‘Nobody will put baby in the corner!’: A qualitative evaluation of a physical activity intervention to improve mental health

Physical activity is beneficial for mental health, but people with mental health issues are less likely to be physically active than the general population. Socially prescribed programmes of activity are rarely adhered to, with high levels of drop out, and the proportion of people who continue after programmes have finished is even smaller. Lasting change therefore needs a fundamental change in behaviour, so an interven tion grounded in behaviour change theory may be more likely to succeed. The aim of this original study was to understand the facilitators and barriers to participation and adherence to a supportive, personalised, physical activity programme for patients with mental health conditions. The intervention entailed a 16-week programme of activity, tailored to individual capability, supported by a dedicated ‘be haviour change’ practitioner trained in motivational interviewing. Fourteen people who had completed the intervention were interviewed in three focus groups in 2018. Data were transcribed verbatim then analysed for barriers and facilitators using Framework Analysis and

There is encouraging evidence to suggest that people with low mood can be motivated to exercise if given appropriate support (Peddie, Snowden, & Westbury, 2019), but the relationship between motivation, exercise and mental ill-health is not clear (Bond et al., 2020), and this is important to understand because people with long-term mental health conditions such as depression can have a reduced life expectancy of 7-11 years (Chang et al., 2011). As much of this mortality is linked to cardiovascular issues, there is clearly a place for PA to reverse some of this harm.
Current guidelines suggest that adults should participate in 150 min of moderate to vigorous physical activity a week (Foster, 2019). Large numbers of adults do not meet these recommendations (Scottish Government, 2018). Exercise referral schemes aim to increase physical activity among people who are inactive or sedentary and/or have an existing health condition or other risk factors for disease; however, the evidence suggests that adherence to these types of programmes is low, with the most optimistic measures ranging from 20% to 49% in an adult population (Gidlow, Johnston, Crone, & James, 2005;James et al., 2008;Pavey et al., 2012). In mental health populations, research suggests that they are even less likely to adhere to prescribed PA than the general population Vancampfort et al., 2017). This lack of adherence to PA interventions is a significant issue, because the majority do not stay long enough to see the health benefits of being active. Allen and Morey (2010) suggested that effective PA interventions should incorporate multiple components and include cognitive behavioural strategies, such as goal setting and self-monitoring of behaviour. This is consistent with studies showing the benefit of including tailored cognitive behavioural techniques alongside PA interventions for mental health populations (Knapen, Vancampfort, Moriën, & Marchal, 2015;Rastad, Martin, & Åsenlöf, 2014;Vancampfort et al., 2017). Furthermore, it makes sense to infer that professional, personalised guidance combined with ongoing support could facilitate long-term behaviour change. Personalisation is a necessary component. Ussher, Stanbury, Cheeseman, and Faulkner (2007) showed that PA interventions designed for individuals with mental health conditions need to be individually tailored to the individual's preferences to improve adherence and produce better outcomes.
Recognising the benefits of PA to both physical and mental health, and the issue of attrition to exercise referral schemes, the

What is known about this topic
• People with enduring mental health issues die considerably younger than people without • Much of this morbidity could be addressed by improvements in physical health • Improving physical health in this population is even more difficult than it is in a general population, but is likely to involve reframing the way physical activity is conceived.

What this paper adds
• Supporting people with mental health conditions to engage in physical activity can help them to change the way they think and feel about physical activity.
• Facilitators of change entail a reframing of previous barriers.
• Reframing is best achieved with peer support and individualised programmes tailored by 'behaviour change' practitioners Scottish Association of Mental Health (SAMH) developed the intervention 'Active Living Becomes Achievable' (ALBA). ALBA aimed to improve adherence to PA in individuals with mental health conditions by delivering a behaviour change intervention using a personally tailored cognitive behavioural approach alongside existing exercise referral schemes. ALBA is based on the capability, opportunity and motivation (COM-B) model of behaviour change (Michie, van Stralen, & West, 2011), aiming to equip participants with skills, knowledge and confidence that will help them feel they are able to participate in physical activity on a regular basis.
The ALBA project was funded by the Scottish Government in 2016. Evaluation was a fundamental part of the agreement, so that any learning from the programme could be articulated and transferred in a systematic manner. A significant part of that evaluation was to understand 'what it is like' to receive the intervention (Cheng & Metcalfe, 2018). Understanding this can help improve subsequent delivery of the intervention and better understand possible contextual factors which influence the implementation (Bauman & Nutbeam, 2013).

