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ORIGINAL PAPER A Qualitative Study of Social Facilitators and Barriers to Health Behavior Change Among Persons with Serious Mental Illness Kelly Aschbrenner Elizabeth Carpenter-Song Kim Mueser Allison Kinney Sarah Pratt Stephen Bartels Received: 27 October 2011 / Accepted: 18 September 2012 / Published online: 29 September 2012 Ó Springer Science+Business Media New York 2012 Abstract This qualitative focus group study was con- ducted to explore social facilitators and barriers to health behavior change in persons with serious mental illness engaged in a healthy lifestyle intervention. Six focus group interviews were conducted with a total of 30 clients strat- ified by ‘‘high’’ and ‘‘low’’ achievers in the program based on clinically significant weight loss or significant increase in fitness. Thematic analysis of focus group discussions revealed that emotional, practical, and mutual support from family members and significant others were social facili- tators to health behavior change, while unhealthy social environments was a barrier. Participants in the ‘‘high’’ achiever group reported more mutual support for health behavior change than participants in the ‘‘low’’ achiever group. Results highlight the need for researchers and cli- nicians to consider the potential role of family and signif- icant others as health supporters for persons with mental illness who could encourage healthy behavior in the social environment. Keywords Serious mental illness Á Healthy lifestyle intervention Á Social support Á Health behavior change Introduction The life expectancy of persons with serious mental illness is an alarming 25–30 years less than that of the general population (Colton and Manderscheid 2006). The main cause of this early mortality is cardiovascular disease associated with modifiable risk factors such as obesity, sedentary lifestyle, poor diet and smoking (Daumit et al. 2008; Mitchell and Malone 2006). While many adults in the general population struggle to change their health habits to lose weight and improve cardiovascular health, mental illness is associated with cognitive, mood, and motivational challenges (Beck et al. 2009; Seidman et al. 1992), making it especially difficult to modify diet and develop an exercise routine. Recent health promotion interventions for the general population have addressed the challenge of making lifestyle changes by harnessing social support from family and friends who can reinforce, prompt, and help monitor desired diet and exercise behaviors (Gorin et al. 2005; Kahn et al. 2002; Wing and Jeffrey 1999). In contrast, scant attention has been paid to the role of social support in healthy lifestyle interventions for per- sons with serious mental illness. Given the mounting evi- dence that social support is a key factor in overcoming barriers to lifestyle change (Fraser and Spink 2002), fam- ilies and significant others present a potentially important, yet untapped source of support for health behavior change for this population. Poor health habits are common among people with mental illness. Fewer than 20 % of individuals with schizophrenia report one or more periods of moderate exercise weekly (Brown et al. 1999), compared to 40 % of adults in the general population who engage in moderate- intensity physical activity at least 5 days per week (CDC 1996). In addition, poor diet is a major problem in persons K. Aschbrenner (&) Á K. Mueser Á A. Kinney Á S. Pratt Á S. Bartels Dartmouth Center for Aging Research, 46 Centerra Parkway, Box 201, Lebanon, NH 03766, USA e-mail: [email protected] E. Carpenter-Song Dartmouth Psychiatric Research Center, 85 Mechanic Street, Suite B4-1, Lebanon, NH 03766, USA 123 Community Ment Health J (2013) 49:207–212 DOI 10.1007/s10597-012-9552-8

A Qualitative Study of Social Facilitators and Barriers to Health Behavior Change Among Persons with Serious Mental Illness

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Page 1: A Qualitative Study of Social Facilitators and Barriers to Health Behavior Change Among Persons with Serious Mental Illness

ORIGINAL PAPER

A Qualitative Study of Social Facilitators and Barriers to HealthBehavior Change Among Persons with Serious Mental Illness

Kelly Aschbrenner • Elizabeth Carpenter-Song •

Kim Mueser • Allison Kinney • Sarah Pratt •

Stephen Bartels

Received: 27 October 2011 / Accepted: 18 September 2012 / Published online: 29 September 2012

