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        “Looking Forward”: a qualitative evaluation of a physical activity program for middle-aged and older adults with serious mental illness
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        “Looking Forward”: a qualitative evaluation of a physical activity program for middle-aged and older adults with serious mental illness
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Abstract

Objectives:

Older adults with serious mental illness (SMI) often have poor physical health in addition to serious mental health issues. Sustained engagement in a group physical activity program may provide necessary physical and mental health benefits. The purpose of this report is to describe participants’ feedback about a video game-based group physical activity program using the Kinect for Xbox 360 game system (Microsoft, Redmond, WA). In particular, we wanted to understand what worked about the program, what was not ideal, and how it impacted their lives.

Design:

Semi-structured interviews were collected and analyzed with grounded theory methodology.

Setting:

Mental health facility.

Participants:

Sixteen older adults with SMI.

Measurements:

Participants played an active video game for 50-minute sessions, three times a week for 10 weeks. Qualitative interviews were conducted with 16 participants upon completion of the program.

Results:

Participants expressed enthusiasm for the physical activity program, indicating it was an activity that they looked forward to doing. The results of the study provide insight into how the program may be implemented into practice at mental health facilities. Three implementation to practice categories were identified: (1) programmatic considerations, such as when to hold the groups and where; (2) the critical importance of staff involvement; and (3) harnessing patients’ interest in the program.

Conclusion:

Our results suggest that engagement in an intense video game-based group physical activity program has a positive impact on participants’ overall health. The group atmosphere, staff involvement, availability of the program at a mental health facility, and health benefits were critical.

Introduction

People with serious mental illness (SMI), such as schizophrenia, are living longer. In fact, the number of people with schizophrenia over 55 years of age will double, reaching 1.1 million by 2025. This number represents one-quarter of all people with schizophrenia (Cohen Vahia et al., 2008). Despite living longer, older adults with SMI tend to have multiple medical problems and poor mobility (Chafetz et al., 2006; Cohen Meesters et al., 2015; Viertio et al., 2009). The ideal trajectory for someone with SMI is a process by which they move from remission (symptomatic recovery), to community reintegration (functional recovery), to successful aging (positive health) (Ibrahim et al., 2010). Although the concept of successful aging in SMI is gaining further attention, it is not the usual trajectory.

Older adults with SMI have a low level of physical activity, and less physical activity contributes to poor health outcomes (Allison et al., 2003; Daumit et al., 2005; Leutwyler et al., 2014b; McKibbin et al., 2006). For example, a study of 30 older adults with schizophrenia from a variety of treatment settings, found that these individuals were sedentary 20 hours a day (Leutwyler et al., 2014a). People with SMI have a higher mortality rate than the general population, and less physical activity contributes to this mortality gap (Daumit et al., 2005; Druss et al., 2011). Physical activity promotes better mental and physical health outcomes (Deslandes et al., 2009; Gorczynski and Faulkner, 2010). Even short periods of low-intensity physical activity can positively influence mental and physical health (Bossmann et al., 2013).

Effective and easily accessible physical activity programs would help to reduce the disability associated with SMI and mitigate other factors that contribute to poor physical health.

A growing body of evidence is available on the effects of physical activity in people with SMI. In a Cochrane review (Gorczynski and Faulkner, 2010), the efficacy of three physical activity RCTs (i.e. walking, combination of walking and jogging, or combination of weight training and aerobic training) in people with schizophrenia were evaluated. The authors concluded that the impact of these programs on health outcomes was mixed. One study provided evidence of improved fitness, and all three studies showed psychological benefits (e.g., less severe psychiatric symptoms) from physical activity. However, RCTs that compared physical activity interventions with standard care failed to demonstrate changes in other health outcomes, such as body mass index (BMI) and blood pressure. Two physical activity RCTs for overweight individuals with SMI published after the Cochrane review showed mixed outcomes. In one study of individuals with SMI, increased physical activity resulted in weight loss but failed to demonstrate changes in blood pressure (Daumit et al., 2013). In the other study of individuals with SMI, increased physical activity improved cardiorespiratory fitness (measured by the six-minute walk test) but had no effect on weight or BMI (Bartels et al., 2013).

