“Well-Track” Healthy Lifestyle Coaching in Severe Mental Illness: A Qualitative Study Exploring Participant Experience and Impact

Alice Sheldon, Chris Griffiths^*, Ema Baukaite, Kate Walker

Research and Innovation, Northamptonshire Healthcare NHS Foundation Trust (NHFT), Berrywood Hospital, Northampton, UK.

DOI: 10.4236/ojpm.2025.155006                

Abstract

Background: Unhealthy lifestyle behaviours contribute to the poor physical health experienced by people with severe mental illness (SMI). Severe mental illness symptoms and the medications used in treatment make adopting a healthy lifestyle challenging. Intervention: Well-Track uses a wearable activity tracker and three sessions with a health coach to promote healthy lifestyle behaviour change. The tracker allows physical activity, sleep and calorie expenditure to be monitored. The coach provides personalised support and accountability through motivational interviewing, goal-setting, healthy lifestyle advice and feedback. Participants: Fifteen participants under the care of a community mental health team (CMHT) were interviewed following their completion of the intervention. They comprised 7 females, 7 males and 1 non-binary, with an age range of 21 to 62 years. Methods: Individual in-depth one-to-one interviews were conducted. The qualitative data collected were analysed using thematic analysis. Results: Participants benefitted from the combination of the activity tracker and health coaching. By setting personalised goals, monitored by the tracker and supported by the health coach, individuals increased physical activity and improved their sleep hygiene and eating habits. Participants described enhanced physical fitness and healthy weight management alongside improvements in mood, self-confidence, positive self-identity and reduced social isolation. Conclusion: Well-Track can enable healthy lifestyle changes to improve the physical and mental health and well-being of people with SMI.

Keywords

Activity Tracker, Healthy Lifestyle, Health Coaching, Severe Mental Illness, Schizophrenia, Diet, Nutrition, Sleep, Exercise, Physical Activity

1. Introduction

Physical health discrepancy between individuals with Severe mental illness (SMI) and the general population is a cause for public health and ethical concern [1]. In those with SMI, increased incidence of concurrent health conditions, such as cardiovascular disease, type 2 diabetes, obesity and metabolic disturbances, is reported [2]-[4] and a reduced life expectancy of 10 - 20 years has been identified [5] [6]. Furthermore, physical disorders have been cited as the cause of up to 70% of premature deaths for people diagnosed with schizophrenia [7]. Reasons for the discrepancy in physical health between people with SMI and the general population are multifactorial and interconnected [8]-[10]. Lifestyle factors, namely physical activity, diet, dental care, sleep, smoking and misuse of drugs and alcohol are commonly cited explanations [9]-[11]. Reduced physical activity and increased sedentary behaviour are widely reported in individuals with SMI [12]-[14]. Dietary intake in this population is higher in saturated fat and sugar, lower in fibre, fruits and vegetables and there is an increased tendency towards daily eating of highly processed “fast foods” compared to the general population [15]-[20].

The combination of physical inactivity and poor diet contributes to increased obesity rates and metabolic abnormalities [16] [21]. Physical health is also impaired by the low nutritional quality of food consumed, increasing the risk of micronutrient deficiencies [22]. Furthermore, SMI symptoms can increase unhealthy behaviours, such as night eating and snacking, and are associated with higher incidences of eating disorders [18] [23]-[26]. Increased consumption of high sugar foods and drinks combined with poor oral hygiene seen in SMI individuals (due to low motivation, anxiety and cost barriers to dental services) presents a further physical health risk through the association between oral disease and cardiovascular disease [10] [25] [27].

Important interconnections between sleep quality and physical and mental health exist [11] [28] [29]. Disordered sleep is frequently reported by those with SMIs [30]. Sleep duration of less than six hours per night has been identified as a risk factor for metabolic syndrome [31] and sleep disorders may present an increased risk of obesity [32]. Poor subjective sleep quality in individuals with schizophrenia has been associated with lower physical health [33]. Sleep problems are associated with increased suicidal ideation [11], impair social relationships and reduce the ability to engage in positive health and wellbeing behaviours [33]-[35].

Smoking rates in people with schizophrenia have been reported to be between two and a half to six times higher than the general population [36] [37]. The use of illicit injectable drugs has been recorded as eight times higher, and 32% of men and 50% of women with SMI reported misusing alcohol [38] [39].

Understanding why there is an increased prevalence of unhealthy lifestyle behaviours is key to addressing the physical health discrepancy experienced by individuals with SMI. Symptoms of mental illness such as suspiciousness, hallucinations, stress, depression, negative self-belief and social withdrawal are barriers to healthy behaviours [25] [40]-[44]. Anxiety and low confidence may be especially relevant in preventing young people (16 - 25 years) with SMI from taking part in sport [45]. Disrupted sleep patterns may accentuate the problem by reducing energy and motivation [35] [44].

Cognition is a factor that may impact prevalence of unhealthy lifestyle behaviours. Altered cognition in SMI may reduce individuals’ ability to learn, plan and maintain new healthy behaviours [25] [46] [47] and dysfunctional reward mechanisms may hinder healthy eating habits [21] [48]. Poor cognitive performance may be associated with increased waist circumference and cardiovascular risk scores leading to the suggestion that cognitive deficits impair understanding of the importance of health check-ups and healthy lifestyle behaviours [49].

Practical barriers to healthy lifestyle behaviours have been identified and these include difficulties around the cost of transport, activities, food and cooking equipment [40] [43] [50]. SMI is associated with low socioeconomic status reducing access to healthy food, opportunities for physical activity, and safe exercise spaces [16] [51]. Lack of support in overcoming these barriers, combined with feelings of stigma associated with mental illness, contribute to the complexity of the problem, reducing the likelihood of those with SMI to participate in mainstream physical activities, adopt a healthy diet and seek appropriate medical help [52]-[55].

Medications used to treat SMI add further complication. In addition to directly inducing cardiovascular and metabolic disturbances and weight gain [56]-[59], antipsychotics can disrupt appetite, cause feelings of drowsiness and amotivation, and induce extrapyramidal symptoms (such as incontrollable movements and tremors) which collectively hamper healthy lifestyle behaviours [21] [41] [52] [60]-[62]. However, medication may not always be a barrier and has been reported as helpful for promoting physical activity through making individuals with schizophrenia feel better in themselves [44].

Interventions to improve lifestyle behaviours have the potential to enhance physical health [63] [64]. For such interventions to be effective in the SMI population, dedicated care and planning is essential given the complexity of challenges faced by these individuals [2] [9] [40] [46] [65]-[68]. Further, lack of time, resources and support can make implementing healthy lifestyle interventions into healthcare systems difficult [68]-[74].

Healthy lifestyle interventions for people with SMI have demonstrated varied successes and systematic reviews highlight weak evidence, a lack of randomised control trials and risk of bias [66] [75] [76]. Positive outcomes for physical health parameters such as reduced BMI, body weight and waist circumference [2] [46] [53] [77] [78] and healthy lifestyle changes such as improved eating habits and increased physical activity are reported [79]-[83]. In addition, there is evidence of positive ripple effects for mental health with reduced depression, anxiety and social isolation and increased sense of achievement, motivation, confidence and adherence to treatment [43] [82] [84]-[87]. However, various group-based interventions have seen no significant weight loss or changes relating to physical activity, diet or substance abuse [86] [88]-[91].

Programmes involving outdoor activities, peer support, non-stigmatising environments, flexible schedules and individualised approaches with collaborative participant-coach relationships have been found to improve engagement in SMI healthy lifestyle interventions [43] [69] [92] [93]. Those that start soon after initial SMI diagnosis and initiation of antipsychotic medications may benefit the most [87] [94]-[96].

As the importance of self-management skills and personalised, holistic approaches are increasingly recognised, health coaches may play a key role in the successful delivery of SMI lifestyle interventions [35] [44] [45] [97]-[99]. Health coaching has been defined as “a goal-orientated, client centred partnership that is health-focused and occurs through a process of client enlightenment and empowerment” [73]. SMI individuals may benefit from this framework, where they are encouraged to make their own goals appropriate for their current health status and cognitive functioning, and are provided with professional, non-judgemental support to achieve them [80] [100] [101].

The use of technology, such as telecoaching and wearable fitness tracker devices, may also enhance lifestyle interventions. Success in the general population has shown improved sleep duration and quality with software application supported online coaching [102] and a telenutrition programme was found to be effective for weight management [103] [104]. Controlled trials using a “Fitbit” wearable activity and sleep tracker device have increased physical activity in the general population [105] and in patients with type 2 diabetes [106]. With the increasing accessibility of mobile technology and trackers this approach offers an opportunity to provide scalable, individualised health interventions to those with SMI [52] [107]-[109] and “Fitbit” have been shown to offer a simple way of monitoring and promoting physical activity and weight loss [109]. Evidence from the general population suggests that combining these technologies with face-to-face health coaching (through increased personalisation) can further enhance an intervention’s impact and sustainability of behaviour changes made [103].

