Given the results of prior studies on this subject, it is not surprising that participants reported that the In SHAPE program's interventions were helpful in promoting engagement in healthier lifestyles. In a cross-sectional survey of 120 mental health clients, Ussher et al.
found that a majority agreed or strongly agreed that they would exercise more if they talked to an instructor or were advised to do so by their doctor (Ussher et al., 2007
). Although the vast majority of these clients believed in the benefits of exercise, they had little confidence in their ability to exercise when sad or stressed and received little, if any, encouragement from family and friends. Conducting semi-structured interviews with 16 persons with SMI, Soundy et al
. found a similar mismatch between high receptiveness to the idea of becoming more physically active and perceived inability to negotiate barriers to doing so (Soundy et al., 2007
). The In SHAPE program helped to capitalize on clients’ interest in healthier lifestyles by providing the required support to negotiate barriers.
Prior qualitative and ethnographic work has elicited the themes of self-confidence, the importance of relationships and symptomatic improvement in exercise programs for people with mental illness and other isolating conditions. Faulkner and Sparkes studied a small group of London hostel residents with schizophrenia and found that the process of exercise, through distraction and social interaction, decreased participants' auditory hallucinations, raised their self-esteem and improved their sleep patterns and general behavior (Faulkner and Sparkes, 1999
). In another report by Faulkner and Biddle, case studies were used to illustrate the value of exercise in the context of participants' lives (Faulkner and Biddle, 2004
). Participant motives for engagement in exercise ranged from promoting social interaction to improving body image and were highly dependent on individual factors. While programmatic factors facilitated engagement in the In SHAPE program, there was a dialectical interpenetration between relationships, self-confidence and physical health improvements.
While this study is unique in using methods of AI to learn more about successful participation in a health-promotion program for persons with SMI, several factors limit its generalizability. The first is the small sample size. We interviewed one-third of participants who met our inclusion criteria and used non-random sampling methods to select them. Participants who were not interviewed because they were not recommended by the health mentors may have had different views about how they made their improvements. However, given that emergent themes resembled those in similar work, we feel this study adds to the existing literature on health promotion in individuals with SMI. The second major limitation is that participants were interviewed only once for 1 h. Additional themes may have emerged had we spent more time with participants. However, the commonality of responses and triangulation with the health mentors suggest that we obtained consistent results.
In conclusion, we used AI to identify important factors associated with achieving physical health improvements in the In SHAPE program. These factors appear to be particularly important in promoting long-term engagement in health behavior change, and will be used to help improve the performance and sustainability of the In SHAPE model. Key factors include relationships and self-confidence developed in the context of long-term engagement in healthy behaviors, support from health mentors and activities that were integrated into community settings. Clinical service providers wishing to implement health-promotion programs for persons with SMI should ensure that these features are incorporated into program designs. Future research should examine the best ways to do so.