These inconsistent findings may be due to a number of factors including the short duration of and low adherence to the various interventions. None of the studies focused on older adults with SMI. Since standard physical activity interventions have failed to improve important health outcomes, more work is needed to understand what will support increased adherence to physical activity programs tailored to improve outcomes in older adults with SMI. Implementation science, which can be defined as the scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice with the ultimate goal to improve the quality and effectiveness of health services (Bauer et al., 2015), may be useful for the field of physical activity and SMI. The application of implementation science may bridge the theory to practice gap as well as inform the design of future interventions.

Our group conducted a small (n = 26) study of a 10-week video game-based physical activity program. In this study, three times a week for 10 weeks, participants attended 50-minute active group video game sessions using the Kinect for Xbox 360 game system. This paper reports the findings of qualitative interviews conducted with 16 participants upon completion of the program. The purpose of the interviews was to gather participants’ feedback about the program, what worked, what was not ideal, and how it impacted their lives.

Methods

Design

The methodological basis for this study was Grounded Theory (Glaser and Strauss, 1967). Symbolic interactionism provides the theoretical framework of Grounded Theory methodology and supports the view that individuals’ understandings occur within the context of relationships (Blumer, 1969). Institutional review board approval was obtained from the sponsoring university’s human subjects committee. Anonymity and confidentiality were maintained according to the guidelines set forth by the sponsoring university’s human subjects committee. Participants selected a pseudonym to be used throughout the study in place of their real names. After consenting to participate, each participant completed a semi-structured interview with the researcher in a private location.

Participants and settings

Inclusion criteria were that the participants be at least 45 years of age or older, be diagnosed with a serious mental illness (i.e., schizophrenia, schizoaffective disorder, anxiety disorder), and pass a capacity to consent test based on comprehension of the consent form. The two recruitment sites included a transitional residential and day treatment center for older adults with severe mental illness and an intensive case management program. Theoretical sampling was implemented in order to ensure maximum variation and to build conceptual density of the emerging results. Sixteen participants consented and completed a semi-structured interview. Participants received five dollars for completing the interview.

Data collection and analysis

Recruitment and data collection began in June 2015 and ended in May 2018. Data collection was comprised of interviews conducted in groups and one-on-one sessions as well as participant observation. Interviews were conducted upon completion of the 10-week physical activity program. The interviews lasted about 60 minutes and were conducted with a semi-structured interview guide that was malleable to the responses and emerging themes encountered. A few questions asked were: What did you enjoy most about the video game-based physical activity program in which you participated? What did you look forward to? Why? What did you enjoy least about the video game-based physical activity program you participated in? Ongoing participant observation was completed during the interview and during return visits to the recruitment sites. This also allowed an opportunity to confirm initial analysis and interpretation with participants.

As is the case with Grounded Theory methodology, data collection and analysis were done simultaneously and used as an approach of constant comparison analysis as initially described by Glaser and Strauss (1967) and further informed by Charmaz (2014) and Clarke (2005). Interviews were transcribed verbatim and next double-checked to the tape for accuracy. Field notes and interview transcriptions were entered into Atlas.ti software to assist with data organization. Initial open coding was done through transcript analysis with word-by-word and segment-by-segment coding. Axial and selective coding were used in order to determine key themes and properties in the data and to eventually develop a conceptual framework of codes and categories. Theoretical memos documented the developing conceptualizations about the codes and categories as well as about relationships between categories. Conceptualizations about the categories and relationship between categories were further discussed with the research team. Theoretical and methodological notes were maintained regarding decisions made during the analytic process. Data collection concluded when theoretical saturation was achieved.