Similar benefits for weight management in individuals with SMI and obesity have been found when wearable trackers were combined with a fitness trainer and lifestyle coaching from peers [65] [110]. The Well-Track intervention combines an activity tracker with three health coaching sessions over eight weeks [111]. Well-Track participants with psychosis described Well-Track as helpful for increasing awareness and motivation around exercise and positively influencing behaviours around sleep hygiene and physical activity [111]. Improvements in mood, self-management, motivation, confidence and social engagement were also recorded following Well-Track [112]. Further evidence suggests that Well-Track can improve general well-being and reduce insomnia in SMI individuals [113].

The aim of this paper is to further assess the usefulness of the Well-Track intervention for those with SMI through qualitative assessment of participant experience. The impact on physical activity, sleep and weight management is investigated. Further, the paper seeks to understand potential benefits of Well-Track for physical, mental and emotional health, and the role of health coaching in supporting behaviour change in SMI.

2. Methods

2.1. Design

A qualitative approach was taken, employing semi-structured interviews.

2.2. Methodology

The interview data were analysed using reflexive thematic analysis (TA), as described by Braun and Clarke [114] [115]. This approach involves a flexible and recursive process of identifying, analysing, and interpreting patterns of meaning (themes) within qualitative data. It emphasises the researcher’s active role in developing themes, allowing for a deep and nuanced understanding of participants’ experiences and perspectives. Both inductive (data-driven) and deductive (theory-informed) approaches were utilised [116], ensuring a comprehensive exploration of participants’ experiences. Themes were developed at both the semantic (explicit) and latent (underlying meaning) levels, allowing for a rich and multilayered interpretation of the data. The study is grounded in a constructionist epistemology, recognising that meaning is socially and individually constructed through participants’ lived experiences [116]. This stance views the researchers as active interpreters of the data, acknowledging that meaning making is shaped by participants’ personal and social contexts, as well as the researchers’ interpretative role [117].

2.3. Intervention

The intervention is an eight-week programme offered to individuals under the care of the United Kingdom’s (UKs) National Health Service (NHS) Community Mental Health Teams (CMHT). The intervention comprised:

• A motivational interview session

• A goal-setting workbook

• A free activity tracker for participants to keep: Fitbit Charge 5

• Sleep hygiene, diet, and physical activity information

• Two follow-up support sessions with a health coach.

2.4. Procedure

The interviews were conducted over the phone. To minimise potential bias in data collection and analysis, the interviewer was independent of the intervention programme. Semi-structured interviews were designed with questions aimed to capture participants’ experiences of Well-Track. The topics covered included: activity tracker usage, physical activity and exercise, sleep and feedback.

The interviews were audio recorded and then transcribed verbatim.

2.5. Ethical Approval

Ethical approval was granted by the NHS healthcare trust in which the services were based (Reference: IFWT3). The study adhered to the Declaration of Helsinki.

2.6. Recruitment of Participants

Adults aged 18 or older under a CMHT with the mental capacity to provide informed verbal consent and the ability to understand spoken English, were eligible for participation. Informed verbal consent was obtained prior to each interview. Of the 28 individuals initially contacted, 13 did not participate: these 13 individuals either did not respond to phone calls or declined participation.

2.7. Data Analysis Process

The researcher familiarised themselves with the data by reading each interview transcript multiple times, immersing themself in the participants’ narratives, noting key insights, recurring topics and subjective experiences. They then initiated the coding process by systematically identifying and labelling significant data segments using manual qualitative coding. Subsequently, a second round of coding was conducted independently by a second analyst. Once the initial coding was completed both analysts began grouping codes into potential themes, codes were grouped into themes by their similarity and connections. During this stage, both analysts developed their own sets of themes based on the coded data. These were later reviewed and refined through discussions with input from a third analyst, discrepancies between the two coders were resolved between the two coders, or if this could not be achieved, by the third analyst.

The iterative review process ensured that the final themes were well-supported and reflective of the data. Trustworthiness of the analysis was ensured through triangulation, peer debriefing, and maintaining an audit trail to document coding decisions and thematic development [118]. Themes were combined, reworded, and refined, ensuring a more integrated and cohesive framework. The final themes were defined collaboratively, with clear descriptions and scopes, incorporating direct quotes from participants to illustrate key insights.

3. Results

The 15 participants comprised seven females, seven males, and one individual identifying as non-binary. The mean age was 42.93 years (SD = 14.72), ages ranging from 21 to 62 years.

The analysis revealed three overarching themes:

(1) Fitness tracker as a driver of healthy habits

(2) Holistic support and coaching for individualised change

(3) Positive impact associated with Well-Track

These themes illustrate how the Well-Track intervention facilitated behavioural change, motivation, and overall well-being. Further detail is presented in Figure 1.

Figure 1. Thematic map.

3.1. Fitness Tracker as a Driver of Healthy Habits

Participants recognised the role of the fitness trackers in supporting engagement with physical activity, weight management, and goal-setting. It provided structured guidance, motivation, and accountability for long-term behaviour change.

(1) Motivates consistent physical activity

Physical activity metrics and visual feedback from the tracker motivated participants to maintain or improve their activity levels.

I think, the encouragement to keep active, with the fact that it gives you the badges that you have walked the length of the London Underground and then the Serengeti and things like that it kind of makes you realise that the steps, you think you have achieved that much, the more it drives you to do more (P01).

The immediate feedback from fitness trackers was important and well received by participants.

When you have ADHD, and you like instant gratification, the Fitbit gives you that because it gives you little rewards. You know, oh, you’ve hit your steps. (P01).

(2) Guidance for weight management

Fitness trackers were found to support weight management and the achievement of some weight loss goals.

I’ve been trying to lose weight for quite some time… I think the Fitbit has helped me a lot with that. I did set a weight loss goal that I did achieve. I started at 13 stone 13, and I’m now 11 stone. (P04).

I have used and monitored this so I can lose weight. (P01).

Fitness trackers heightened awareness of the need for adequate calorie intake through a healthy diet.

If I look and think, oh, actually, you’ve done more steps than you thought you did today, so why not carry it on and eat something decent? (P06).

(3) Feedback loop enabling ongoing positive behaviour change

Real-time feedback from the tracker reassured participants of their progress, fostering a sense of accomplishment and sustained motivation. Fitness trackers were incorporated into daily life, helping participants become more aware of how their behaviour changes impacted their physical health, which encouraged further positive changes.

My increased heartbeat and as I lost weight it was going down, so that was good… Just use it as a tool for helping with your day-to-day living, really, and monitoring your sleep. (P03).

Participants mentioned how feedback encouraged more physical activity.

P01: I can do that when I go swimming. I do that so I know how many calories I have burned and how much time I’ve spent in cardio, and fat burn, across different exercises and activities. (P01).

Additionally, through their activity tracker, participants discovered the interconnectedness of sleep, eating, and physical activity in their well-being. Recognising how these elements influenced one another helped reinforce positive behavioural changes.

I’ve realised how positive exercise can be, again for mental and physical health. When my conditions flare up and I can’t exercise, I see the impact on my mental health, and it does go downhill. It’s a complete holistic thing. (P01).

When I work out or, when I’m active during the day, or when I get enough sleep and reach my goals, it just makes me feel better inside. (P07).

(4) A mechanism to reassure and validate

Fitness trackers improved well-being using a range of tools, highlighting incremental progress, setting reminders, and providing objective reassurance.

I think with that kept on your wrist, even when you have a rubbish day. I think it helps to reassure you. (P06).

I would say just try and use every feature that you can to make the most of it. (P01).

(5) Facilitates and supports goal-setting

Participants highlighted how the tracker enabled them to set, monitor, and adjust personal health goals, reinforcing self-discipline and commitment.

The daily step goal definitely because that helped me motivate myself and it gave me a reason to keep sticking at it because I really like to achieve goals. If I’ve set out to do something, 10K steps, first time I hit 10K steps, I was ecstatic. (P05).

Small goals and incremental progress led to significant long-term achievements.

When I started, I was a little overwhelmed with all the changes I wanted to make. And… this has allowed me to make practical steps on making those changes, which has made me not feel so overwhelmed. (P02).

It’s like the 10,000 steps a day. I couldn’t achieve that before…, but because I’ve done it slowly and I’ve worked up, I’m now doing it. That’s good. (P04).

3.2. Holistic Support and Coaching to Promote an Individualised Approach

Alongside the activity tracker, coaching provided significant benefits, offering personalised support for physical activity, eating habits, weight management, and sleep. It fostered behaviour change, accountability, and achievement.

(1) Tailored advice promoting healthy eating and weight loss

The health coach played a key role in promoting healthier eating habits and weight management, offering tailored advice, practical tips, and emotional support to address poor diet, lack of meal planning, and emotional eating.

There have been times where I’ve gone to order a takeaway, and I’ve thought, “No, you’ve got all your stuff in the fridge and freezer—use it.” My coach suggested chopping up vegetables on Sunday nights so they’re ready for the week, and it worked. (P06).