| AIM/RE S E ARCH QUE S TION
The study aimed to explore participant's experience of taking part in the ALBA intervention, and to identify the barriers and facilitators to participation.

| Analytic plan
The analytic plan consisted of a theoretical model of behaviour change linked to a set of domains the intervention was designed to impact on. The model of behaviour change was the COM-B model (Michie et al., 2011). The domains were articulated by the theoretical domains framework (TDF; Atkins et al., 2017). For a detailed discussion on the links between COM-B and TDF, please see Richardson, Khouja, Sutcliffe, and Thomas (2019). In brief, the TDF is an integrated framework of behaviour change theories that has been used widely in implementation research (Atkins et al., 2017). It consists of 14 domains (Cane, O'Connor, & Michie, 2012)

| Intervention
The ALBA intervention was a multicomponent intervention based on the COM-B model, designed to equip participants with skills, knowledge and confidence to help them feel able to participate in physical activity on a regular basis. It consisted of the following: 1. Weekly or fortnightly 1:1 hourly meeting with a behaviour change practitioner (BCP) over the course of 16 weeks; 2. Access to the exercise referral programme that was offered by the local leisure centre; 3. An activity tracker and the 'Get Active' app which was designed to increase motivation and facilitate self-monitoring of behaviour; and 4. Access to peer supporters, who have been through the ALBA intervention and peer supporter training. Their role was to offer support outside of the sessions with the BCPs.
In the 1:1 sessions, the BCPs used motivational interviewing techniques alongside the 'Living Life to the Full' materials (Williams, 2015) to help elicit behaviour change by supporting participants to set goals designed to identify and overcome barriers which prevent them from engaging in physical activity. BCPs were workers in the local gymnasiums. To prepare for the role of deliv-

| Setting
The intervention was delivered in three regions in Scotland: Fife, West Lothian and North Ayrshire, and was offered through all local authority leisure trusts in these areas. All three regions were composed of a mixture of both urban and rural areas. Fife is a socioeconomically diverse with 19.84% of the data zones according to the SIMD in the 20% most deprived. West Lothian has 15.48% of the data zones in the 20% most deprived. North Ayrshire is the third most deprived local authority in Scotland (Scottish Government, 2020), with 39.78% of the data zones in the 20% most deprived.

| Data collection: participants, information and consent
Participants: All participants of the focus groups were individuals who had either completed the ALBA intervention or were currently taking part in the intervention.
Inclusion criteria: People aged over 18 who were inactive and have been referred either by their GP or health professional into an exercise referral scheme due to a mild to moderate mental health condition. Recruitment: Participants were recruited by the BCP who had supported them throughout the intervention.
Consent: At least one week before the focus group, all participants were provided with an information sheet to take home with them, which informed them of the purpose of the focus group and how any data would be used. Informed consent was obtained from all participants on the day of the focus group, prior to the discussion beginning. Participants were also asked to complete a demographics questionnaire.

| Data collection: process
Focus groups are a type of group interview which uses the communication between participants to generate data (Kitzinger, 1995).
Focus groups work best when there is group cohesion, formed through sharing similar cultural backgrounds and social status for example (Acocella, 2012). In this case, all participants would have shared experience of ALBA.
Three focus groups were run, one in each of the three areas where ALBA was in operation. All participants took part in only one of the focus groups. Participation was voluntary, and any costs in-   Michie et al. (2011) 11, cross-checked against the audio recordings for accuracy and de-identified.

