Physical activity and motivational readiness for physical activity behavior change in adults with non-communicable diseases in Germany: a trend analysis of two cross-sectional health surveys from the German GEDA study 2014/2015 and 2019/2020 | BMC Public Health

We analysed PA among adults with certain NCD for GEDA 2019/20-EHIS in comparison to the population without this specific NCD. Furthermore, we observed temporal trends of PA between the two German health monitoring surveys GEDA 2014/15-EHIS and GEDA 2019/20-EHIS. Our analysis of GEDA 2019/20-EHIS PA data showed that PA and motivational readiness for PA remains low in adults with NCD, with differences between the NCD. PA behavior of adults with NCD has been first analysed for Germany by Sudeck et al. in 2021 [14]. Our analyses are based on the same definitions and therefore our methodological approach is almost identical to those of Sudeck et al. and suitable for trend analysis. PA for health promotion is strongly recommended for adults with and without NCD in national and international PA guidelines like the Global Action Plan on Physical Activity 2018–2030 of the WHO or the German guidelines for PA [35, 39].

The analyses of GEDA 2019/20-EHIS underline that PA is low in adults with NCD, whether you focus on health-enhancing aerobic PA or muscle-strengthening. The results also show a wide range of PA prevalence for different NCD. For example, adults with musculoskeletal diseases like lower back pain, neck pain or osteoarthritis are almost as physically active as the population without this specific disease. Adults reporting COPD, CHD, obesity and depressive symptoms were found to be highly inactive in regards to health-enhancing aerobic activity while adults reporting stroke and type 2 DM were found to be particularly inactive in both dimensions. With regards to motivational readiness for PA the analysis found that the majority of adults with NCD were in the no intention group (precontemplation). At the same time, the findings show that a great amount of adults reporting NCD are ready to change PA behavior (contemplation and preparation group together ranged between 23 and 45%). Motivational readiness to increase PA was observed to be higher in adults with obesity, low back pain, neck pain and depressive symptoms compared to adults reporting CHD, stroke, type 2 DM and COPD. Our results show that little has changed regarding aerobic PA in adults with NCD since 2014/2015 in Germany, with a negative trend for adults reporting stroke and osteoarthritis. One positive trend which was identified is that muscle-strengthening has increased in almost all NCD except for adults reporting stroke. In the general adult population, both PA dimensions have significantly increased over time by 2.7% for aerobic PA and by 6.9% for muscle-strengthening in 2019/20 compared to 2014/15. However, a current study by Strain et al. reports that in 2022 only 12.0% (9.2-15.1%) of the German adult population were not sufficiently physically active [13]. One reason for the differences could be the use of a different PA questionnaire. The International Physical Activity Questionnaire short form (IPAQ-SF) was used in the Eurobarometer 2022, which was the data source for the analysis of Strain et al., includes walking, moderate-intensity activities and vigorous intensity activities, while in our analysis walking was excluded, because of not meeting the threshold for moderate PA. Furthermore, the admittedly large difference in the fulfilment of PA recommendations may be due to a different data source used by Strain et al. and a much smaller sample size (N = 1,466) compared to the national representative GEDA EHIS survey we used for our analyses.

Our results regarding low PA among adults with NCD are not only in line with GEDA 2014/15 but also with the results of a study by Brawner et al. (2016) which reported a low PA prevalence among adults with myocardial infarction, DM, kidney diseases, stroke and COPD compared to the general population [20]. To date, only a few surveys have looked at trends of PA behavior in adults with NCD in European countries over time and results have been diverging. While Llamas-Saez et al. in 2023 found a positive trend of PA behavior over time among adults with NCD in Spain between 2014 and 2020 [40], a study from Austria conducted by Dorner et al. 2021 found a negative trend of PA behavior in adults with DM [41]. Since PA produces multiple health benefits not only but especially for adults with NCD, countries like Germany should establish and/or expand a monitoring system on PA for adults with NCD for a better understanding and monitoring of population health as recommended by the WHO Global Action Plan on Physical Activity 2018–2030 (GAPPA) [22].

One reason why the proportion of adults with osteoarthritis, low back and neck pain who fulfil the recommendations for muscle-strengthening is higher and almost equal compared to the general adult population without this specific NCD and adults with these musculoskeletal diseases are more ready to increase or maintain PA behavior might be that the health services infrastructure is better for these conditions compared to others. For example, physicians can easily prescribe physiotherapy for persons with low back or neck pain and costs are covered by the health insurances. In the best case adults are then treated according to the guidelines with PA and muscle-strengthening exercise [42].