Through the tailored advice, participants reported successful weight management and loss.

I have lost nearly three stone, six inches around my waist, and my body shape has completely changed. My polycystic ovary syndrome, which I’ve had since I was 16, has completely gone because of the weight loss. (P01).

(2) Individualised coaching to encourage physical activity

Coaching support enabled improvements in physical activity habits by providing practical strategies, motivational feedback, and encouragement. Incremental goal-setting emerged as a powerful success method; for instance, P05 noted the coach’s advice to “start off really slow, really small”; this helped them progress from 4,000 - 5,000 steps to 20,000 steps a day.

Coaching was found to boost confidence and motivation, and positive affirmations reinforced progress.

When I came back and told her, “Hey, I exercised this week,” it increased my confidence because she’d give me some positive affirmation, like ‘Well done’, and that spurred me on to do more. (P07).

Regular check-ins helped maintain accountability.

If I hadn’t had [health coach] to talk to, I probably would have stopped doing the exercise. (P08).

3.3. Positive Impact Associated with Well-Track

Overall, participants reported various positive outcomes that they associated with their Well-Track experience, including shifts in self-identity, increased physical independence, reduced isolation, and improved mood.

(1) Provision of strategies to overcome previous barriers

Participants faced psychological, physical, technological, and external/social challenges. Professional guidance, personalised strategies, and social support helped mitigate these obstacles.

Many participants found the health coach was essential in overcoming barriers. P03 highlighted how one-on-one support from the coach was a key motivator during low points, offering reassurance and reducing feelings of isolation. Others emphasised the value of the coach’s guidance:

It was very helpful for her to go through everything with me and tell me about it, give me advice, because some of the stuff I wouldn’t have noticed, or ignored thinking it wasn’t worth it. Thanks to her knowledge and advice I did some things. (P14).

Participants discussed the health coach’s personalised approach such as recommending additional courses for binge eating. This personalised, compassionate support was seen as a critical element in helping participants navigate their challenges.

Participants also adopted an effective strategy of having personalised exercise plans. P04 mentioned how her health coach suggested wheelchair-friendly fitness videos suited to her mobility needs, allowing her to exercise without overexertion. Many also found a combination of tools, such as the fitness tracker, health coaching, and workbooks, effective in overcoming obstacles and helping to maintain accountability and motivation.

I think it was a combination of the two that made it worthwhile you had [health coach] there to remind you, guide you and motivate you. Then you had the Fitbit when she wasn’t there to keep you in check. (P03).

Participants highlighted the role of social support in maintaining motivation and achieving goals. P08 mentioned her family’s encouragement to walk the dog, with her sister checking in regularly. P07 noted how her parents motivated her by asking about her gym or walking routine, fostering accountability. Others found motivation by comparing progress with others.

My mother… she’s got the old pedometer thing on her phone, but obviously, I’ve got the Fitbit. We’re always like, I’ve done so many steps, she’s done so many steps, and we’re trying to outdo each other. (P10).

(2) Improved and healthier sleep habits and routines

Participants reported the useful impact of fitness trackers and guidance provided by the health coach on sleep awareness and regulation.

The sleep, definitely, because one of the readings was like I was restless 43 times, and things like that. It was showing me how I was having a lack of sleep, really, and not sleeping properly, so that has encouraged me to try and do different things. (P06).

Sleep-tracking features facilitated healthier sleep patterns and implementation of a good routine and practices.

To track my sleep, which has been really helpful because I set a bedtime and a time to wake up. It buzzes when I need to wake up, and then it sets a reminder of when I need to go to sleep, so that’s helped regulate my sleeping pattern and my circadian rhythm, making sure that I get enough sleep in. (P07).

The health coach offered practical sleep hygiene advice alongside this, and helped establish healthier routines.

The lady that was helping with the Fitbit gave me some advice, so things like making sure I went for an early morning walk because of the need to get sunlight in the morning, allowing me to get melatonin in the evening…. So, just learning a bit more sleep hygiene to get better stages of sleep. (P01).

Participants reported improved sleep quality, reduced insomnia, and greater consistency in their sleep routines.

At the beginning of this exercise, I wasn’t sleeping very well. I wouldn’t say I’m sleeping great now, but I’m sleeping a lot better. The quality of my sleep has got better. (P02).

(3) Enhanced physical independence, reduced isolation, and improved mood

Improved mobility, and stamina allowed more engagement in daily life: P05: “I used to have mobility aids... Now, I can walk from my house to town and more. It opens up many options”. Physical improvements helped reconnections with other people and local communities. P04 highlighted the social benefits of regular walks with a neighbour, while P02 shared their involvement in social prescribing programmes, coffee mornings, and group walks, leading to new, healthy lifestyle-supporting social connections.

The positive effects of physical activity extended to mood and mental health. Several participants found exercise to be a valuable tool for managing stress and improving their emotional state:

Exercise for stress... You can exercise the stress away and just reset yourself. (P01).

P06 observed that Well-Track “chilled me out... making me more relaxed and dealing with things better”.

There was a reduction in negative mental health symptoms and an increase in overall happiness. P11 described overcoming a ‘depression slump’ through consistent activity: “I like going out on a walk, or going swimming, because I think it’s very calming, and sometimes you just need that fresh air’”.

The structured nature of Well-Track was instrumental in fostering these changes. By providing measurable goals and feedback, it encouraged participants to stay consistent and motivated, ultimately leading to sustained improvements in mood, confidence, and overall quality of life, P08: “I’ve found that I’m a lot happier”.

(4) Positive shifts in self-identity

Engaging in consistent physical activity and receiving coaching support led to positive changes in participants’ self-perception. Many individuals highlighted newfound confidence in their abilities and a redefined sense of self.

I realised that I was capable of doing more than I thought, and my body has become stronger over the time. (P01).

Several participants emphasised how their achievements in physical activity positively transformed their self-view. P07 described themselves as “someone that works out and exercises”; P05 described themselves as “moving through life differently now” as they adapted to a more active and confident self-identity.

For some, these changes extended to a more positive sense of self-identity:

I hated myself. I don’t love myself right this second, but I like myself, so that’s a start. (P06).

4. Discussion

Qualitative analysis of in-depth interviews of individuals with SMI revealed insights into the benefits and mechanisms of action of Well-Track, supplementing quantitative data previously published showing enhanced well-being and improved sleep quality and reduced insomnia [113]. The activity tracker was identified as a helpful tool for making positive lifestyle changes. Improvements in physical activity levels, sleep hygiene and eating habits were described supporting evidence from other tracker-based interventions for SMI individuals [65] [109] [119].

Evidence from the interviews suggests the activity tracker facilitated these improvements in three ways. Firstly, the activity tracker provided feedback and sense of achievement. Increasing motivation is recognised as an important first step for change in individuals with little or no initial engagement in health promoting habits [120]. The activity tracker may be of particularly value when people are first establishing new behaviours and have not yet experienced tangible health benefits to encourage consistent adoption as well as enabling longer term engagement through regular boosts in motivation.

Secondly, the activity tracker provided an increased awareness of overall physical health [112] [119]. Participants could see how their heart-rate and calorie expenditure changed in response to physical activity and gained valuable insights into the quality of their sleep. Autonomous motivation is key for the sustainability of healthy behaviours [121]. For those with SMI, an important balance is described between encouraging this motivation and applying too much pressure to achieve which may cause individuals to suffer disappointment and disengage from healthy lifestyle habits [121]. The personalised information Well-Track participants received from their activity tracker encouraged self-motivation as individuals made changes that were relevant and important to them.

Thirdly, by providing a practical means to set, monitor and achieve healthy lifestyle goals, the tracker boosted self-confidence [112]. Participants developed resilience to persist with their new healthy behaviours, seeing their progression to significant achievements such as consistently recording 10,000 daily steps. In some individuals, this extended to positive changes in their self-identity as they began to view themselves as people who were active and made healthy lifestyle choices, which is key to creating long term behaviour change after the initial motivation fades [120].

For people with SMI, health coach support can facilitate behaviour change addressing additional challenges such as low mood, reduced cognitive function and psychosocial difficulties [40] [46] [52] [53], making it easier to initiate and sustain new health habits. Participants reported direct coaching benefits for the development and maintenance of their new physical activity, sleep and weight management behaviours. Motivational interviewing techniques were used to good effect in the coaching process [112]. This is an important component to lifestyle intervention programmes given the lack of motivation commonly experienced by people with SMI [100]. The health coach boosted confidence through positive affirmation of participants’ progress at follow up sessions and encouraging maintenance of new healthy behaviours by providing accountability.

An effective professional working relationship between a health coach and the individual being coached is important and may be especially relevant for SMI individuals [100] [112] given previous reports of negative attitudes from healthcare staff impeding behaviour change [122] [123]. Participants benefitted from specific knowledge gained from the coach. Advice regarding meal planning and preparation was highlighted as pivotal to achieving nutritional improvements, healthier food choices and weight loss in people with SMI who may struggle to maintain a daily routine [25] [52]. Practical sleep hygiene advice was also instrumental in participants making positive changes that resulted in more consistent bedtime routines and reduced insomnia [35] [112]. Specific guidance to make small incremental changes enabled substantial progression over time.