� Springer Science+Business Media New York 2012

Abstract This qualitative focus group study was con-

ducted to explore social facilitators and barriers to health

behavior change in persons with serious mental illness

engaged in a healthy lifestyle intervention. Six focus group

interviews were conducted with a total of 30 clients strat-

ified by ‘‘high’’ and ‘‘low’’ achievers in the program based

on clinically significant weight loss or significant increase

in fitness. Thematic analysis of focus group discussions

revealed that emotional, practical, and mutual support from

family members and significant others were social facili-

tators to health behavior change, while unhealthy social

environments was a barrier. Participants in the ‘‘high’’

achiever group reported more mutual support for health

behavior change than participants in the ‘‘low’’ achiever

group. Results highlight the need for researchers and cli-

nicians to consider the potential role of family and signif-

icant others as health supporters for persons with mental

illness who could encourage healthy behavior in the social

environment.

Keywords Serious mental illness � Healthy lifestyle

intervention � Social support � Health behavior change

Introduction

The life expectancy of persons with serious mental illness

is an alarming 25–30 years less than that of the general

population (Colton and Manderscheid 2006). The main

cause of this early mortality is cardiovascular disease

associated with modifiable risk factors such as obesity,

sedentary lifestyle, poor diet and smoking (Daumit et al.

2008; Mitchell and Malone 2006). While many adults in

the general population struggle to change their health

habits to lose weight and improve cardiovascular health,

mental illness is associated with cognitive, mood, and

motivational challenges (Beck et al. 2009; Seidman et al.

1992), making it especially difficult to modify diet and

develop an exercise routine. Recent health promotion

interventions for the general population have addressed the

challenge of making lifestyle changes by harnessing social

support from family and friends who can reinforce, prompt,

and help monitor desired diet and exercise behaviors

(Gorin et al. 2005; Kahn et al. 2002; Wing and Jeffrey

1999). In contrast, scant attention has been paid to the role

of social support in healthy lifestyle interventions for per-

sons with serious mental illness. Given the mounting evi-

dence that social support is a key factor in overcoming

barriers to lifestyle change (Fraser and Spink 2002), fam-

ilies and significant others present a potentially important,

yet untapped source of support for health behavior change

for this population.

Poor health habits are common among people with

mental illness. Fewer than 20 % of individuals with

schizophrenia report one or more periods of moderate

exercise weekly (Brown et al. 1999), compared to 40 % of

adults in the general population who engage in moderate-

intensity physical activity at least 5 days per week (CDC

1996). In addition, poor diet is a major problem in persons

K. Aschbrenner (&) � K. Mueser � A. Kinney � S. Pratt �S. Bartels

Dartmouth Center for Aging Research, 46 Centerra Parkway,

Box 201, Lebanon, NH 03766, USA

e-mail: [email protected]

E. Carpenter-Song

Dartmouth Psychiatric Research Center, 85 Mechanic Street,

Suite B4-1, Lebanon, NH 03766, USA

123

Community Ment Health J (2013) 49:207–212

DOI 10.1007/s10597-012-9552-8

Page 2: A Qualitative Study of Social Facilitators and Barriers to Health Behavior Change Among Persons with Serious Mental Illness

with schizophrenia, including lower consumption of fruits,

vegetables, and fiber, and consumption of more calories

and saturated fats compared to the general population

(Allison et al. 1999; Jones et al. 2004). Lifestyle inter-

ventions adapted to persons with serious mental illness

show promise in promoting weight loss and reducing risk

factors for metabolic syndrome (Cabassa et al. 2010),

although the results of research indicates modest and mixed

outcomes (Faulkner and Biddle 1999; Hutchinson 2005;

Stathopoulou et al. 2006). These findings highlight the

need to further improve the effectiveness of healthy life-

style interventions. Harnessing support from people in

participants’ daily lives, such as family members and sig-

nificant others, may be a key resource for facilitating health

behavior change.