| ANALYSIS
Framework Analysis (Ritchie & Spencer, 1994) was used to analyse the data. This process broadly followed the principles described by Richardson et al. (2019). The Theoretical Domains Framework was used as the 'framework' against which thematic analysis was carried out (Srivastava & Thomson, 2009). Data were coded and sorted in accordance with the preconstructed themes of the TDF.
In more detail, following anonymisation of the transcripts, a familiarisation process was carried out (Srivastava & Thomson, 2009

| RE SULTS
A total of 28 (20% of total population) participants were invited to take part in the focus groups and 14 (50%) participated (11 females and 3 males; mean age 46.6; 85% White British). Reasons given for not wishing to attend included anxiety about the group setting, difficulty travelling to the focus group location, work and childcare commitments.
Twenty-five overarching themes were identified, which mapped onto 11 of the 14 domains from the TDF. Ten of the themes were

| Learning something new
Participants spoke about learning something new as being positive.
As becoming active was new to a lot of the participants, they particularly valued the support they received from leisure trust staff,

| Confidence
Participants discussed the effect that taking part in ALBA had on their beliefs about their capabilities, reporting that they had a new sense of confidence in themselves, and their abilities, which had encouraged them to engage and stay with the intervention. A recurring theme was the importance of 'pacing yourself', with participants frequently talking about the importance of going at their own pace, and how breaking down goals made them more achievable.
Participants reported that they felt they had learnt to be kinder to themselves after taking part in ALBA. They felt the intervention had equipped them with the life skills to escape what they called the 'vicious cycle', and how they felt they were more capable of recognising this and as a consequence help themselves overcome any mental health challenges that they may face in the future.

| Don't feel alone
ALBA helped to foster a sense of community, as participants reported that it helped them to feel less alone. They were more able to talk about their mental health and as result they found that others were open about their own mental health. The intervention also helped to foster a sense of optimism for the future, as well as helping participants to feel proud of themselves. Measurement of progress was important, as participants felt that through participating in ALBA, they could see how far they had come. Importantly, the ALBA intervention had helped them to change the way they thought of PA, with some participants reporting that they did not think of themselves as being an active person, but through ALBA they realised that being active did not just mean participating in sport or being 'fit', but encompassed all aspects of activity.

| Sense of purpose
Participants reported that ALBA had given them a new sense of purpose, as they felt attending intervention appointments and engaging in PA helped to give them some structure in their lives. Participants spoke about how the appointments with BCP helped them to feel motivated to get out the house. They now felt like they made more effort to be active and that they thought about their activity more than they ever had before.

| Lifestyle change
A common theme throughout the group discussions was change, with participants describing changes in thinking and how taking part in ALBA had a positive wider impact on other aspects of their life and their behaviour. For example, some felt that taking part in ALBA had helped them better manage their anger and had helped them to improve relationships with people around them. Participants frequently discussed how the intervention had encouraged them to set goals, and the positive benefit that this had on their mental well-being. For the most part, goal setting was discussed as a positive, that made them feel like they had something they were working to achieve, be it a step goal or taking up a new hobby. Participants also discussed how becoming engaged with the intervention had made them feel more socially connected.

| Support from BCP
The participants all put a lot of emphasis on the importance of the interpersonal factors, particularly the 1:1 behaviour change sessions. the skills needed to make the most of each individual's abilities will be returned to.

| Technology
The discussion about the activity trackers suggested that the participants found them motivating, as they could see when they were achieving their goal. Participants reported that they enjoyed using them, as they enjoyed seeing high step counts, and found it encouraging when they saw they how much activity they had done just going about their day. They also reported that the use of the trackers helped them to monitor their mood as well as their behaviour, as they could look back on how far they had come.
In this reflective mode, they expressed relief that they felt they had found something that was helping to improve their mental well-being. Some spoke about how they felt they had got their life back, wishing they had been able to do something like ALBA sooner, as they realised that the intervention had changed the 'vi- yourself out, and it was like digging with a teaspoon to begin with, but then you kinda moved up to a shovel, cause you can see the light now, which just makes an awful difference! It's like 'nobody will keep me down.
Nobody will put baby in the corner!' -P13

| Stigma
Participants spoke at length about the stigma they felt existed around mental health issues which had prevented them speaking about their mental health before. Some felt that there was a lack of awareness at the Leisure Centres about mental health, which put them off attending. Some talked of having an invisible illness. They perceived their mental ill-health as not being recognised, and as a result they felt they struggled to get access to support and services that they needed, including benefits in some cases.

| Beliefs about self
Negative self-beliefs were frequently discussed as being barriers for both engaging with the intervention and in PA in general. Participants spoke about how low mood and negative thoughts about themselves had made them feel so uncomfortable in themselves that they did not want to engage with others. Participants also spoke a lot about a sense of guilt they felt for putting themselves first and how this had stopped them from acting or seeking help in the past.