A negative spiral has been described for SMI individuals whereby obesity and reduced cardiovascular functioning hampers physical activity resulting in greater depressive symptoms and low self-esteem which in turn may reduce motivation for healthy lifestyle behaviours [44] [98] [99]. Well-Track may reverse this negative spiral. Participants who increased their activity levels reported better quality sleep and improvements in their mood. This can increase their motivation for further positives health choices resulting in additional mental health benefits [40] [113]. Well-Track permitted personalised discussions around a range of lifestyle habits which enhanced this positive spiral, recognising synergistic benefits of physical activity, healthy eating, and quality sleep [95] [96].

Well-Track increased physical mobility independence, reduced isolation and improved mental well-being [66] [87] [112] [124]. This has important implications for people with SMI as reductions in loneliness and increased social support are recognised factors for promotion of mental health recovery [125] [126]. Participants revealed intrinsic and extrinsic barriers to lifestyle change [43] [52]. The strategies described to overcome this included social support from either the health coach or friends and family. Overcoming mobility restrictions due to concurrent physical health problems was another barrier reduced by the coach through provision of personalised advice for safe exercise modifications.

Strengths of this qualitative study is that it revealed personal experiences, and it recruited from a CMHT which is representative of other UK CMHTs. Its generalisability is limited by recruiting in a single UK county. Participants were self-selecting which may have created bias if those putting themselves forward had above average mental and physical health for individuals with SMI and were, therefore, more able to make lifestyle changes. Self-selection might have also resulted in more of those with a positive experience putting themselves forwards for interview.

Further research is required to determine the sustainability of healthy lifestyle changes made during Well-Track. Given benefits of personal coaching reported here, investigation into the effect of additional sessions and at what time intervals these are most impactful would give further guidance to the intervention’s application. Investigation could be undertaken to see how the intervention could be strengthened by exploring strategies to promote long-term adherence. In addition, determination of potential subgroups of individuals with SMI that may respond most favourably to Well-Track would help direct this resource towards those most likely to benefit. For example, does age, health goals, SMI diagnosis, or current medication type influence participant experience and success as suggested recently in other healthy lifestyle interventions [59] [100] [127].

5. Conclusion

By combining an activity tracker with individual consultations with a professional health coach, Well-Track offers the potential for an efficient, scalable and impactful approach for supporting healthy lifestyle changes in SMI individuals to improve their physical and mental health, well-being and overall quality of life.

Conflicts of Interest

The authors declare no conflicts of interest regarding the publication of this paper.