Social support interventions for people with serious

mental illness have primarily focused on teaching family

members about mental illness and its treatment, and

reducing stress and tension in family relationships

(McFarlane et al. 2003), but not on promoting change in

health behavior. This exploratory qualitative focus group

study was designed as a first step toward understanding the

potential role of family members and significant others in

supporting health behavior change among persons with

serious mental illness. We sought to explore social facili-

tators and barriers to health behavior change among par-

ticipants engaged in a healthy lifestyle program for persons

with serious mental illness (In SHAPE) embedded within

community-based mental health settings.

Methods

The study was conducted at three public mental health

centers, including two in New Hampshire and one in Bos-

ton. Participants had serious mental illness (schizophrenia,

schizoaffective disorder, major depression, or bipolar dis-

order) and were enrolled in In SHAPE, an integrated health

promotion program specifically designed to improve phys-

ical fitness through dietary change and increasing exercise

in adults with serious mental illness (Van Citters et al.

2010). The program embeds health promotion within

community-based mental health services by providing each

participant with a health mentor, who helps him or her

develop a personal health plan and provides ongoing edu-

cation, assistance with goal setting, and motivational sup-

port through weekly, individual, 1-hour contacts.

Inclusion criteria for participating in the study were: (1)

enrollment in In SHAPE for a minimum of 6 months; (2)

attendance in over 50 % of meetings with their health

mentor over a 6 month-period; and (3) face-to-face contact

with a family member or friend at least twice in the past

month. Separate focus groups were conducted with high

and low achiever participants in the In SHAPE program.

There are substantial health benefits to both improving

cardiorespiratory fitness and losing weight, particularly for

obese individuals. For example, improved cardiorespira-

tory fitness in obese adults in the general population is

associated with a significant reduction in cardiovascular

risk, independent of change in body weight (Lee et al.

2010). However, research indicates that weight loss may

improve survival in those who have an obesity related

disease (Williamson et al., 2000). Therefore, we assessed

both increased fitness and weight loss as indicators of

success in the present study.

Consistent with qualitative methods, we relied on the

expert judgment of key informants (health mentors) to

identify participants who most emulated high versus low

achievement in the program. Health mentors classified

participants as ‘‘high’’ achievers if they had a clinically

significant weight loss (5 % of baseline body weight) or a

significant increase in fitness over the past 6 months based

on the health mentor’s assessment of participant’s exercise

capacity. Specifically, health mentors were instructed to

assess participant’s level of fitness based on three areas:

increased endurance, stamina, and/or muscle strength.

Examples include being able to engage in longer exercise

sessions and/or higher intensity workouts. Health mentors

identified ‘‘low’’ achievers among participants who were

engaged in the program but did not achieve either of these

criteria. Health mentors assessed the participant’s weight

and fitness during a weekly session with participants at the

time of the study.

A total of 30 people participated: 15 men and 15

women. The participants had a mean (SD) age of 48.23

(8.2) years, 7 % of participants were married, and 33 %

were living with a family member or a significant other at

the time of the interview. The majority of participants

(86 %) were Caucasian, and 73 % had a diagnosis of

schizophrenia or schizoaffective disorder. Four Institu-

tional Review Boards (IRBs) approved the research across

three sites. All participants provided either written or ver-

bal consent depending on the requirements of the IRB

affiliated with the organization from which they were

recruited.

We conducted six focus groups, each consisting of three

to eight persons. Of the 30 participants, 10 participated in

three low achiever groups and 20 participated in three high

achiever groups. We elected to use the focus group tech-

nique because it would enable us to learn about a wide

range of social facilitators and barriers in an interactive

setting where participants could relate to one another’s

experiences. The semi-structured, facilitated discussions

covered the ways in which family members and significant

others supported or interfered with participants’ efforts to

make desired changes in diet and exercise. During each

208 Community Ment Health J (2013) 49:207–212

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session, one facilitator guided the discussion while a sec-

ond operated the audio recorder, took thematic notes, and

acted as a secondary facilitator. We used a focus group

topic guide that followed the ‘funnel structure’ described

by Krueger (1994). Broad questions were asked at the

beginning of the interview and the facilitator gradually

proceeded to more specific questions related to the research

objectives. Sessions lasted 60–90 min and participants

were each compensated $25 at the end of the group.

