implement consumer-centred solutions, co-production is an important component. Co-production involves the establishment of partnerships between healthcare professionals and consumers in the design and provision of healthcare services (Palumbo 2016). Using co-production to address barriers to physical healthcare is promising due to the association with better service developments and innovation, improved health outcomes, enhanced patient satisfaction, and cost savings (Palumbo 2016). Meaningfully involving consumers in research and physical health service development can offer real-time solutions to healthcare barriers.
The consumer's voice is generally absent from solution-focused discussions directed at improving their physical healthcare (Morse et al. 2019). The literature surrounding consumer views of physical health and experiences with physical healthcare indicate a wider acceptance of consumer participation in research (Happell et al. 2016a(Happell et al. , 2016b(Happell et al. , 2016c. The present review demonstrated the importance and benefit of involving consumers to evaluate physical healthcare by highlighting the perceived markers and recommendations for a successful physical health intervention. Historically, clinical measures of success for physical health interventions focus on clinical outcomes such as weight loss or blood markers, which do not always align with the consumers' personal measure of success (Van Eck et al. 2018). To consumers, personal measures of success are equally important as clinical outcomes in defining the success of a physical health intervention. Consistent with a previous review (Mason & Holt 2012), personal outcomes from a physical health intervention included improved overall health, increased opportunities for social connections, and a sense of mental health sensitivity from the therapeutic relationship with the healthcare professional. In the broader context, the inconsistent and sometimes small negative associations between clinical and personal outcomes reflect the need to move from solely relying on biomedical outcomes, to extending the promotion and use of personal measures of success (Van Eck et al. 2018). It is important to converge these measures of success when evaluating physical health interventions because the detail gathered from personal outcomes ensures a holistic approach. Future research, policy, and practice directions need to identify methods of intersecting personal outcomes in overall service evaluations.
The advocacy for integrated and coordinated approaches to physical healthcare identified in this review supports this consistent theme in literature (Clancy et al. 2019;Edmunds 2018;Laugharne et al. 2016). Improved multidisciplinary and service collaboration between mental and physical health services is required to mobilize any improvements to the physical health of consumers. Without such action, the incidence of morbidity and premature mortality endures, access to quality physical healthcare is limited, and the human rights of consumers continue to be threatened (Edmunds 2018). Even with the awareness of the impacts of poor physical health on consumers, integration remains a complex challenge. There is a disconnection between the physical healthcare recommendations articulated in policy and the implementation of these recommendations in practice. Fragmentation of services has previously been attributed to the inequitable access and distribution of funds to mental health services by policy-makers, and discrimination and marginalization of consumers by physical healthcare services (Duggan et al. 2020;Happell et al. 2014aHappell et al. , 2014bHappell et al. , 2014cLerbaek et al. 2019). These barriers should caution healthcare systems to be more considerate and clearer with their physical healthcare funding, responsibility structures, and use of specialist mental health nursing roles (Duggan et al. 2020;Happell et al. 2014aHappell et al. , 2014bHappell et al. , 2014cLerbaek et al. 2019).
When appropriately funded, supported, and resourced, specialist mental health nursing roles are integral to coordinating and integrating mental and physical healthcare. Mental health nurses are consistently deemed by consumers and other healthcare professionals as capable of delivering systematic and comprehensive preventative physical healthcare (Clancy et al. 2019;Happell et al. 2013Happell et al. , 2018. The comprehensive educational background of mental health nurses, proximity, and therapeutic relationship with consumers place specialist mental health nurses in an ideal position to improve consumers' physical health outcomes. Evidence for the benefits of a specialist mental health nursing role has been previously articulated (Happell et al. 2014a(Happell et al. , 2014b(Happell et al. , 2014c. Consumers' working with a Cardiometabolic Health Nurse (CHN) increased their physical health activity to that observed in the wider Australian population. Additionally, health behaviour knowledge and attitudes towards illicit drug use and alcohol consumption shifted positively (Happell et al. 2014a(Happell et al. , 2014b(Happell et al. , 2014c. The results from the CHN study assert the case for embedding specialist mental health nursing roles within healthcare systems. Consumers believe holistic and supportive services can help them achieve their desired good physical health. Specialist mental health nurses have been attributed as the key to improving their physical health. Further research regarding consumer perspectives of specialist mental health nursing roles is required.

Limitations and strengths
A potential limitation to this review relates to the search criteria where only peer-reviewed journals published in English language were included. This approach may exclude relevant evidence published in other languages or from non-peer-reviewed sources such as government policy.
This review demonstrated several strengths such as the search strategy adopting an inclusive approach of carers and clinicians in the population domain. This ensured a robust search strategy to identify and include consumer perspectives that may be hidden within other populations. The search strategy contributed to the number of eligible studies included in this review. The use of comprehensive databases identified various sources necessary to undertake a thorough review regarding consumer perception of physical health and experiences with physical healthcare.

CONCLUSION
Consumer attitudes towards physical health reflect their awareness and concern for poor physical health and its impact on overall health. Their attempts to engage with various healthcare professionals and services to redress these physical health concerns are apparent. However, in doing so, consumers continue to face systemic and personal barriers which reduce accessibility and the quality of physical healthcare. It is increasingly understood that consumer evaluations are necessary avenues for generating solutions to improve physical healthcare. Experiences with a variety of physical health interventions including, specialist mental health nursing roles, have established what matters to consumers. Physical health interventions are considered impactful if they improve not only clinical outcomes but also incorporate and heighten personal outcomes.

RELEVANCE FOR CLINICAL PRACTICE
The review findings suggest the importance of genuine consumer involvement for policy, practice, and research directions in relation to physical healthcare. Consumers provide invaluable insights into the barriers and enablers of physical health interventions and services, and consumer evaluation is the cornerstone required to successfully implement tailored physical health services. Specialist mental health nursing roles potentially exemplify the desired physical health interventions that encompass attributes required from a healthcare provider, and the integration of physical and mental healthcare. Co-production may be the approach required to further consumer-centred physical health services that intersect clinical and personal outcome measures during evaluation.