References

[1]	Maj, M. (2009) Physical Health Care in Persons with Severe Mental Illness: A Public Health and Ethical Priority. World Psychiatry, 8, 1-2. https://doi.org/10.1002/j.2051-5545.2009.tb00196.x
[2]	Daumit, G.L., Dalcin, A.T., Dickerson, F.B., Miller, E.R., Evins, A.E., Cather, C., et al. (2020) Effect of a Comprehensive Cardiovascular Risk Reduction Intervention in Persons with Serious Mental Illness: A Randomized Clinical Trial. JAMA Network Open, 3, e207247. https://doi.org/10.1001/jamanetworkopen.2020.7247
[3]	Laursen, T.M., Munk-Olsen, T. and Vestergaard, M. (2012) Life Expectancy and Cardiovascular Mortality in Persons with Schizophrenia. Current Opinion in Psychiatry, 25, 83-88. https://doi.org/10.1097/yco.0b013e32835035ca
[4]	Luppino, F.S., de Wit, L.M., Bouvy, P.F., Stijnen, T., Cuijpers, P., Penninx, B.W.J.H., et al. (2010) Overweight, Obesity, and Depression: A Systematic Review and Meta-Analysis of Longitudinal Studies. Archives of General Psychiatry, 67, 220-229. https://doi.org/10.1001/archgenpsychiatry.2010.2
[5]	Hjorthøj, C., Stürup, A.E., McGrath, J.J. and Nordentoft, M. (2017) Years of Potential Life Lost and Life Expectancy in Schizophrenia: A Systematic Review and Meta-Analysis. The Lancet Psychiatry, 4, 295-301. https://doi.org/10.1016/s2215-0366(17)30078-0
[6]	Walker, E.R., McGee, R.E. and Druss, B.G. (2015) Mortality in Mental Disorders and Global Disease Burden Implications: A Systematic Review and Meta-Analysis. JAMA Psychiatry, 72, 334-341. https://doi.org/10.1001/jamapsychiatry.2014.2502
[7]	Nielsen, R.E., Uggerby, A.S., Jensen, S.O.W. and McGrath, J.J. (2013) Increasing Mortality Gap for Patients Diagnosed with Schizophrenia over the Last Three Decades—A Danish Nationwide Study from 1980 to 2010. Schizophrenia Research, 146, 22-27. https://doi.org/10.1016/j.schres.2013.02.025
[8]	Robson, D. and Gray, R. (2007) Serious Mental Illness and Physical Health Problems: A Discussion Paper. International Journal of Nursing Studies, 44, 457-466. https://doi.org/10.1016/j.ijnurstu.2006.07.013
[9]	Scott, D. and Happell, B. (2011) The High Prevalence of Poor Physical Health and Unhealthy Lifestyle Behaviours in Individuals with Severe Mental Illness. Issues in Mental Health Nursing, 32, 589-597. https://doi.org/10.3109/01612840.2011.569846
[10]	Stanley, S. and Laugharne, J. (2013) The Impact of Lifestyle Factors on the Physical Health of People with a Mental Illness: A Brief Review. International Journal of Behavioral Medicine, 21, 275-281. https://doi.org/10.1007/s12529-013-9298-x
[11]	Ayers, N., McCall, W.V. and Miller, B.J. (2023) Sleep Problems, Suicidal Ideation, and Psychopathology in First-Episode Psychosis. Schizophrenia Bulletin, 50, 286-294. https://doi.org/10.1093/schbul/sbad045
[12]	Schuch, F., Vancampfort, D., Firth, J., Rosenbaum, S., Ward, P., Reichert, T., et al. (2017) Physical Activity and Sedentary Behavior in People with Major Depressive Disorder: A Systematic Review and Meta-Analysis. Journal of Affective Disorders, 210, 139-150. https://doi.org/10.1016/j.jad.2016.10.050
[13]	Smith, S., Yeomans, D., Bushe, C.J.P., Eriksson, C., Harrison, T., Holmes, R., et al. (2007) A Well-Being Programme in Severe Mental Illness. Baseline Findings in a UK Cohort. International Journal of Clinical Practice, 61, 1971-1978. https://doi.org/10.1111/j.1742-1241.2007.01605.x
[14]	Stubbs, B., Firth, J., Berry, A., Schuch, F.B., Rosenbaum, S., Gaughran, F., et al. (2016) How Much Physical Activity Do People with Schizophrenia Engage In? A Systematic Review, Comparative Meta-Analysis and Meta-Regression. Schizophrenia Research, 176, 431-440. https://doi.org/10.1016/j.schres.2016.05.017
[15]	Brown, S., Birtwistle, J., Roe, L. and Thompson, C. (1999) The Unhealthy Lifestyle of People with Schizophrenia. Psychological Medicine, 29, 697-701. https://doi.org/10.1017/s0033291798008186
[16]	Dipasquale, S., Pariante, C.M., Dazzan, P., Aguglia, E., McGuire, P. and Mondelli, V. (2013) The Dietary Pattern of Patients with Schizophrenia: A Systematic Review. Journal of Psychiatric Research, 47, 197-207. https://doi.org/10.1016/j.jpsychires.2012.10.005
[17]	Kilian, R., Becker, T., Krüger, K., Schmid, S. and Frasch, K. (2006) Health Behavior in Psychiatric In-Patients Compared with a German General Population Sample. Acta Psychiatrica Scandinavica, 114, 242-248. https://doi.org/10.1111/j.1600-0447.2006.00850.x
[18]	Mötteli, S., Provaznikova, B., Vetter, S., Jäger, M., Seifritz, E. and Hotzy, F. (2023) Examining Nutrition Knowledge, Skills, and Eating Behaviours in People with Severe Mental Illness: A Cross-Sectional Comparison among Psychiatric Inpatients, Outpatients, and Healthy Adults. Nutrients, 15, Article 2136. https://doi.org/10.3390/nu15092136
[19]	Osborn, D.P.J., Nazareth, I. and King, M.B. (2007) Physical Activity, Dietary Habits and Coronary Heart Disease Risk Factor Knowledge Amongst People with Severe Mental Illness. Social Psychiatry and Psychiatric Epidemiology, 42, 787-793. https://doi.org/10.1007/s00127-007-0247-3
[20]	Ryan, R.M. and Deci, E.L. (2017) Self-Determination Theory: Basic Psychological Needs in Motivation, Development, and Wellness. Guilford Press.
[21]	Holt, R.I.G. and Peveler, R.C. (2009) Obesity, Serious Mental Illness and Antipsychotic Drugs. Diabetes, Obesity and Metabolism, 11, 665-679. https://doi.org/10.1111/j.1463-1326.2009.01038.x
[22]	Risch, L., Hotzy, F., Vetter, S., Hiller, S., Wallimann, K., Seifritz, E., et al. (2022) Assessment of Nutritional Status and Risk of Malnutrition Using Adapted Standard Tools in Patients with Mental Illness and in Need of Intensive Psychiatric Treatment. International Journal of Environmental Research and Public Health, 20, Article 109. https://doi.org/10.3390/ijerph20010109
[23]	Hancox, L.E., Lee, P.S., Armaghanian, N., Hirani, V. and Wakefield, G. (2021) Nutrition Risk Screening Methods for Adults Living with Severe Mental Illness: A Scoping Review. Nutrition & Dietetics, 79, 349-363. https://doi.org/10.1111/1747-0080.12652
[24]	Kim, S.R., Kim, J.Y., Kim, H.Y., Nho, J., Kim, Y.H. and Min, S. (2018) Factors Related to Malnutrition in Community‐dwelling Patients with Schizophrenia. Perspectives in Psychiatric Care, 55, 415-423. https://doi.org/10.1111/ppc.12327
[25]	Teasdale, S.B., Samaras, K., Wade, T., Jarman, R. and Ward, P.B. (2017) A Review of the Nutritional Challenges Experienced by People Living with Severe Mental Illness: A Role for Dietitians in Addressing Physical Health Gaps. Journal of Human Nutrition and Dietetics, 30, 545-553. https://doi.org/10.1111/jhn.12473
[26]	Yum, S.Y., Caracci, G. and Hwang, M.Y. (2009) Schizophrenia and Eating Disorders. Psychiatric Clinics of North America, 32, 809-819. https://doi.org/10.1016/j.psc.2009.09.004
[27]	Carr, V.J., Whiteford, H., Groves, A., McGorry, P. and Shepherd, A.M. (2012) Policy and Service Development Implications of the Second Australian National Survey of High Impact Psychosis (Ship). Australian & New Zealand Journal of Psychiatry, 46, 708-718. https://doi.org/10.1177/0004867412446488
[28]	Howarth, N.E. and Miller, M.A. (2024) Sleep, Sleep Disorders, and Mental Health: A Narrative Review. Heart and Mind, 8, 146-158. https://doi.org/10.4103/hm.hm-d-24-00030
[29]	Stafford, A., Oduola, S. and Reeve, S. (2024) How Sleep in Patients with Serious Mental Illness Is Recorded and Treated, and Its Impact on Service Engagement. Sleep Medicine, 124, 58-69. https://doi.org/10.1016/j.sleep.2024.09.002
[30]	Wulff, K., Dijk, D., Middleton, B., Foster, R.G. and Joyce, E.M. (2012) Sleep and Circadian Rhythm Disruption in Schizophrenia. British Journal of Psychiatry, 200, 308-316. https://doi.org/10.1192/bjp.bp.111.096321
[31]	Chaput, J., McNeil, J., Després, J., Bouchard, C. and Tremblay, A. (2013) Short Sleep Duration as a Risk Factor for the Development of the Metabolic Syndrome in Adults. Preventive Medicine, 57, 872-877. https://doi.org/10.1016/j.ypmed.2013.09.022
[32]	Hargens, T., Kaleth, A.S., Edwards, E.S. and Butner, K.L. (2013) Association between Sleep Disorders, Obesity, and Exercise: A Review. Nature and Science of Sleep, 5, 27-35. https://doi.org/10.2147/nss.s34838
[33]	Ong, W.J., Tan, X.W., Shahwan, S., Satghare, P., Cetty, L., Ng, B.T., et al. (2020) Association between Sleep Quality and Domains of Quality of Life Amongst Patients with First Episode Psychosis. Health and Quality of Life Outcomes, 18, Article No. 114. https://doi.org/10.1186/s12955-020-01367-3
[34]	Blanchard, J.J., Savage, C.L.G., Orth, R.D., Jacome, A.M. and Bennett, M.E. (2020) Sleep Problems and Social Impairment in Psychosis: A Transdiagnostic Study Examining Multiple Social Domains. Frontiers in Psychiatry, 11, Article 486. https://doi.org/10.3389/fpsyt.2020.00486