The audio-recordings were transcribed and all identify-

ing information was deleted. We used standard thematic

analysis to analyze the transcripts. Thematic analysis is the

systematic examination of text by identifying and grouping

themes and coding, classifying, and developing categories

(Whitley and Crawford 2005). After creating broad cate-

gories based on research objectives and interview notes,

transcripts were coded by the primary author and a mas-

ter’s level research assistant. We used multiple coding to

reduce the risk of investigator bias (Whitley and Crawford

2005). Both authors independently examined the data

before inspecting each other’s coding scheme. After dis-

cussion, both authors agreed on the prominence of the

themes listed in the results. We identified six initial themes

in the exploratory phase of data coding. However, we

merged two themes together with a broader theme once we

identified significant conceptual overlap between themes.

Thus, we report and discuss the four final themes in the

present study. The authors know of no conflicts of interest

regarding the planning, conduct, analysis, or interpretation

of the study. All authors certify responsibility for the study.

Results

The primary social facilitators of health behavior change

described by In SHAPE participants included emotional,

practical, and mutual support from family members and

significant others. Participants in the high achiever focus

groups reported more instances of mutual support for

health behavior change than participants in the low

achiever focus group. The most prominent barrier identi-

fied in both groups was unhealthy social environment. Each

theme is discussed briefly below.

Social Facilitators

Emotional Support

Participants cited empathy, validation, praise and encour-

agement from family members and significant others as

supporting their efforts to achieve their health goals. One

participant described receiving praise from friends when

she lost weight: ‘‘My friends noticed that I lost a lot of

weight, they go, ‘You’re losing weight, I can tell,’ which is

true, I lost a lot of weight, I lost a pants size, I’m skinnier.

And it’s very nice to hear that from your friends, ‘Gee, you

look better,’ so I’m on the right road.’’ Some participants

described ways in which their family members and friends

provided much needed encouragement to exercise. As one

participant stated, ‘‘I guess it’s because it’s a little moti-

vator. It’s like I can’t get away with it [skipping the gym].’’

Participants found it especially helpful when family

members and friends reinforced the idea that exercise

would make them feel good. One participant described how

her parents helped motivate her to get to the gym: ‘‘They’ll

tell me, ‘You need to go to the gym. Think how good you’ll

feel afterwards’.’’

Practical Support

Practical support included tangible assistance that facili-

tated participants’ dietary changes or engagement in

physical activity. For example, several participants

received help with transportation to a fitness facility or

recreational area. Assistance with transportation appeared

to combine practical and emotional support for some par-

ticipants. One participant explained that getting a ride from

a loved one provided the motivation needed to go to the

gym: ‘‘My husband drives me there [to the gym] even

when I don’t want to be there. I can walk. It’s not that far

from my house to the gym, but it’s just that some days I

don’t want to leave the house and he’ll say, ‘Get your shoes

on,’ and ‘We’re leaving.’ It’s just that little push. And then

when I get there, I’m okay, but it’s just getting from the

house to where I’m going.’’

Practical support for dietary changes included willing-

ness on the part of others to make compromises and set

limitations on dining out. One participant commented that

her friends were willing to meet her for dinner at restau-

rants that offered low-calorie menus that would not sabo-

tage her diet. Several participants found it useful when a

family member or significant other reviewed their food

intake or helped them with food portion size.