Results

Sixteen participants completed an interview. Five group interviews and six individual interviews were conducted. The mean age of the sample was 59 years (range 51–70; SD = 5.2), 38% were female, 50% were White, 19% were Black or African American, 6% were Latino, 13% were Asian, and 12% reported other ethnicity. Participants attended an average of 25 (SD = 4.7, range 13–30) out of a possible 30 video game sessions. The diagnostic breakdown of participants was: schizophrenia (56%), major depression (19%), bipolar (6%), Post-traumatic Stress Disorder (12.5%), and psychotic disorder (6%).

The results of the study provide insight into how the program may be implemented into the practice at mental health facilities. Three implementation to practice categories were identified: (1). programmatic considerations such as when to hold the groups and where; (2) the critical importance of staff involvement; and (3) harnessing patients’ motivation in the program.

Programmatic considerations

During the interviews, we asked participants about specific details of the program that we could improve or keep the same. We inquired about ideal frequency, timing, and group size. In general, the participants agreed that three to four times a week was ideal but they were not interested in having the program “every day”. Approximately an hour session was favored. We also inquired about the preferred number of participants per group, and the responses ranged from three to five participants. We also inquired if there was interest in playing solo versus in a group. Across the participants interviewed, it was expressed that a group was a much better experience. Some participants would play the games on the weekends or during downtime between groups to sharpen their skills, but admitted the experience in a group was much livelier and fun. One participant described the group nature of the program:

“Almost like a home-like experience. Everybody was welcoming and the staff and everything…You didn’t feel left out; you were included in everything.”

The ideal location to hold the program was on-site at a facility where they could all be “in it together.” Participants consistently indicated the ideal time of day to have the program was at the end of the day, after psychotherapeutic and social skills training groups had concluded. Participants also provided feedback about the games they preferred, and a consistent theme was the importance of variety. Variety in the games offered but also the variety that the game sessions provided to the treatment milieu. For example, one participant said:

“Try a whole variety in the first two or three weeks, and then…people get hooked on it… we only did soccer once and I kind of thought that was fun. And we only did the bubble things…20-thousand whatever, Leagues Under the Sea, and I thought that was kind of fun.”

The participant suggested the facilitators of the program should be more direct about encouraging the group to try new games each session, even if only for half the session.

“If you’re doing the 30-minute one would be like the very active one…like the river rafting, or the skiing, or the bubble number. Then people could just sort of rest, because bowling isn’t that strenuous. And table tennis, well, that can be strenuous, but people really like it.”

A recommendation was also made about how to get participants to play on their own and perhaps create their own group experiences.

“I had trouble figuring out how to turn it on and get it going. But after a while of fiddling, I figured it out…Maybe put a sign up…how to turn the machine on…And maybe just volunteers to have a class with some of the people who haven’t been in the program and show…how it’s done.”

Staff involvement

Another key to implementation to practice is the importance of the staff involvement. For our program, the staff were the research personnel, which included the principal investigator (PI), project coordinator, and graduate student researchers. The recommendations are based on the role the research staff played in the group, and how mental health staff may play those same roles with the program. The staff played a role in getting patients interested in the program and keeping them involved.

“They were rooting us on too, but that made a difference.”

Staff went beyond cheering and often also provided concrete guidance about how to play specific games, how to modify for specific abilities, and how to better use the technology:

“But when she (research staff) pointed those things out, I was able to change my strategy and hit the ball with the wind, instead of going against the wind…she was very helpful in pointing things out.”

One participant described the key role of staff and the need for staff to be involved in a program like this:

“It is going to take that person to facilitate and…give direction to the group…I can be a self-starter…in a group early on…one in particular needed direction…what to do. And with that particular person, once he got the direction, he kind of did get into it a little more…”

Some participants easily picked up how to play the games and use the technology, while other participants needed a little more one-on-one guidance. The research staff were critical in providing that help and guidance to help the group remain cohesive, competitive yet fun. The research staff were also mentioned as being adept at catering to the physical needs of the group by meeting people where they are at.

“we went on our own pace…and it wasn’t really pushing– in the beginning, it was okay, my turn, and then in the end, it was my turn, and went out of turn, because you wanted to go quicker”

Participants described how the research staff worked together with the group members to create a positive environment. It was a collaborative group effort to keep everyone engaged, especially with group members that had varying physical and technological capabilities.