[35]	Faulkner, S. and Bee, P. (2017) Experiences, Perspectives and Priorities of People with Schizophrenia Spectrum Disorders Regarding Sleep Disturbance and Its Treatment: A Qualitative Study. BMC Psychiatry, 17, Article No. 158. https://doi.org/10.1186/s12888-017-1329-8
[36]	Filik, R., Sipos, A., Kehoe, P.G., Burns, T., Cooper, S.J., Stevens, H., et al. (2006) The Cardiovascular and Respiratory Health of People with Schizophrenia. Acta Psychiatrica Scandinavica, 113, 298-305. https://doi.org/10.1111/j.1600-0447.2006.00768.x
[37]	de Leon, J. and Diaz, F.J. (2005) A Meta-Analysis of Worldwide Studies Demonstrates an Association between Schizophrenia and Tobacco Smoking Behaviors. Schizophrenia Research, 76, 135-157. https://doi.org/10.1016/j.schres.2005.02.010
[38]	Davidson, S., Judd, F., Jolley, D., Hocking, B., Thompson, S. and Hyland, B. (2001) Risk Factors for HIV/AIDS and Hepatitis C among the Chronic Mentally Ill. Australian & New Zealand Journal of Psychiatry, 35, 203-209. https://doi.org/10.1046/j.1440-1614.2001.00867.x
[39]	Ogloff, J.R.P., Lemphers, A. and Dwyer, C. (2004) Dual Diagnosis in an Australian Forensic Psychiatric Hospital: Prevalence and Implications for Services. Behavioral Sciences & the Law, 22, 543-562. https://doi.org/10.1002/bsl.604
[40]	Carney, R., Cotter, J., Bradshaw, T. and Yung, A.R. (2017) Examining the Physical Health and Lifestyle of Young People at Ultra-High Risk for Psychosis: A Qualitative Study Involving Service Users, Parents and Clinicians. Psychiatry Research, 255, 87-93. https://doi.org/10.1016/j.psychres.2017.05.023
[41]	Lee, S., Kim, G., Kim, C. and Ryu, S. (2018) Physical Activity of Patients with Chronic Schizophrenia and Related Clinical Factors. Psychiatry Investigation, 15, 811-817. https://doi.org/10.30773/pi.2018.04.15.1
[42]	Pearsall, R., Hughes, S., Geddes, J. and Pelosi, A. (2014) Understanding the Problems Developing a Healthy Living Programme in Patients with Serious Mental Illness: A Qualitative Study. BMC Psychiatry, 14, Article No. 38. https://doi.org/10.1186/1471-244x-14-38
[43]	Quirk, H., Hock, E., Harrop, D., Crank, H., Peckham, E., Traviss-Turner, G., et al. (2020) Understanding the Experience of Initiating Community-Based Group Physical Activity by People with Serious Mental Illness: A Systematic Review Using a Meta-Ethnographic Approach. European Psychiatry, 63, e95. https://doi.org/10.1192/j.eurpsy.2020.93
[44]	Rastad, C., Martin, C. and Åsenlöf, P. (2014) Barriers, Benefits, and Strategies for Physical Activity in Patients with Schizophrenia. Physical Therapy, 94, 1467-1479. https://doi.org/10.2522/ptj.20120443
[45]	Brooke, L.E., Gucciardi, D.F., Ntoumanis, N. and Lin, A. (2019) Qualitative Investigation of Perceived Barriers to and Enablers of Sport Participation for Young People with First Episode Psychosis. Early Intervention in Psychiatry, 14, 293-306. https://doi.org/10.1111/eip.12854
[46]	Daumit, G.L., Dickerson, F.B., Wang, N., Dalcin, A., Jerome, G.J., Anderson, C.A.M., et al. (2013) A Behavioral Weight-Loss Intervention in Persons with Serious Mental Illness. New England Journal of Medicine, 368, 1594-1602. https://doi.org/10.1056/nejmoa1214530
[47]	Sass, L.A. and Parnas, J. (2003) Schizophrenia, Consciousness, and the Self. Schizophrenia Bulletin, 29, 427-444. https://doi.org/10.1093/oxfordjournals.schbul.a007017
[48]	Thornley, S., Russell, B. and Kydd, R. (2011) Carbohydrate Reward and Psychosis: An Explanation for Neuroleptic Induced Weight Gain and Path to Improved Mental Health? Current Neuropharmacology, 9, 370-375. https://doi.org/10.2174/157015911795596513
[49]	Luciano, M., Sampogna, G., Del Vecchio, V., Giallonardo, V., Palummo, C., Andriola, I., et al. (2021) The Impact of Clinical and Social Factors on the Physical Health of People with Severe Mental Illness: Results from an Italian Multicentre Study. Psychiatry Research, 303, Article ID: 114073. https://doi.org/10.1016/j.psychres.2021.114073
[50]	Mangurian, C., Sreshta, N. and Seligman, H. (2013) Food Insecurity among Adults with Severe Mental Illness. Psychiatric Services, 64, 931-932. https://doi.org/10.1176/appi.ps.201300022
[51]	Hudson, C.G. (2005) Socioeconomic Status and Mental Illness: Tests of the Social Causation and Selection Hypotheses. American Journal of Orthopsychiatry, 75, 3-18. https://doi.org/10.1037/0002-9432.75.1.3
[52]	Firth, J., Rosenbaum, S., Stubbs, B., Gorczynski, P., Yung, A.R. and Vancampfort, D. (2016) Motivating Factors and Barriers Towards Exercise in Severe Mental Illness: A Systematic Review and Meta-Analysis. Psychological Medicine, 46, 2869-2881. https://doi.org/10.1017/s0033291716001732
[53]	Luciano, M., Sampogna, G., Amore, M., Andriola, I., Calcagno, P., Carmassi, C., et al. (2021) How to Improve the Physical Health of People with Severe Mental Illness? A Multicentric Randomized Controlled Trial on the Efficacy of a Lifestyle Group Intervention. European Psychiatry, 64, e72. https://doi.org/10.1192/j.eurpsy.2021.2253
[54]	Mazzi, F., Baccari, F., Mungai, F., Ciambellini, M., Brescancin, L. and Starace, F. (2018) Effectiveness of a Social Inclusion Program in People with Non-Affective Psychosis. BMC Psychiatry, 18, Article No. 179. https://doi.org/10.1186/s12888-018-1728-5
[55]	Thornicroft, G., Brohan, E., Rose, D., Sartorius, N. and Leese, M. (2009) Global Pattern of Experienced and Anticipated Discrimination against People with Schizophrenia: A Cross-Sectional Survey. The Lancet, 373, 408-415. https://doi.org/10.1016/s0140-6736(08)61817-6
[56]	Correll, C.U. (2009) Cardiometabolic Risk of Second-Generation Antipsychotic Medications during First-Time Use in Children and Adolescents. JAMA, 302, 1765-1773. https://doi.org/10.1001/jama.2009.1549
[57]	De Hert, M., Detraux, J., van Winkel, R., Yu, W. and Correll, C.U. (2011) Metabolic and Cardiovascular Adverse Effects Associated with Antipsychotic Drugs. Nature Reviews Endocrinology, 8, 114-126. https://doi.org/10.1038/nrendo.2011.156
[58]	Green, A.I., Patel, J.K., Goisman, R.M., Allison, D.B. and Blackburn, G. (2000) Weight Gain from Novel Antipsychotic Drugs: Need for Action. General Hospital Psychiatry, 22, 224-235. https://doi.org/10.1016/s0163-8343(00)00081-5
[59]	Sampogna, G., Di Vincenzo, M., Luciano, M., Della Rocca, B., D’Ambrosio, E., Rampino, A., et al. (2025) Improving the Physical Health of Overweight/Obese People Suffering from Severe Mental Disorders: What Is the Role of Antipsychotic Drugs and of Lifestyle Psychosocial Interventions? Journal of Psychiatric Research, 181, 570-578. https://doi.org/10.1016/j.jpsychires.2024.11.029
[60]	Covell, N.H., Weissman, E.M., Schell, B., McCorkle, B.H., Summerfelt, W.T., Weiden, P.J., et al. (2007) Distress with Medication Side Effects among Persons with Severe Mental Illness. Administration and Policy in Mental Health and Mental Health Services Research, 34, 435-442. https://doi.org/10.1007/s10488-007-0131-1
[61]	Katekaru, M., Minn, C. E. and Pobutsky, A. M. (2015) Weight Reduction among People with Severe and Persistent Mental Illness after Health Behavior Counseling and Monitoring. Hawai’i Journal of Medicine & Public Health, 74, 146-149. https://pmc.ncbi.nlm.nih.gov/articles/PMC4407458/
[62]	Perez-Cruzado, D., Cuesta-Vargas, A., Vera-Garcia, E. and Mayoral-Cleries, F. (2018) Medication and Physical Activity and Physical Fitness in Severe Mental Illness. Psychiatry Research, 267, 19-24. https://doi.org/10.1016/j.psychres.2018.05.055
[63]	Lin, C., Huang, L., Chang, Y., Chen, R. and Yang, S. (2021) Effectiveness of Health Coaching in Diabetes Control and Lifestyle Improvement: A Randomized-Controlled Trial. Nutrients, 13, Article 3878. https://doi.org/10.3390/nu13113878
[64]	Long, H., Howells, K., Peters, S. and Blakemore, A. (2019) Does Health Coaching Improve Health-Related Quality of Life and Reduce Hospital Admissions in People with Chronic Obstructive Pulmonary Disease? A Systematic Review and Meta‐analysis. British Journal of Health Psychology, 24, 515-546. https://doi.org/10.1111/bjhp.12366
[65]	Aschbrenner, K.A., Naslund, J.A., Shevenell, M., Mueser, K.T. and Bartels, S.J. (2015) Feasibility of Behavioral Weight Loss Treatment Enhanced with Peer Support and Mobile Health Technology for Individuals with Serious Mental Illness. Psychiatric Quarterly, 87, 401-415. https://doi.org/10.1007/s11126-015-9395-x
[66]	Griffiths, C. and Hina, F. (2021) Integrated Review of Lifestyle Interventions Targeting Diet and Exercise in Early or First-Episode Psychosis. Open Journal of Psychiatry, 11, 265-278. https://doi.org/10.4236/ojpsych.2021.114021