Our findings suggest that an adequate infrastructure in ambulatory health care, which considers motivational readiness to change behavior and includes tailored interventions to initiate regular PA and exercise as a valuable health resource is needed to address the growing number of adults living with one or more NCD. Although, there is convincing scientific evidence for the treatment with PA and exercise for most NCD, most countries, and this is also true for Germany, have no measures for sport and exercise therapy for cardiovascular, metabolic or lung diseases implemented in primary health care. Exercise specialists like sports therapists are well trained in treating patients with diseases like CHD, DM, cancer, lung diseases and musculoskeletal disorders with PA and exercise in disease specific training groups. So far, in Germany this is, however, mainly implemented in the tertiary rehabilitation settings (ambulatory and stationary) for which coverage is limited and should be expanded to additional health care facilities, including to primary health care settings. Programs should also be needs-oriented taking into account the specific needs, limitations and illnesses of individuals to ensure everyone can participate at their own pace and level. Our results also suggest that there is great potential to increase PA in NCD through targeted measures that are tailored to the different stages of motivational readiness, especially for adults in the contemplation and preparation group. In order to design tailored interventions further research and qualitative insights are, however, needed to better understand factors that influence individuals’ readiness for behavior change in adults with NCD, including reasons for low motivational readiness for persons with NCD like stroke or diabetes. Exercise therapy is safe and effective, evidence based and implemented in numerous disease specific treatment guidelines as well as in international health promotion strategies [8,9,10, 42,43,44]. Several countries already developed different approaches in ambulatory health care to promote PA in adults with NCD. Studies from Sweden (‘Physical activity on prescription’), England (‘Exercise on referral’) or New Zealand (‘Green prescription’) demonstrate that exercise referral schemes have advantages when interdisciplinary teams of different health care professionals are in place, with higher adherence rates to PA following PA prescription [45,46,47].

Our results confirm the great importance of integrating comprehensive low-threshold approaches that are tailored to the specific needs of the different NCD groups in the ambulatory health care system to promote PA among adults with NCD in Germany. Multiple inter- and multidisciplinary projects of medical and exercise professionals have been developed to promote PA in adults with different NCD, from which the health care system can draw on. For example, the ImPuls project is a structured transdiagnostic group-based PA intervention for patients with psychological disorders (major depressive disorders, insomnia, agoraphobia, panic disorder, or post-traumatic stress disorder (PTSD)). The project has been successfully evaluated and has recently shown that the group exercise therapy by qualified exercise professionals’ is effective in reducing global symptom severity and symptoms of depression, general anxiety, panic, and PTSD at six and 12 months assessment [48]. This approach demonstrated the potential for scaling up on a nationwide level and the integration into the German health care system. The MoveOnko project addresses patients with cancer by implementing a multi-professional health care structure to promote needs-oriented PA programs in combination with home-based PA treatment for oncological patients [49]. The BewegtVersorgt project developed and implemented a regional PA and exercise counselling and referral structure in primary health care, where physicians can prescribe PA to patients with NCD and refer them to exercise specialists [50,51,52]. These projects and initiatives can serve as good examples, how PA can be integrated in routine health care to promote PA in patients with NCD. Especially because these projects adopt a behavior-oriented approach and empower patients to change their behavior, effects can be expected not only at the level of PA but also at the motivational level for motivational readiness to change.

Strength and limitations

A major strength of our analysis is the large and representative nationwide database of two GEDA surveys with combined more than 40,000 participants. Furthermore, validated questionnaires were used to assess data on PA and motivational readiness for PA [24, 34, 37]. Our findings are, however, limited as the data on PA behavior, NCD and motivational readiness are based on self-reports which may lead to over- or under-reporting due to recall bias. While the definition of variables in GEDA 2014/15-EHIS and GEDA 2019/20-EHIS is identical, changes in the survey method must be considered. While GEDA 2014/15-EHIS was based on a self-administered questionnaire, which was completed either as a paper or online questionnaire, GEDA 2019/20-EHIS is based on telephone interviews [27, 53]. The data from the GEDA 2014/15-EHIS survey is comparable with the GEDA 2019/20-EHIS as the questionnaire has remained largely unchanged. For example, GEDA 2014/15-EHIS had a list of ten NCD including cancer, but the item for cancer was not asked in GEDA 2019/20-EHIS anymore. Therefore, no PA trends for cancer could be analysed. In addition, our analysis provides for the first time the prospect of more in-depth investigations for the relationship between motivational readiness and PA of adults reporting NCD, albeit the items of motivational readiness were only available for GEDA 2014/15-EHIS and not collected in GEDA 2019/20-EHIS. Therefore the analysis on motivational readiness is restricted to a descriptive analysis and no trends over time are available.

Furthermore, for GEDA 2019/20-EHIS the survey was carried out during the COVID-19 pandemic and during the spring lockdown in 2020. Social isolation have had a negative effect on PA behavior of individuals in general [54]. Particular in adults reporting NCD who are at higher risk of severe COVID-19-related illness and death. This may have led to lower PA rates in the 2019/20 survey compared to 2024/15 and may be partly an explanation for negative activity trends in our analysis. In addition, in our results of GEDA 2014/15 EHIS it is noticeable that there are small differences to the published data of Sudeck et al. 2021 [14]. For example, the differences for the prevalence of depression symptoms. We used the self-reported 12-month prevalence for depression in both GEDA data sets, while Sudeck et al. used a binary indicator for at least moderate depressive symptoms, asking for the last two weeks based on the 8‑item version of Patient Health Questionnaire (PHQ-8). Finally, we used fewer covariates in our analyses, while Sudeck et al. included socioeconomic status as a covariate in the regression model, we used sociodemographic as covariates [14].