Mutual Support

Mutual support occurred when participants and their family

members or significant others supported each other’s

efforts to make lifestyle changes. Participants remarked

that it was easier to stick to dietary or exercise goals when

they had friends or family members with similar health

goals. One participant remarked: ‘‘My girlfriend is in the

program [In SHAPE] with me. Actually, I found out about

the program through her. She told me about it and I was

interested. So, we sort of help and support each other. We

try to push each other, like maybe I don’t really want to go

Community Ment Health J (2013) 49:207–212 209

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to the gym but she is going so she’ll say, ‘Why don’t you

come along,’ and I eventually do go, and I feel better

afterwards. And I’ve said, ‘Why don’t you come with

me?,’ just so she’ll go more consistently. So we’ve helped

each other.’’ These factors appeared to facilitate success in

the In SHAPE program as participants in the high achiever

focus groups reported more instances of mutual support for

health behavior change.

Social Barriers

Unhealthy Social Environment

Unhealthy social environments included repeated exposure

to the poor eating habits and sedentary lifestyles of family

members and significant others. Many participants felt that

they were set up for failure when time with family and

friends involved exposure to ‘‘junk food’’ high in calories,

fat, and sugar and low in nutritional content. One partici-

pant explained that as a caregiver to her mother, she does

her grocery shopping, which includes buying junk food. As

a reward for shopping, her mother offers to share the food

even though it undermines her goal of improving her diet:

‘‘I do a lot of her shopping, so I actually have to go buy

crap, all the sweet stuff and junk. And then it’s really hard

not to share that with her when I get back, and not eat it and

want it. I go to her house and put everything away and give

her bag of treats, and she starts opening and putting it

away. ‘Want one?’ Stop asking me if I want one, I’ll

always say ‘yes’!’’

Many participants reported that they were challenged by

temptations at social gatherings, and some described giving

into the pressure from family and friends to engage in poor

health behaviors like overeating and drinking. One partic-

ipant described how her family members piled the food on

her plate and encouraged her to drink during holiday meals:

‘‘One plate isn’t going to hurt you,’’ but the plate is like this

[gestures] big, and it’s all mounded, it’s huge, and then

everyone had to have a drink, and I’m like, ‘I don’t drink

anymore,’ But one drink turns into…they have an open bar.

My father-in-law makes them pretty stiff. So, everyone is

drunk by 2 o’clock in the afternoon.

Discussion

Participants’ descriptions of social facilitators and barriers

to health behavior change were similar to those identified

in studies of people without mental illness trying to lose

weight (Falba and Sindelar 2008; Novak and Webster

2011). Participants described the advantages of reciprocal

relationships in which they gave and received support for

healthy behaviors, including the fact that engaging in

dietary changes and physical activity was easier when done

with a partner who was also committed to achieving health

goals. Mutual engagement in healthy eating and exercise

seemed to facilitate success in the In SHAPE program as

participants in the high achiever focus groups reported

more instances of mutual support for health behavior

change. Research in the general population suggests that

involving supportive partners in behavioral weight control

treatment is effective at producing both initial weight loss

and maintenance of weight loss over time (Wing and Jef-

frey 1999), and studies indicate that the strongest effects

occur when partners are themselves successful at losing

weight (Gorin et al. 2005).

The link between social environments and health

behaviors has long been recognized in the general popu-

lation (Berkman 1995), and the presence of unhealthy

social environments was noted as a prominent barrier to

health behavior change in this study. Participants often

reported that their family members and significant others

have poor eating habits and sedentary lifestyles, and

emphasized that social environments often exposed them to

junk foods that triggered overeating. Social contextual

factors, including social values and norms, have been

shown to influence nutrition practices and physical activity

in a variety of populations, including working-class, multi-

ethnic adults (Emmons et al. 2007) and college students

(Okun et al. 2003).

While the social barriers and facilitators to health

behavior change described by persons with serous mental

illness in this sample were similar to those documented in

the general population, people living with serious mental

illness face a unique set of challenges that could be

addressed in future healthy lifestyle interventions. First, the

metabolic effects of psychiatric medications make weight

loss especially challenging, even when engaged in exercise

and dietary interventions. A recent comprehensive review

failed to identify any interventions achieving a mean 5 %

weight loss (considered to be clinically significant) for

people with serious mental illness (Verhaeghe et al. 2011).