[67]	Stubbs, B., Vancampfort, D., Hallgren, M., Firth, J., Veronese, N., Solmi, M., et al. (2018) EPA Guidance on Physical Activity as a Treatment for Severe Mental Illness: A Meta-Review of the Evidence and Position Statement from the European Psychiatric Association (EPA), Supported by the International Organization of Physical Therapists in Mental Health (IOPTMH). European Psychiatry, 54, 124-144. https://doi.org/10.1016/j.eurpsy.2018.07.004
[68]	Walburg, F.S., de Joode, J.W., Brandt, H.E., van Tulder, M.W., Adriaanse, M.C. and van Meijel, B. (2022) Implementation of a Lifestyle Intervention for People with a Severe Mental Illness (SMILE): A Process Evaluation. BMC Health Services Research, 22, Article No. 27. https://doi.org/10.1186/s12913-021-07391-3
[69]	Bishop, L., Hemingway, A. and Crabtree, S.A. (2018) Lifestyle Coaching for Mental Health Difficulties: Scoping Review. Journal of Public Mental Health, 17, 29-44. https://doi.org/10.1108/jpmh-04-2017-0018
[70]	Bodai, B.I., Nakata, T.E., Wong, W.T., Clark, D.R., Lawenda, S., Tsou, C., et al. (2018) Lifestyle Medicine: A Brief Review of Its Dramatic Impact on Health and Survival. The Permanente Journal, 22, 17-25. https://doi.org/10.7812/tpp/17-025
[71]	Kivelä, K., Elo, S., Kyngäs, H. and Kääriäinen, M. (2014) The Effects of Health Coaching on Adult Patients with Chronic Diseases: A Systematic Review. Patient Education and Counseling, 97, 147-157. https://doi.org/10.1016/j.pec.2014.07.026
[72]	Meade, O., Aehlig, L., O’Brien, M., Lawless, A., McSharry, J., Dragomir, A., et al. (2025) Implementation of a National Programme to Train and Support Healthcare Professionals in Brief Behavioural Interventions: A Qualitative Study Using the Theoretical Domains Framework. British Journal of Health Psychology, 30, e12777. https://doi.org/10.1111/bjhp.12777
[73]	Olsen, J.M. (2013) Health Coaching: A Concept Analysis. Nursing Forum, 49, 18-29. https://doi.org/10.1111/nuf.12042
[74]	Perlman, A.I. and Abu Dabrh, A.M. (2020) Health and Wellness Coaching in Serving the Needs of Today’s Patients: A Primer for Healthcare Professionals. Global Advances in Health and Medicine, 9. https://doi.org/10.1177/2164956120959274
[75]	Holt, R.I.G. (2019) The Management of Obesity in People with Severe Mental Illness: An Unresolved Conundrum. Psychotherapy and Psychosomatics, 88, 327-332. https://doi.org/10.1159/000503835
[76]	Naslund, J.A., Whiteman, K.L., McHugo, G.J., Aschbrenner, K.A., Marsch, L.A. and Bartels, S.J. (2017) Lifestyle Interventions for Weight Loss among Overweight and Obese Adults with Serious Mental Illness: A Systematic Review and Meta-Analysis. General Hospital Psychiatry, 47, 83-102. https://doi.org/10.1016/j.genhosppsych.2017.04.003
[77]	Chacón, F., Mora, F., Gervás-Ríos, A. and Gilaberte, I. (2011) Efficacy of Lifestyle Interventions in Physical Health Management of Patients with Severe Mental Illness. Annals of General Psychiatry, 10, Article No. 22. https://doi.org/10.1186/1744-859x-10-22
[78]	Walburg, F.S., van Meijel, B., Hoekstra, T., Kol, J., Pape, L.M., de Joode, J.W., et al. (2023) Effectiveness of a Lifestyle Intervention for People with a Severe Mental Illness in Dutch Outpatient Mental Health Care: A Randomized Clinical Trial. JAMA Psychiatry, 80, 886. https://doi.org/10.1001/jamapsychiatry.2023.1566
[79]	Browne, J., Naslund, J.A., Salwen‐Deremer, J.K., Sarcione, C., Cabassa, L.J. and Aschbrenner, K.A. (2023) Factors Influencing Engagement in In-Person and Remotely Delivered Lifestyle Interventions for Young Adults with Serious Mental Illness: A Qualitative Study. Early Intervention in Psychiatry, 18, 42-48. https://doi.org/10.1111/eip.13432
[80]	Luciano, M., Sampogna, G., Amore, M., Bertolino, A., Dell’Osso, L., Rossi, A., et al. (2022) Improving Physical Activity and Diet in Patients with Severe Mental Disorders: Results from the LIFESTYLE Multicentric, Real-World Randomized Controlled Trial. Psychiatry Research, 317, Article ID: 114818. https://doi.org/10.1016/j.psychres.2022.114818
[81]	O’sullivan, J., Gilbert, J. and Ward, W. (2006) Addressing the Health and Lifestyle Issues of People with a Mental Illness: The Healthy Living Programme. Australasian Psychiatry, 14, 150-155. https://doi.org/10.1080/j.1440-1665.2006.02275.x
[82]	Silvestro, R., Dello Stritto, V., Catapano, P., Di Vincenzo, M., Della Rocca, B., Lapadula, M.V., et al. (2024) Physical Activity and Treatment Adherence in Patients with Mental Disorders: A Randomized Controlled Trial. European Psychiatry, 67, S63-S64. https://doi.org/10.1192/j.eurpsy.2024.177
[83]	Sollo, V., Di Vincenzo, M., Carbone, M., Rosa, A., Toricco, R., Tretola, L., et al. (2023) The Improvement of Healthy Habits in Patients with Severe Mental Disorders: The LIFESTYLE Trial. European Psychiatry, 66, S74-S75. https://doi.org/10.1192/j.eurpsy.2023.243
[84]	Firth, J., Carney, R., Jerome, L., Elliott, R., French, P. and Yung, A.R. (2016) The Effects and Determinants of Exercise Participation in First-Episode Psychosis: A Qualitative Study. BMC Psychiatry, 16, Article No. 36. https://doi.org/10.1186/s12888-016-0751-7
[85]	Luciano, M., Sampogna, G., D’Ambrosio, E., Rampino, A., Amore, M., Calcagno, P., et al. (2023) One-year Efficacy of a Lifestyle Behavioural Intervention on Physical and Mental Health in People with Severe Mental Disorders: Results from a Randomized Controlled Trial. European Archives of Psychiatry and Clinical Neuroscience, 274, 903-915. https://doi.org/10.1007/s00406-023-01684-w
[86]	Smith, J., Griffiths, L.A., Band, M., Hird-Smith, R., Williams, B., Bold, J., et al. (2020) Early Intervention in Psychosis: Effectiveness and Implementation of a Combined Exercise and Health Behavior Intervention within Routine Care. Frontiers in Endocrinology, 11, Article 577691. https://doi.org/10.3389/fendo.2020.577691
[87]	Watkins, A., Denney‐Wilson, E., Curtis, J., Teasdale, S., Rosenbaum, S., Ward, P.B., et al. (2019) Keeping the Body in Mind: A Qualitative Analysis of the Experiences of People Experiencing First-Episode Psychosis Participating in a Lifestyle Intervention Programme. International Journal of Mental Health Nursing, 29, 278-289. https://doi.org/10.1111/inm.12683
[88]	Heslin, M., Patel, A., Stahl, D., Gardner-Sood, P., Mushore, M., Smith, S., et al. (2017) Randomised Controlled Trial to Improve Health and Reduce Substance Use in Established Psychosis (IMPaCT): Cost-Effectiveness of Integrated Psychosocial Health Promotion. BMC Psychiatry, 17, Article No. 407. https://doi.org/10.1186/s12888-017-1570-1
[89]	Holt, R.I.G., Gossage-Worrall, R., Hind, D., Bradburn, M.J., McCrone, P., Morris, T., et al. (2018) Structured Lifestyle Education for People with Schizophrenia, Schizoaffective Disorder and First-Episode Psychosis (STEPWISE): Randomised Controlled Trial. The British Journal of Psychiatry, 214, 63-73. https://doi.org/10.1192/bjp.2018.167
[90]	Jakobsen, A.S., Speyer, H., Nørgaard, H.C.B., Karlsen, M., Birk, M., Hjorthøj, C., et al. (2017) Effect of Lifestyle Coaching versus Care Coordination versus Treatment as Usual in People with Severe Mental Illness and Overweight: Two-Years Follow-Up of the Randomized CHANGE Trial. PLOS ONE, 12, e0185881. https://doi.org/10.1371/journal.pone.0185881
[91]	Mohanty, K., Gandhi, S., Krishna Prasad, M., John, A.P., Bhaskarapillai, B., Malo, P., et al. (2024) Effectiveness of Lifestyle Intervention on Prevention/Management of Antipsychotic-Induced Weight Gain among Persons with Severe Mental Illness: A Systematic Review and Meta-analysis. Journal of Health Psychology, 29, 690-706. https://doi.org/10.1177/13591053241227384
[92]	Larsen, L.Q., Schnor, H., Tersbøl, B.P., Ebdrup, B.H., Nordsborg, N.B. and Midtgaard, J. (2019) The Impact of Exercise Training Complementary to Early Intervention in Patients with First-Episode Psychosis: A Qualitative Sub-Study from a Randomized Controlled Feasibility Trial. BMC Psychiatry, 19, Article No. 192. https://doi.org/10.1186/s12888-019-2179-3
[93]	Méndez-Aguado, C., Cangas, A.J., Aguilar-Parra, J.M. and Lirola, M.J. (2023) Benefits, Facilitators and Barrier Reductions in Physical Activity Programmes for People with Severe Mental Disorder: A Systematic Review. Healthcare, 11, Article 1215. https://doi.org/10.3390/healthcare11091215
[94]	Curtis, J., Watkins, A., Rosenbaum, S., Teasdale, S., Kalucy, M., Samaras, K., et al. (2015) Evaluating an Individualized Lifestyle and Life Skills Intervention to Prevent Antipsychotic-Induced Weight Gain in First‐episode Psychosis. Early Intervention in Psychiatry, 10, 267-276. https://doi.org/10.1111/eip.12230
[95]	Mishu, M.P., Peckham, E.J., Heron, P.N., Tew, G.A., Stubbs, B. and Gilbody, S. (2018) Factors Associated with Regular Physical Activity Participation among People with Severe Mental Ill Health. Social Psychiatry and Psychiatric Epidemiology, 54, 887-895. https://doi.org/10.1007/s00127-018-1639-2