| Trust
A recurring theme was the issue of trust, with the majority reporting that they were apprehensive about putting their trust in the BCPs.
This acted as a barrier to participating in the intervention, as par- previous bad experiences. They were also sceptical about how becoming more active would improve their mental health. They found aspects of the intervention challenging, and at times they found that they had set goals that were too difficult to achieve. If they set a goal that was unattainable at the time, then this had a negative effect on how they felt about themselves. Occasionally they found that the intervention material made them face issues and feelings that they did not feel they were prepared to face.

| Access
Participants reported several barriers that had prevented them from accessing the ALBA intervention. Some said that they had not heard about the intervention before. Issues around access included the settings in which the intervention was delivered. The intervention was initially planned to be implemented within the local leisure centres, intended in part to help participants become familiar with the centres. However, in practice, this was not always appropriate as there were often limited availability of private rooms and public spaces were not always suitable.

| Intervention resources
Participants also commented on the evaluation process. Particularly at their first appointment, nearly all felt that filling in the questionnaires required for the baseline measurement was very overwhelming and they found them very challenging, as it required both concentration and to think about how their mental health had been.

| Social influence
Finally, some participants explained that they had complicated relationships with family and friends, making them hesitant to share that they were participating in the ALBA intervention, as they were concerned about judgement or lack of support. For some these difficult relationships were a source of anxiety or depression. Feelings of fear were a common barrier to PA discussed during the groups, with many agreeing that prior to taking part in the intervention they felt scared of going to the gym and exercising. They feared others would laugh or stare at them for going to the gym. Participants also described a 'fear of failure', concern about starting an activity and not being able to keep it up. Participants in the past had made 'excuses' so that they did not have to do the activity.

| D ISCUSS I ON
On the whole, the facilitators outweighed the barriers, and most of the barriers consisted of reflections on life before ALBA. These barriers did not apply following the intervention. For example, participants discussed not wanting to go out of the house prior to ALBA, but not afterwards. Likewise, they would never have been seen in a gym before, but spoke of being more comfortable in the present. It is important to recognise that these barriers need to be overcome, but the clear message is that engaging with ALBA had helped them do so.
In relation to the theoretical domains framework, it would appear that individual beliefs about personal capabilities were both a barrier and a facilitator to participating in ALBA, as were beliefs about consequences, social influences, goals, environmental context and resources. This is consistent with Glowacki et al. (2017) who found the most common barriers to PA in people with depression were also the most common facilitators: capability, context, consequences. What changed was the nature of the belief. As participants achieved their personal goals they felt more capable, and so their beliefs about the other factors associated with activity shifted too (Festinger, 1957). In other words, the theoretical domains should be considered as lying on a continuum. None are inherently positive or negative. They are instead a useful method of understanding and communicating how a particular intervention might work or not depending on its likelihood to invoke personal change; moving from the negative to the positive. which suggested that the relationship between the participants and the BCP influenced engagement with ALBA. It appears to be one of the biggest strengths of the ALBA intervention. It is well known that enjoyment, mastery of skills/goals, autonomous motivation, choice, social interaction and a sense of belonging all contribute positively to engagement with physical activity (Teychenne et al., 2020), and these are all elements of ALBA, but the role of individual BCP was singled out as a major factor in adherence. It has been argued in psychotherapy literature that the therapeutic alliance which develops between practitioner and client is more important than any specific technique or approach (Horvath, Del Re, Flückiger, & Symonds, 2011), with evidence suggesting that the quality of the alliance is a consistent predictor of treatment success. Stronger alliances improve trust and hence cooperation. Participants are unlikely to agree to therapeutic tasks or enact health actions without it (Wampold & Imel, 2015), although the role and function of social interaction during exercise is less clear (Kandola, Ashdown-Franks, Hendrikse, Sabiston, & Stubbs, 2019).