Hence, it may be especially important to educate family

members and significant others about the special challenge

for weight loss for a person on psychoactive medications so

that they may provide continued encouragement and rein-

forcement to help their loved one overcome self-doubt in

the face of setbacks and help to maximize the potential to

achieve progress.

Second, people with SMI have higher rates than the

general population of other unhealthy lifestyle behaviors

such as substance use disorders (Dixon1999) and smoking

(de Leon and Diaz 2005) that may undermine attempts to

achieve a lifestyle change in diet and exercise, requiring

additional positive social support in the natural environ-

ment where temptation may be highly prevalent. Health

210 Community Ment Health J (2013) 49:207–212

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interventionists could attempt to engage family members

and significant others as key partners who can help indi-

viduals with serious mental illness successfully cope with

social-environmental triggers for substance use and ciga-

rette smoking. This may ultimately increase the ability of

participants to achieve and maintain health goals.

Third, improving communication skills and social sup-

port may be an important component of future healthy

lifestyle interventions for some individuals. Poor commu-

nication skills and difficulty initiating and sustaining social

relationships are among the most disabling impairments

experienced by individuals with serious mental illness

(Mueser and Bellack 1998). Participants who have diffi-

culty articulating their diet and exercise goals to family

members and significant others may fail to receive the

support they need to make health behavior changes. Par-

ticipants may benefit from learning how to effectively

request support and help from family and friends. Similarly,

limited communication skills and lack of support by family

members and significant others can undermine attempts by

individuals with serious mental illness to change their

health behaviors. Improving these skills in family members

could reduce criticism and tension, and facilitate healthy

behavior change in participants working on these goals.

Family-oriented interventions for the management of

medical conditions in the general population have been

categorized into two primary types: (1) educational inter-

ventions that inform patients and family members about the

disease with the goal of increasing knowledge and self-

management; and (2) interventions that address interper-

sonal relationships, with the goal of improving family

functioning with respect to health (Hartmann et al. 2011).

Such models have yet to be adapted for families coping with

the challenges of both mental illness and physical health

problems, despite the fact that family psychoeducation is an

evidence-based practice for improving the course of serious

mental illness (McFarlane et al. 2003). For healthy lifestyle

interventions to be optimally beneficial for this population,

family members and significant others may need informa-

tion about their relative’s physical and mental health

problems and health promotion techniques.

Potential limitations of this study include the relatively

small sample size and imbalance in the number of partic-

ipants in the low versus high achiever focus group inter-

views. Of the 30 participants, 10 met criteria for low

achievers and 20 were high achievers. However, the overall

sample size (n = 30) is consistent with both qualitative

methods (Miles and Huberman 1994) and the intent and

scope of a pilot study aimed at determining feasibility and

achieving preliminary descriptive findings (Leon et al.

2011). At the outset, we identified fewer In SHAPE par-

ticipants in the low achiever group who met the study

criteria of face-to-face contact with a family member or

friend at least twice in the past month. Recruitment

methods were the same for both the low and high achiever

groups; yet the lower representation in the low achieving

group may be reflective of fewer contacts with family

members and significant others in this group overall.

Despite this limitation, the focus group interview data

collected was sufficient to identify important differences in

social facilitators and barriers to health behavior change

between the high and low achiever groups.

Conclusions

Preliminary findings from this study of focus groups

comparing high and low achievers in a health promotion

intervention suggest that social environments of persons

with serious mental illness have an impact on health

behaviors, including diet and exercise. As in the general

population, family members and significant others of per-

sons with serious mental illness have the potential to

engage as key partners to maximize the potential effec-

tiveness of healthy lifestyle interventions. Researchers and

clinicians designing future healthy lifestyle interventions

for this population should consider the potential role of

family members and significant others as health supporters,

and evaluate what types of information and communication

skills would most beneficial to them in this role.