[96]	Teasdale, S.B., Ward, P.B., Rosenbaum, S., Samaras, K. and Stubbs, B. (2017) Solving a Weighty Problem: Systematic Review and Meta-Analysis of Nutrition Interventions in Severe Mental Illness. British Journal of Psychiatry, 210, 110-118. https://doi.org/10.1192/bjp.bp.115.177139
[97]	NHS England (2024) 10 Key Actions: Improving the Physical Health of People Living with Severe Mental Illness. https://www.england.nhs.uk/long-read/10-key-actions-improving-the-physical-health-of-people-living-with-severe-mental-illness
[98]	Vancampfort, D., Probst, M., Scheewe, T., Maurissen, K., Sweers, K., Knapen, J., et al. (2011) Lack of Physical Activity during Leisure Time Contributes to an Impaired Health Related Quality of Life in Patients with Schizophrenia. Schizophrenia Research, 129, 122-127. https://doi.org/10.1016/j.schres.2011.03.018
[99]	Vancampfort, D., Probst, M., Stubbs, B., Soundy, A., De Herdt, A. and De Hert, M. (2014) Metabolic Syndrome and Lung Function in Schizophrenia: A Pilot Study. Psychiatry Research, 220, 58-62. https://doi.org/10.1016/j.psychres.2014.06.008
[100]	Hassan, S., Ross, J., Marston, L., Burton, A., Osborn, D. and Walters, K. (2020) Exploring How Health Behaviours Are Supported and Changed in People with Severe Mental Illness: A Qualitative Study of a Cardiovascular Risk Reducing Intervention in Primary Care in England. British Journal of Health Psychology, 25, 428-451. https://doi.org/10.1111/bjhp.12415
[101]	Pedley, R., Lovell, K., Bee, P., Bradshaw, T., Gellatly, J., Ward, K., et al. (2018) Collaborative, Individualised Lifestyle Interventions Are Acceptable to People with First Episode Psychosis; a Qualitative Study. BMC Psychiatry, 18, Article No. 111. https://doi.org/10.1186/s12888-018-1692-0
[102]	Gorovoy, S.B., Campbell, R.L., Fox, R.S. and Grandner, M.A. (2023) App-Supported Sleep Coaching: Implications for Sleep Duration and Sleep Quality. Frontiers in Sleep, 2, Article 1156844. https://doi.org/10.3389/frsle.2023.1156844
[103]	Eid, N.M.S., Al-ofi, E.A., Enani, S., Mosli, R.H., Saqr, R.R., Qutah, K.M., et al. (2024) A 6-Month Randomised Controlled Trial to Compare the Effectiveness of Telenutrition v. Telenutrition Supported by Telemonitoring and Health Coaching in a Weight Loss Programme: A Study Protocol. British Journal of Nutrition, 132, 1224-1232. https://doi.org/10.1017/s0007114524002563
[104]	Eid, N.M.S. and Eid, S.M.S. (2024) Impact of Integrative Nutrition Health Coaching in Weight Management Programs: A Case Report. Open Journal of Preventive Medicine, 14, 173-184. https://doi.org/10.4236/ojpm.2024.149013
[105]	Ringeval, M., Wagner, G., Denford, J., Paré, G. and Kitsiou, S. (2020) Fitbit-Based Interventions for Healthy Lifestyle Outcomes: Systematic Review and Meta-Analysis. Journal of Medical Internet Research, 22, e23954. https://doi.org/10.2196/23954
[106]	Kooiman, T.J.M., de Groot, M., Hoogenberg, K., Krijnen, W.P., van der Schans, C.P. and Kooy, A. (2018) Self-Tracking of Physical Activity in People with Type 2 Diabetes: A Randomized Controlled Trial. CIN: Computers, Informatics, Nursing, 36, 340-349. https://doi.org/10.1097/cin.0000000000000443
[107]	Aledavood, T., Torous, J., Triana Hoyos, A.M., Naslund, J.A., Onnela, J. and Keshavan, M. (2019) Smartphone-Based Tracking of Sleep in Depression, Anxiety, and Psychotic Disorders. Current Psychiatry Reports, 21, Article No. 49. https://doi.org/10.1007/s11920-019-1043-y
[108]	Aschbrenner, K.A., Naslund, J.A., Tomlinson, E.F., Kinney, A., Pratt, S.I. and Brunette, M.F. (2019) Adolescents’ Use of Digital Technologies and Preferences for Mobile Health Coaching in Public Mental Health Settings. Frontiers in Public Health, 7, Article 178. https://doi.org/10.3389/fpubh.2019.00178
[109]	Naslund, J.A., Aschbrenner, K.A., Scherer, E.A., McHugo, G.J., Marsch, L.A. and Bartels, S.J. (2016) Wearable Devices and Mobile Technologies for Supporting Behavioral Weight Loss among People with Serious Mental Illness. Psychiatry Research, 244, 139-144. https://doi.org/10.1016/j.psychres.2016.06.056
[110]	Aschbrenner, K.A., Naslund, J.A., Barre, L.K., Mueser, K.T., Kinney, A. and Bartels, S.J. (2015) Peer Health Coaching for Overweight and Obese Individuals with Serious Mental Illness: Intervention Development and Initial Feasibility Study. Translational Behavioral Medicine, 5, 277-284. https://doi.org/10.1007/s13142-015-0313-4
[111]	Griffiths, C., Hina, F., Pollard, L., Jugon, S., Sam, M. and Kelbrick, M. (2021) A Qualitative Study of Early Intervention Psychosis (EIP) Service Patient’s Experience of Sleep, Exercise, Sleep Hygiene Advice and Fitbit Wearable Activity and Sleep Tracker. Open Journal of Psychiatry, 11, 91-106. https://doi.org/10.4236/ojpsych.2021.112009
[112]	Griffiths, C., Walker, K. and Jiang, H. (2023) Experience and Impact of the “Well-Track” Physical Activity and Sleep Tracker Based Healthy Lifestyle Intervention for Patients in an Early Intervention in Psychosis (EIP) Service. Open Journal of Psychiatry, 13, 73-93. https://doi.org/10.4236/ojpsych.2023.132009
[113]	Griffiths, C., Silva, K.D., Sheldon, A. and Smith, G. (2024) “Well-Track” Healthy Lifestyle (Physical Activity, Sleep Hygiene, Diet, Wearable Activity Tracker) Coaching in Severe Mental Illness (SMI). Psychology, 15, 1208-1220. https://doi.org/10.4236/psych.2024.157071
[114]	Braun, V. and Clarke, V. (2006) Using Thematic Analysis in Psychology. Qualitative Research in Psychology, 3, 77-101. https://doi.org/10.1191/1478088706qp063oa
[115]	Braun, V. and Clarke, V. (2021) Thematic Analysis. SAGE Publications.
[116]	Byrne, D. (2021) A Worked Example of Braun and Clarke’s Approach to Reflexive Thematic Analysis. Quality & Quantity, 56, 1391-1412. https://doi.org/10.1007/s11135-021-01182-y
[117]	Braun, V. and Clarke, V. (2019) Reflecting on Reflexive Thematic Analysis. Qualitative Research in Sport, Exercise and Health, 11, 589-597. https://doi.org/10.1080/2159676x.2019.1628806
[118]	Nowell, L.S., Norris, J.M., White, D.E. and Moules, N.J. (2017) Thematic Analysis: Striving to Meet the Trustworthiness Criteria. International Journal of Qualitative Methods, 16. https://doi.org/10.1177/1609406917733847
[119]	Chum, J., Kim, M.S., Zielinski, L., Bhatt, M., Chung, D., Yeung, S., et al. (2017) Acceptability of the Fitbit in Behavioural Activation Therapy for Depression: A Qualitative Study. Evidence Based Mental Health, 20, 128-133. https://doi.org/10.1136/eb-2017-102763
[120]	Hardcastle, S.J., Hancox, J., Hattar, A., Maxwell-Smith, C., Thøgersen-Ntoumani, C. and Hagger, M.S. (2015) Motivating the Unmotivated: How Can Health Behavior Be Changed in Those Unwilling to Change? Frontiers in Psychology, 6, Article 835. https://doi.org/10.3389/fpsyg.2015.00835
[121]	Vancampfort, D., De Hert, M., Broderick, J., Lederman, O., Firth, J., Rosenbaum, S., et al. (2016) Is Autonomous Motivation the Key to Maintaining an Active Lifestyle in First-Episode Psychosis? Early Intervention in Psychiatry, 12, 821-827. https://doi.org/10.1111/eip.12373
[122]	Burton, A., Osborn, D., Atkins, L., Michie, S., Gray, B., Stevenson, F., et al. (2015) Lowering Cardiovascular Disease Risk for People with Severe Mental Illnesses in Primary Care: A Focus Group Study. PLOS ONE, 10, e0136603. https://doi.org/10.1371/journal.pone.0136603
[123]	Roberts, S.H. and Bailey, J.E. (2011) Incentives and Barriers to Lifestyle Interventions for People with Severe Mental Illness: A Narrative Synthesis of Quantitative, Qualitative and Mixed Methods Studies. Journal of Advanced Nursing, 67, 690-708. https://doi.org/10.1111/j.1365-2648.2010.05546.x
[124]	Harvey, C., Ratcliffe, P. and Gulliford, M.C. (2020) Well-Being, Physical Activity and Long-Term Conditions: Cross-Sectional Analysis of Health Survey for England 2016. Public Health, 185, 368-374. https://doi.org/10.1016/j.puhe.2020.06.013
[125]	Tee, H., Priebe, S., Santos, C., Xanthopoulou, P., Webber, M. and Giacco, D. (2020) Helping People with Psychosis to Expand Their Social Networks: The Stakeholders’ Views. BMC Psychiatry, 20, Article No. 29. https://doi.org/10.1186/s12888-020-2445-4
[126]	Wood, L. and Alsawy, S. (2017) Recovery in Psychosis from a Service User Perspective: A Systematic Review and Thematic Synthesis of Current Qualitative Evidence. Community Mental Health Journal, 54, 793-804. https://doi.org/10.1007/s10597-017-0185-9
[127]	Chew, H.S.J., Rajasegaran, N.N., Chin, Y.H., Chew, W.S.N. and Kim, K.M. (2023) Effectiveness of Combined Health Coaching and Self-Monitoring Apps on Weight-Related Outcomes in People with Overweight and Obesity: Systematic Review and Meta-Analysis. Journal of Medical Internet Research, 25, e42432. https://doi.org/10.2196/42432