A systematic review of physical activity policy recommendations and interventions for people with mental health problems in Sub-Saharan African countries

Introduction There is a need for interventions to address the escalating mental health burden in Sub-Saharan Africa (SSA). Implementation of physical activity (PA) within the rehabilitation of people with mental health problems (PMHP) could reduce the burden and facilitate recovery. The objective of the current review was to explore (1) the role of PA within mental health policies of SSA countries, and (2) the current research evidence for PA to improve mental health in SSA. Methods We screened the Mental Health Atlas and MiNDbank for mental health policies in SSA countries and searched PubMed for relevant studies on PA in PMHP in SSA. Results Sixty-nine percent (=33/48) of SSA countries have a dedicated mental health policy. Two of 22 screened mental health policies included broad physical activity recommendations. There is clear evidence for the role of PA in the prevention and rehabilitation of depression in SSA. Conclusion Despite the existing evidence, PA is largely a neglected rehabilitation modality in the mental health care systems of SSA. Continued education of existing staff, training of specialized professionals and integration of PA for mental health in public health awareness programs are needed to initiate and improve PA programs within the mental health care systems of SSA.


Introduction
Mental and substance use disorders are the leading cause of years lived with disability (YLD) in Sub-Saharan Africa (SSA), accounting for 19% of all disability-associated burden (YLD) [1]. Major depressive disorders are the second leading cause of disability following chronic back pain while anxiety disorders the fifth leading cause of disability in SSA. In terms of mental and substance use disorders, all SSA regions will experience an increase in burden of approximately 130% and it is estimated that the YLDs will rise from between 20 to 45 million YLDs by 2050 [2]. Moreover, by 2050 mental and substance use disorders may be equivalent to approximately two thirds the YLDs of the entire non-communicable diseases group (67 million YLDs) of SSA [3]. The consequences of the rising and devastating burden of mental and substance use disorders are far-reaching and long-lasting, not only for the individual but also for the family and community as a whole. The quality of life of those affected is severely impacted and economic costs are significant. It is estimated that the cumulative global impact of mental and substance disorders may amount up to US$16 trillion due to lost economic output over the next 20 years [4].
Moreover, secondary co-morbidities need to be considered which can add to the increased disability and burden [5,6]. For example, severe mental illness has been shown to be an independent risk factor for other important non-communicable disorders such as cardio-metabolic diseases, albeit inconsistently in SSA studies [7].
Consistent associations are however reported between HIV/AIDS and poor mental health [8,9] and chronic pain and poor mental health [10,11]. Also the strong and often bidirectional relationships of mental disorders with substance use disorders and the associated increased risk for accidents and injuries emphasizes the critical role of a rigorous mental health policy in SSA [3].
Given the increasing pressures of communicable diseases and malnutrition, a mental health policy has been relatively low on the priority list in most of SSA countries [12,13]. Only a median of 0.62% of the health budget is spent on mental health [14]. As a result, mental health services are poorly resourced and typically very few inpatient facilities are available in the larger urban cities [ 13]. Treatment rates for people with mental disorders remain low, with treatment gaps over 90% [15]. The World Health Organization Comprehensive Mental Health Action Plan for 2013 to 2020 [3] outlines targets for its member countries, which include updating existing mental health policies and plans, integrating mental health care into community-based settings, and strengthening evidencebased research. One major concern of the plan is the limited research in mental health care in the Sub-Saharan region [16]. To date, within low-to-middle income countries, community-based rehabilitation, psychoeducation and support for families (delivered by non-specialists) are recommended for low resource settings, with assertive community care and cognitive therapy recommended as additions in higher resourced settings with stronger service-delivery platforms [17]. The potential role of low-cost physical activity interventions seems to be given low priority and neglected. This is not surprising since the emphasis in health service delivery in SSA is based on the biomedical model (versus the biopsychosocial model) with an important focus on pharmacology in the management of mental disorders [13]. As a result, more doctors and nurses are recruited as key cadres as compared to any other cadre of staff and this stifles the promotion of other biopsychosocial packages (including physical activity) in the management of most conditions [13]. There is however an increasing body of research demonstrating that physical activity interventions prevent the onset of mental illnesses such as depression [18] while it can improve physical, mental and social health outcomes in people with established mental disorders [19][20][21][22]. Physical activity has also been shown to reduce cognitive deficits [19,23,24], aspects of the illness which are often left untreated and particularly influential on long-term functioning [25,26]. Thus, implementation of physical activity interventions within the care of people with mental health problems could reduce the mental, physical and social burden, while facilitating functional recovery and consequently reducing disability.
This will on its turn reduce the societal costs. The aim of the current systematic review is twofold. First, we set out to explore the role of physical activity within the current mental health policies and plans of SSA. Specifically, we wanted to explore whether any priorities or recommendations were reported and in particular explore the integration of health care professionals with potential expertise in delivering physical activity interventions (i.e., physical therapists, physical educators, exercise physiologists and occupational therapists). Second, we explored the current research evidence from physical activity studies performed in Sub-Saharan Africa. the mental health policy and/or plan was not available google scholar was screened using the search terms: "mental health" AND "plan" OR "policy" and the name of the country, or its equivalents in other languages. Mental health policies and plans were screened for physical activity priorities and recommendations. Search terms used, were: "physical activity" OR "exercise" OR "sports" OR "activities" OR "rehabilitation" OR "active lifestyle" OR "physical health", or its equivalents in other languages. In a third stage, we summarized the with severe mental illness in SSA. The following search strategy was used: "physical activity" OR "exercise" OR "sports" OR "rehabilitation" AND "mental" OR "depression" OR "psychosis" OR "schizophrenia" OR "bipolar" AND the name of the country.