| Therapeutic relationship
Another important element was the warmth and empathy conveyed by the BCP, which helped the participants to feel comfortable opening up about their mental health. Expressing empathy is an integral part of most psychotherapies. According to Rogers (1975), underlying the principle of empathy is acceptance, and an understanding of the client's emotions. Wampold and Imel (2015) found that rating of therapist's empathy is often correlated with a positive outcome. Participants from the focus group valued having somebody who listened to them without judgement. This 'unconditional positive regard' is a well-known Rogerian principle (Amadi, 2013).
Helping people to be able to talk about what is on their mind, whatever that may be, is a central tenet of expert spiritual care (Snowden et al., 2018), so the importance of an empathic BCP should not be underestimated here.
In ALBA, this helpful therapeutic environment had a positive impact on other aspects of the framework, for example, making exercise more enjoyable. It is well known that where exercise is enjoyable and achievable, it is much more likely to be autonomously sustained (White et al., 2018). Participants discussed how meeting with the BCP helped to provide structure and routine in their lives, which helped to give them a sense of purpose. This 'virtuous circle' of positive reinforcement (Stanislaus, 2016) is the opposite of the 'vicious circle', where low self-esteem reinforces negative beliefs about poor performance that reinforce low self-esteem and so on (Baron & Kenny, 1986;Steca et al., 2017;Wäschle, Allgaier, Lachner, Fink, & Nückles, 2014). Positive beliefs about capabilities increased self-efficacy, which facilitated engagement in ALBA, making PA enjoyable and so on.
Such findings have been explained in the exercise literature by Self-Determination Theory (SDT; Deci & Ryan, 1985). For example, White et al. (2018) used the theory to explain the improvement in well-being seen in the adolescents with mental health issues in their study. Akin to the virtuous circle (Steca et al., 2017), SDT proposes that steady increases in self-efficacy and self-esteem can be achieved through achieving self-directed goals. The simple state of enjoyment should never be undervalued as part of this process (Lambert et al., 2018). As highlighted by Glowacki et al. (2017), emotion is a particularly important domain within mental health populations, but is often neglected in the literature. Previous research into adherence to PA has often found enjoyment to be a key determinant (Malik, Williams, Weston, & Barker, 2018;Raedeke, 2007), whereas 'low mood' or fatigue are frequently found to be barriers to PA, particularly in individuals with poor mental health (Firth et al., 2016). ALBA worked because participants were valued, listened to and encouraged to see active living not only as achievable but also enjoyable (Teychenne et al., 2020).

| Limitations
Participation in the focus groups was low. A frequently cited reason for not wishing to take part in the focus groups was due to anxiety about the group setting. Participants in qualitative research often feel uncertainty or anxiety about participating, but often decide to take part for the sake of others who would benefit from the research (Dennis, 2014). It is understandable that the idea of the group setting was off putting to some in this particular study, and individual interviews could have been offered to participants who wished to share their experience but were uncomfortable attending a focus group.
Another limitation of this study was the potential for bias. The participants who attended the focus groups were individuals who had completed the intervention or were still actively taking part. The focus group discussions reflected a mostly positive view of the ALBA intervention as the individuals who had participated had actively engaged with the intervention and had been able to overcome their barriers. An additional limitation was that the focus groups were only conducted at one time point, so can only represent a snapshot of a single time point. With greater resources, the groups would have been returned to.
Possibly the most serious limitation was theoretical. To obtain funding, evaluation methods had to be articulated earlier on in the research process that would otherwise be the case. As a consequence, the theoretical underpinning was 'fixed' from the start and could therefore be seen as a form of conceptual bias. Having said this, the TDF model proved very useful in explaining the findings here. It was also good for checking for any data falling outside the model.

| CON CLUS ION
This original intervention has succeeded in an area where many others have tried and failed. Helping people to change the way they think about activity has been a difficult problem, and so any intervention that appears to have achieved this is worthy of attention. While it is certainly true that the intervention required a lot of investment, particularly in training the trainers, ALBA nevertheless succeeded in changing the way these participants with mental health problems thought about physical activity. By reframing it as not just physically beneficial but personally achievable, participants' attitudes and behaviour changed as well, making it more likely they would sustain physical activity in future. While it is clear that larger multicentre studies would help formalise the intervention further, there is sufficient information in this paper for local community teams to get together with mental health service users to consider adopting and evaluating their own versions of structured support to make active living become achievable for all.

E TH I C A L A PPROVA L
Ethical approval for this project was granted by the NRES Committee