“What I liked about it was that the facilitators…were very kind to us. If someone wasn’t able to comprehend the game, they had patience, and as well as their peers. We had patience to kind of like be the safety net for the individual that had a challenge with it…We inspired them. Even if their score was low, we gave them cheers…it was motivating…”

Participants described how mental health staff involvement could make a physical activity program fun for all patients in the program.

“The staff here will have to get involved with it. And if they can get involved and do it like you guys did, then it will be fun, for not just the group, but for the whole house. I think it would be a good thing, because exercise, it gives you a burst of energy at first, and then it gets you kind of sore, kind of tired. And then you get that energy again, see?”

Harnessing patients’ motivation in the program

In order for participants to adhere to the program, they needed motivation and reasons to get involved and stay engaged. The staff involvement, as described in the previous section, played a role in this engagement. Other factors also played a role in getting patients engaged, and then recognizing the benefits gained from engaging in the program. Across interviews, it was obvious that the social nature of the program was a critical factor to the success of getting patients involved and keeping them engaged. Participants spoke about looking forward to playing their favorite games, cheering each other on, and shaking off the worries of the day.

“I knew I was exercising, but I was also having fun. And that made me look forward to the next day, and the next day. And then, like I said for my arthritis, it – coming down here would eliminate me having to do other things because I was always down here exercising three days a week. And it was really, really good fun.”

For some participants, it was necessary to overcome fear of technology in order to engage in the program.

“I have a 16-year-old grandson, and a six-year-old granddaughter, and a four-year-old granddaughter – they play those games all the time, but they’re intimidating to me, because I’m an older person…I just learned how to use my smart phone, you know? And to get on the computer, that Xbox thing, I just didn’t think I could do it. And after I got on it, I found out it was fun. It was easy.”

After participants played just a few sessions, most were proficient with how to turn on the Xbox, load a game, and navigate the game menus. Participants spoke about the benefits gained by “sticking with” the program.

“I stuck with it. And that’s one of the reasons why I wanted to continue with this, because in this group, we get so much experience in things that we never did before and you’re always enriching our lives…make it better, because it’s never where you get to a certain age where you think you’ve done everything. Then something comes along…you guys didn’t make us feel old.”

Participants also described how it felt to be competent at a variety of games and the process of gradual improvement.

“I noticed the mental point, too, because one day I bowled two-something, and the next day…it went up. When I was doing the blocks, I noticed the first time, I knocked two hundred-and-something and then the next time, it was nine hundred-and-something. So it was gradual steps that I was gaining. I was gaining more blocks or better bowling score, or even the dancing. That was my least one I liked – the dancing – but I noticed I was able to keep up with the man more.”

In addition to the sense of accomplishment gained from mastering the technology and trying something new, participants described additional benefits gained from the groups that seemed to keep them interested in the program.

“I enjoyed it…on days when I wasn’t feeling really energetic, I could kind of tap into their energy a little bit. It would elevate mine a little bit and, yeah, I could get into it a little bit more. There was kind of a group synergy that kind of happens. I can kind of tell that with the others, too, that like one of the fellas would come in. He wouldn’t maybe be up to just all happy and smiles that day. And that particular group would elevated the mood a little bit of that person. I could sense that in the group.”

This additional motivation to stay involved in groups seemed to be particularly important for overcoming some of the mental health symptoms that could be a barrier to exercise and group involvement. The group energy was a collaborative effort among the participants. For some, the games also set the stage to push their boundaries and may have opened an opportunity to pursue additional physical activity or try new activities outside of the mental health program:

“Well, the tone for me, it set that more want to get up and go, not go home, go back to the residential house, or want to go to sleep, or slugging around. It set the tone for me to want to walk to the library, or walk from here all the way home, you know. It set the tone for me physically to want to continue to move on, you know, to exercise my muscles and stuff.”