Eligibility criteria
Participants: Although we were interested in people with mental disorders, we did not exclude any people due to age or whether or

Data extraction
Two authors (DV, BS) extracted data using a predetermined data extraction form. The data extracted for were country, study setting, patient characteristics (diagnosis, age, % male). Duration (weeks), frequency (times per week), intensity (as defined by the authors), and type (aerobic exercise, resistance training, mixed) of the physical activity intervention, whether the exercise was supervised or not and qualified versus non-qualified providers. Providers of physical activity interventions were considered experts when they had at a minimum a bachelor-level degree in physical therapy, exercise physiology or a similar that included education in exercise prescription and assessment. Finally we did extract physical activity and sedentary assessments and motivational strategies used to improve adherence and reduce dropout.

Results
Physical activity priorities or recommendations in mental health policies and plans in SSA In terms of policy, 69% (=33/48) of SSA countries report having a dedicated mental health policy or plan. Ten policies were not found while one (Sudan) was written in Arabic, and therefore not meeting our inclusion criteria and was not screened. Two (Namibia and Uganda) of 22 screened mental health policies or plans included physical activity priorities or recommendations. None of these recommendations were based on scientific evidence, defined physical activity according to frequency, intensity, type or time, nor defined any implementation strategies. Per 100,000 inhabitants the number of occupational therapists available ranged from 0 (n=20) to 5.36 (Seychelles) An overview of the presence of a mental health policy or plan, the number of occupational therapists involved for each country and the availability of physical activity priorities or recommendations is presented in Table 1, while the physical activity priorities or recommendations are summarized in Table 2.
Screening for physical activity studies conducted in people with mental health problems in SSA

Search results
Out of 7,133 search hits, 8 potentially eligible studies were retrieved. After applying the eligibility criteria 7 studies [33-39] were included. One study was excluded as it overlapped a study already included in the review [35]. An overview of the search results for each country is presented in Table 3.  Table 3. Providers, when reported, were physiotherapists (n=1) or trained community coaches (n=1). In cross-sectional studies, the physical activity behavior was assessed with self-report instruments.

Physical activity outcomes
In the 2 RCTs in people with HIV, aerobic exercise reduced depression and improved psychological quality of life, self-esteem, body image and emotional stress. In one RCT in adolescents sports delivered by trained community coaches had a negative effect on depression and anxiety like symptoms in boys while no effect on girls. In one RCT in depressed adults only moderate and high but not light intensity aerobic exercise resulted in significantly less depressive symptoms. When looking at the 3 cross-sectional studies in adolescents all 3 studies consistently showed that less physical activity participation is associated with more severe depressive symptoms. Details of the physical activity intervention characteristics, outcomes and assessment tools are presented in Table 4.
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Discussion
The current systematic review shows that 69% of the SSA countries have a mental health policy or plan. When screening the available mental health policies or plans we found that less than 1 in 10 makes reference to the importance of considering an active lifestyle and/or structured exercise. Therefore, although physical activity is

Conclusion
The current data shows that in SSA the importance of considering

Competing interests
The authors declare no competing interest.

Authors' contributions
The study was designed by Davy Vancampfort and James Mugisha.      UN=unknown, NA=not available, °per 100,000 population, *plan written in Arabic.
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