Acknowledgments The authors thank the Dartmouth Medical

School Department of Psychiatry Gary Tucker Junior Investigator

Award for funding this study. The In SHAPE study was supported by

grants R01 MH089811 and R01 MH078052 from the National

Institute of Mental Health.

References

Allison, D. B., Fontaine, K. R., Heo, M., Mentore, J. L., Cappelleri, J.

C., Chandler, L. P., et al. (1999). The distribution of body mass

index among individuals with and without schizophrenia.

Journal of Clinical Psychiatry, 60, 215–220.

Beck, A. T., Rector, N. A., Stolar, N. M., & Grant, P. M. (2009).

Schizophrenia: Cognitive theory, research, and therapy. New

York: Guilford Press.

Berkman, B. (1995). The role of social relationships in health

promotion. Pychosomatic Medicine, 57, 245–254.

Brown, S., Birtwistle, J., Roe, L., & Thompson, C. (1999). The

unhealthy lifestyle of people with schizophrenia. PsychologicalMedicine, 29, 697–701.

Cabassa, L. J., Ezell, J. M., & Lewis-Fernandez, R. (2010). Lifestyle

interventions for adults with serious mental illness: A systema-

tive literature review. Psychiatric Services, 61, 774–782.

Centers for Disease Control and Prevention. (1996). Physical activityand health: A report of the surgeon general. Retrieved from

Centers for Disease Control and Prevention website: http://

www.cdc.gov/nccdphp/sgr/index.htm.

Colton, C. W., & Manderscheid, R. W. (2006). Congruencies in

increased mortality rates, years of potential life lost, and causes

Community Ment Health J (2013) 49:207–212 211

123

Page 6: A Qualitative Study of Social Facilitators and Barriers to Health Behavior Change Among Persons with Serious Mental Illness

of death among public mental health clients in eight states.

Preventive Chronic Disease, 3, 1–14.

Daumit, G. L., Goff, D. C., Meyer, J. M., Davis, V. G., Nasrallah, H.

A., & McEvoy, J. P. (2008). Antipsychotic effects on estimated

10-year coronary heart disease risk in the CATIE schizophrenia

study. Schizophrenia Research, 105, 175–187.

de Leon, J., & Diaz, F. (2005). A meta-analysis of worldwide studies

demonstrates an association between schizophrenia and tobacco

smoking behaviors. Schizophrenia Research, 76, 135–150.

Dixon, L. (1999). Dual diagnosis of substance abuse in schizophrenia:

Prevalence and impact on outcomes. Schizophrenia Research,35, S93–S100.

Emmons, K. M., Barbeau, E. M., Gutheil, C., Stryker, J., & Stoddard,

A. M. (2007). Social influences, social context, and health

behaviors among working class, multi-ethnic adults. HealthEducation and Behavior, 34, 315–334.

Falba, T. A., & Sindelar, J. L. (2008). Spousal concordance in health

behavior change. Health Services Research, 43, 96–116.

Faulkner, G., & Biddle, S. (1999). Exercise as an adjunct treatment

for schizophrenia: A review of the literature. Journal of MentalHealth, 8, 441–457.

Fraser, S. N., & Spink, K. S. (2002). Examining the role of social

support and group cohesion in exercise compliance. Journal ofBehavioral Medicine, 25, 233–249.

Gorin, A., Phelan, S., Tate, D., Sherwood, N., Jeffery, R., & Wing, R.

(2005). Involving support partners in obesity treatment. Journalof Consulting and Clinical Psychology, 73, 341–343.

Hartmann, M., Bazner, E., Wild, B., Eisler, I., & Herzog, W. (2011).

Effects of interventions involving the family in the treatment of

adult patients with chronic diseases: A meta-analysis. Psycho-therapy and Psychosomatics, 79, 136–148.

Hutchinson, D. S. (2005). Structured exercise for persons with serious

psychiatric disabilities. Psychiatric Services, 56, 353–354.