“It made me happy more… no one wants to be in treatment. So it put a smile more on my face than it did – without it, I would probably still have that grumpy look on my face.”

The games sessions also provided an opportunity to try new activities that some participants would not have felt comfortable exploring outside of the group, such as dancing or skiing. The sessions also provided a place for participants to enjoy exercise, while being aware of physical limitations

“I just had to kind of come to terms with, well, I’m not going to get the best score I can get on the TV screen, and but go on and do what I can, okay, and then I kind of satisfied myself with that thought. I did what I could without hurting myself, which would be a bad thing.”

Engaging in positive health behaviors also emerged as an important benefit. Smoking reduction was one of the specific health behaviors that participants discussed.

“Well, my smoking went down, because you can’t exercise good and smoke, because it hurts your lungs and it hurts your chest. And when I was doing this, I didn’t want to smoke after that… after exercise, I didn’t want to smoke a cigarette.”

Participants told us that they had less cravings to smoke, and they noticed that they had cut back the amount smoked per day. Participants also noticed that they were engaging in more physical activity outside groups.

“I could walk a block further. That’s about it. Easier for me to get on the bus with my leg…some of the things you need to balance with your leg and everything.”

Some participants noticed that they could do their daily activities more easily with their improved balance and endurance.

“I’m of the age that…I need to keep moving and got sort of arthritic things and it’s sort of hard for me to kneel or sometimes go up and down stairs. So it really helped going up and down stairs or being able to kneel in my room if I had to look under my bed for anything, or something like that, because before, I couldn’t do that.”

Participants frequently described the benefit for their mental health.

“It helped, you know, fire the brain a bit and, you know, interact with people and,– you’re not quite – you can’t be really depressed when you’re doing games on the Xbox.”

The video game groups seemed to be a platform for participants to work on their physical health but also served as another way to focus on their mental health.

“For me, it (the videogame group) made me want to do more things like that for – not just for my arthritis, but for my mental health, too. Because my post traumatic stress syndrome, interacting with the machine, and the other participants, made it more like it – it was fun. It wasn’t work…I was looking forward to going down there and doing it.”

In addition, participants described how the groups help with managing anxiety and stressful situations, such as trying to find stable housing.

“And it’s like when we got done doing this in here, it was like meditating.”

Participants noted that the group atmosphere created a positive environment that played a role in harnessing their interest and attendance at the groups. Being cheered on by others in the group was frequently mentioned as a strength of the program

“I was a decent dancer, but I didn’t realize I was that good. According to everyone else, I was pretty good.”

Participants described a sense of accomplishment and claimed that their “day was completed” after doing the game sessions. The groups were a physical and tangible activity to do at the end of a day following psychotherapeutic groups.

“Felt like you completed the day with – you went to your groups and it always gave you some more information to feel good. And then you came down here (to the game sessions), and this was almost like a social time. We had fun doing it and it made me feel like my day was completed. And I got closer to some of you guys that was in here. And I liked that.”

“I was looking – I was future tripping…It made it less like exercise, and more like fun.”

Discussion

This is the first study to qualitatively evaluate the impact of a physical activity program designed for older adults with serious mental illness. Our findings illustrate the importance of programmatic and pragmatic considerations when designing and implementing a physical activity program for people with SMI, the importance of staff involvement even if the participants could run the group on their own (i.e., turn on the game console and play a game), and motivations to get and keep patients’ interest. The importance of the group-based program was a consistent theme throughout.

