Embedding Physical Activity into Community-Based Peer Support Groups for those Severely Affected by Mental Illness

This research paper investigates the impact of integrating physical activity into community-based peer support groups for individuals with severe mental illness (SMI). It addresses a critical gap in the literature, as existing studies on community-based physical activity interventions for mental health often overlook individuals with SMI, a population characterized by poorer physical health and lower physical activity levels compared to the general population. The study also examines the under-researched role of peer support groups in this context, despite documented benefits in other areas. The research question focuses on understanding the impact and processes involved in embedding physical activity within these peer support groups, considering the social dynamics, the preference for informal activities over organized sports, the challenges of project implementation, and the influence of unforeseen events such as the COVID-19 pandemic. The importance of this study lies in its potential to inform the development of more effective and inclusive interventions to improve the physical and mental health of individuals with SMI, a population facing significant health disparities and often struggling with social isolation. The study's nationwide scope, utilizing a national charity's existing peer support network, offers valuable insights into the practicalities and complexities of implementing such interventions across diverse communities. The paper employs a mixed-methods approach, focusing primarily on the qualitative analysis of interview and focus group data to capture the rich experiences of participants.

The introduction extensively reviews existing literature on the relationship between mental health and physical activity across various settings such as community settings, secure mental health settings, and community sports settings. It highlights the documented physical and psychosocial benefits of physical activity for individuals with poor mental health, including improved cardiovascular fitness, reduced social isolation, and enhanced social skills. The literature further emphasizes the role of physical activity in mental health recovery, referencing the CHIME framework (connectedness, hope, identity, meaning, empowerment) which highlights the impact of physical activity on social interaction, self-identity, and empowerment. Despite the growing body of evidence, the review identifies a crucial gap in research on community-based physical activity interventions specifically targeting individuals with SMI. This population often experiences poorer physical health, lower activity levels, and increased mortality rates compared to the general population. While some studies have shown positive effects of physical activity for individuals with SMI, they are often small-scale and lack exploration of the role of peer support. The review also mentions barriers identified by previous studies, including psychological and socio-ecological barriers, and stresses the importance of larger-scale, nationwide projects that address the diverse contexts and challenges faced by this specific population.

The study employs a mixed-methods approach, but this paper focuses solely on the qualitative component. The philosophical underpinnings of the study are rooted in a relative ontology (acknowledging multiple subjective realities) and a constructionist epistemology (recognizing the socially constructed nature of knowledge). This approach is deemed suitable given the complexity of the nationwide project and its diverse participant population. Semi-structured individual and focus group interviews were used as the primary data collection methods. Participants included peer support group members, group leads, group development officers (GDOs), and project managers. Ethical approval was obtained from the Non-invasive Human Ethics committee at the first author's institution. The researchers incorporated peer researchers with lived experience of SMI into the evaluation process. These peer researchers were trained in ethical research practice, data collection, and analysis, and contributed significantly to the study. Data were collected through in-person and remote interviews and focus groups. The interview guides were developed based on existing literature and the research aims. Focus groups with peer support group members focused on their experiences, views on physical activity, and mental and physical health. Interviews with group leads explored their backgrounds, views on physical activity, experiences embedding physical activity, and opinions on the project toolkit. Interviews with GDOs and project managers addressed project delivery, recruitment, perceptions of impact, and identified facilitators and barriers. Data analysis involved a reflexive thematic analysis, an inductive approach allowing themes to emerge from the data while considering the research aims and existing literature. Multiple researchers independently analyzed transcripts, generating codes and initial themes, followed by group discussions involving the entire research team (including peer researchers) to refine and interpret the themes. The researchers ensured rigorous analysis through critical friend feedback, aiming to fully interrogate the data and produce a robust analysis.

The qualitative analysis revealed four key themes: 1. **The Social Aspects of Embedding Physical Activity in Peer Support Groups:** The social aspects of the groups were considered at least as beneficial as the physical activity itself. Participants highlighted the importance of trust, shared experiences, and a sense of belonging, noting that the social interaction within the group was a major motivator for continued engagement with physical activity. Support from peers was vital, aiding in physical and mental health improvements and mitigating social isolation. The simple act of sharing coffee and conversation was valued highly. 2. **Focus on Peer Support and Informal Physical Activity (Rather Than Organised Sport):** There was considerable diversity in types and frequency of physical activities. Informal activities such as walking were preferred due to their accessibility and ability to adapt to individual needs and attendance patterns. Organized sports posed challenges due to unpredictable attendance and requiring a minimum number of participants. The flexibility of informal activities allowed participants to easily re-engage if they missed sessions. 3. **Doing Things Differently and Lessons to Learn:** Participants suggested improvements for future projects, emphasizing realistic timescales, providing adequate resources and support for group leads, and ensuring project sustainability. The importance of acknowledging and adapting to the diversity of group contexts was highlighted, suggesting that a ‘one-size-fits-all’ approach is ineffective. A longer pre-delivery phase, allowing for co-production and establishing strong group engagement, was deemed crucial. GDOs also pointed out the overly ambitious targets set for the number of participating groups. 4. **The Impact of the COVID-19 Pandemic:** The pandemic had a significant impact on both the delivery of the project and the mental health of participants. The loss of in-person meetings significantly impacted participants' engagement with physical activity and social connection. While some groups used online communication, this was not accessible for all due to technological barriers, highlighting the importance of face-to-face interaction, especially for those with SMI. Although physical activity levels decreased during lockdowns, some participants recognized the renewed value of physical activity for both physical and mental wellbeing.

The findings underscore the crucial role of social interaction in community-based physical activity interventions for individuals with SMI. The social aspect of peer support groups was highly valued, confirming previous research that suggests social elements are at least as important as the physical activity itself. The importance of peer support aligns with the recovery literature, particularly the 'connectedness' aspect of the CHIME framework. The study's findings highlight the need to recognize the diverse needs and preferences of individuals with SMI and to tailor interventions to specific local contexts. The preference for informal physical activity, such as walking, reveals the importance of flexible and accessible activities. The study also emphasizes the vital role of group leaders, who need support to effectively facilitate physical activity and foster a supportive environment. The challenges faced by the project, particularly in terms of unrealistic timescales and communication barriers, emphasize the need for better planning, resource allocation, and co-production across different levels of the project. The study adds to the limited research on community-based peer support interventions with physical activity, providing valuable insights into the needs of this vulnerable population and offering practical recommendations for future interventions.

This research demonstrates the substantial value of incorporating peer support into physical activity initiatives for people with SMI. Key recommendations include prioritizing the social aspects of peer support groups, providing group leaders with adequate training and resources, ensuring comprehensive co-production throughout the project lifecycle, and establishing effective communication channels between organizations and front-line staff. Future research should investigate whether the combination of physical activity and peer support produces greater benefits than either intervention alone. However, the complex nature of SMI necessitates careful consideration of study design to ensure that participant preferences and needs are central to the research process.

The study acknowledges challenges in accessing and engaging with group members. Data collection primarily relied on group leads, potentially limiting the perspectives captured. The COVID-19 pandemic exacerbated these challenges, further impacting data collection and the overall project. Future evaluations should strive for more direct access to participants to enhance the breadth and depth of the findings. The qualitative nature of the study limits the generalizability of some findings; however, the inclusion of peer researchers with lived experience of SMI adds confidence to the applicability of these findings to similar contexts.