Jones, D. R., Macias, C., Barreira, P. J., Fisher, W. H., Hargreaves,

W. A., & Harding, C. M. (2004). Prevalence, severity, and co-

occurrence of chronic physical health problems of persons with

serious mental illness. Psychiatric Services, 55, 1250–1257.

Kahn, E. B., Ramsey, L. T., & Brownson, R. C. (2002). The

effectiveness of interventions to increase physical activity.

American Journal of Preventive Medicine, 22, 73–107.

Krueger, R. A. (1994). Focus groups (2nd ed.). Thousand Oaks: Sage

publications.

Lee, D., Artero, E. G., Sui, X., & Blair, S. (2010). Mortality trends in

the general population: The importance of cardiorespiratory

fitness. Journal of Psychopharmacology Research, 24, 27–35.

Leon, A. C., Davis, L. L., & Kraemer, H. C. (2011). The role and

interpretation of pilot studies in clinical research. Journal ofPsychiatric Research, 45, 626–629.

McFarlane, W. R., Dixon, L., Lukens, E., & Lucksted, A. (2003).

Family psychoeducation and schizophrenia: A review of the

literature. Journal of Marital and Family Therapy, 29, 223–245.

Miles, M. B., & Huberman, A. M. (1994). Qualitative data analysis(2nd ed.). Thousand Oaks, CA: Sage Publications.

Mitchell, A. J., & Malone, D. (2006). Physical health and schizo-

phrenia [review]. Current Opinion in Psychiatry, 19, 432–437.

Mueser, K. T., & Bellack, A. S. (1998). Social skills and social

functioning. In K. T. Mueser (Ed.), Tarrier N (Eds) Handbook ofsocial functioning in schizophrenia (pp. 79–96). Boston, MA:

Allyn & Bacon.

Novak, S. A., & Webster, G. D. (2011). Spousal social control during

a weight loss attempt: A daily diary study. Personal Relation-ships, 18, 224–241.

Okun, M. A., Ruehlman, L., Karoly, P., Lutz, R., Fairholme, C., &

Schuab, R. (2003). Social support and social norms: Do both

contribute to predicting leisure-time exercise? American Journalof Health Behavior, 27, 493–507.

Seidman, L. J., Cassens, G. P., Kremen, W. S., & Pepple, J. R. (1992).

Neuropsychology of schizophrenia. In R. F. White (Ed.),

Clinical syndromes in adult neuropsychology: The practitioner’shandbook. New York, NY: Elsevier Science.

Stathopoulou, G., Powers, M. B., Berry, A. C., Smitts, J., & Otto, M.

W. (2006). Exercise interventions for mental health: A quanti-

tative and qualitative review. Clinical Psychology: Science andPractice, 13, 179–193.

Van Citters, A. D., Pratt, S. I., Jue, K., Williams, G., Miller, P. T.,

Xie, H., et al. (2010). A pilot evaluation of the In SHAPE

individualized health promotion intervention for adults with

mental illness. Community Mental Health Journal, 46, 540–542.

Verhaeghe, N., De Maeseneer, J., Maes, L., Van Heeringen, C., &

Annemans, L. (2011). Effectiveness and cost-effetiveness of

lifestyle interventions on physical activity and eating habits in

persons with severe mental disorders: A systematic review.

International Journal of Behavioral Nutrition and PhysicalActivity, 8, 1–12.

Whitley, R., & Crawford, M. (2005). Qualitative research in

psychiatry. Canadian Journal of Psychiatry, 50, 108–114.

Williamson, D. F., Thompson, T. J., Thun, M., Flanders, D., Pamuk,

E., & Byers, T. (2000). Intentional weight loss and mortality

among over-weight individuals with diabetes. Diabetes Care, 23,

1499–1504.

Wing, R., & Jeffrey, R. W. (1999). Benefits of recruiting participants

with friends and increasing social support for weight loss and

maintenance. Journal of Consulting and Clinical Psychology,67, 132–138.

212 Community Ment Health J (2013) 49:207–212

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