Prior literature has shown patient’s with SMI prefer group-based physical activity because it encourages engagement in the program and reinforces structure. (Leutwyler et al., 2014b) In order for a physical activity program to create a significant and lasting positive impact on health outcomes, adherence with the program is critical. Availability of activity programs within mental health facilities (Daumit et al., 2013) and ensuring social support (Beebe et al., 2012) have been shown to improve adherence. The theoretical framework for our study was based on a model originally developed by Dr. Debra Lieberman, Director of the Health Games Research national program and later refined by an American Heart Association scientific panel, and published in a report entitled “The Power of Play: Innovations in Getting Active Summit 2011” (Lieberman et al., 2011). This theoretical model illustrates ways that active video games may improve health behaviors by influencing mediating factors (i.e., self-concepts; self-efficacy; physical skills, fitness, well-being; and communication and social support) that are known to improve health behaviors. The findings from our study provide support for the communication and social support mediating factors. According to the model, when people play active video games with others and share this experience, they often begin discussing their workouts and their health with family and friends, or in this case, with other players in the group. This communication leads to encouragement, praise, coaching, sharing thoughts and feelings, giving and receiving social support for being physically active—all elements known to improve health behaviors.

Another finding that magnifies the importance of group-based physical activity programs was participants’ discussion about staff involvement. Although the program could theoretically be run without a staff facilitator (after a training session on how to set up and choose the games), participants described how critical the staff involvement was for group cohesion, problem solving, and enhancing the overall morale of the sessions. Another study that evaluated active video games for people with SMI living in community housing, found that the program was not successful in part due to lack of staff involvement (Gyllensten and Forsberg, 2017). Previous qualitative work with staff in mental health settings also emphasized the importance of staff as role models for physical activity and the need for staff to be involved with the groups (Leutwyler et al., 2013). Staff often have an understanding of the patients’ individual needs, preferences, and symptoms, which can help the staff to find ways to get and keep patients involved in the program (Leutwyler et al., 2013).

Participants in our program described how they needed an incentive to join the program but, once engaged, were motivated to keep coming. Some of the reasons that participants adhered to the program included the competition, a sense of belonging with the group, and noticing the positive impact on their health. Prior research has shown the importance of a sense of belonging and social connection for older adults with SMI (Leutwyler et al., 2010). This connectedness may be a lever to engage patients in their mental and physical heath care. Gyllensten and Forsberg (2017) also found that competition helped participants to engage in their program. The competitive nature of the groups may be an aspect to include in other physical health promoting interventions for older adults with SMI through the use of engaging video games or receiving points. Participants also described how they looked forward to the games at the end of a long day of going to groups. Looking forward to an activity and noticing the benefits of the activity are an important aspect of behavior change theories (Bandura, 1989; Lieberman et al., 2011). If an individual looks forward to an activity and is motivated to engage in the activity, they will be more likely to make it a routine part of their lives. In addition, having a dedicated space to play the games facilitated participation and encouraged participants to play the games on their own. The study by Gyllensten and Forsberg (Gyllensten and Forsberg, 2017) found that not having a dedicated space for the games was a barrier to participation and engagement in their program.

Research in active-play video games shows that as people become more involved and successful with video game-based physical activity, they develop skills that make it easier to engage in activity (Lieberman et al., 2011). As seen in our study, participants enjoy the perception that their bodies are becoming more fit and experience more physical and emotional well-being. This is yet another reward and benefit that provides motivation for more engagement in physical activity. It may help if staff draw the connection between engaging in exercise and the benefits found (e.g., increased balance, endurance).

Study limitations

Limitations to our study include the evaluation of only patients’ perspectives. Future work should focus efforts on evaluating the mental health staff perspective for suggestions on how to implement the program into practice.

Conclusion

Increasing adherence to physical activity programs in people with SMI is challenging (Gorczynski and Faulkner, 2010). In order for a physical activity program to create a significant and lasting positive impact on health outcomes, adherence with the program is critical. Availability of activity programs within mental health facilities (Daumit et al., 2013) and ensuring social support (Beebe et al., 2012) have been shown to improve adherence. The interviews with participants in our study emphasize the importance of social support, co-locating programs at mental health facilities, and the patients’ perceived benefits of physical activity participation.

Conflict of interest

None.

Funding

National Institute on Aging.

Description of authors’ roles

H. Leutwyler designed the study, supervised the data collection, carried out the analyses, and wrote the paper. S. Dobbins collected the data, assisted with data analysis, and assisted with writing the paper. E. Hubbard collected the data, assisted with data analysis, and assisted with writing the article.

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