The barriers to participation in leisure time physical activities among Iranian women with severe mental illness: A qualitative study

Mental Health and Physical Activity xxx (2017) 1e7

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The barriers to participation in leisure time physical activities among Iranian women with severe mental illness: A qualitative study Leeba Rezaie a, *, Narges Shafaroodi b, David Philips c a

Sleep Disorders Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran Department of Occupational Therapy, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran c Department of Psychology, 341 Science Complex, Eastern Michigan University, Ypsilanti, MI, 48197, USA b

a r t i c l e i n f o

a b s t r a c t

Article history: Received 10 June 2017 Received in revised form 18 September 2017 Accepted 22 September 2017 Available online xxx

Background and objectives: Sedentary behavior and physical inactivity are known risk factors for poor health and increased mortality in patients with severe mental illness. Identifying the barriers to participation in leisure-time physical activities among these patients can be helpful in planning effective interventions aimed at increasing activity level. Prior to the present study, the barriers experienced by female patients in Iran were unknown. Materials and methods: This was a qualitative study using conventional content analysis. Participants were 32 women with severe mental illness who were hospitalized at women's psychiatric wards of Farabi Teaching Hospital in Kermanshah, Iran, from September 2015 to March 2016. Data were collected through four focus group discussion sessions and were then analyzed. Results: Participants had a mean age of 42 (SD ¼ 7.8) and an active diagnosis of schizoaffective disorder (n ¼ 10), schizophrenia (n ¼ 8), a chronic bipolar disorder (n ¼ 8), or major depression disorder (n ¼ 6). Two main barrier categories emerged: Personal experience of disease and Non-supportive context. Within the former, stigma of disease, signs and symptoms of disease, and medication side effects were the constituent subcategories. Non-supportive context subcategories consisted of family, cultural, environmental, and medical staff barriers that influenced non-participation in leisure-time physical activities. Conclusion: Iranian women with severe mental illness face a number of barriers to participation in leisure-time physical activities including the stigma, symptoms, and treatment of mental illness; and contextual barriers such as family expectations, societal perceptions, environmental factors, and lack of medical staff support. It is recommended that providers consider these factors when developing therapeutic plans for similar patient populations. © 2017 Elsevier Ltd. All rights reserved.

Keywords: Severe mental illness Leisure time physical activity Barriers Qualitative study

1. Introduction Patients with severe mental illness (SMI) such as schizophrenia, schizoaffective disorder, major depression, and chronic bipolar disorders have poorer physical health and a reduced life expectancy (i.e., 20e30% lower) when compared to the general public (Colton & Manderscheid, 2006; Daumit, Pratt, Crum, Powe, & Ford, 2002). Rates of mortality, due to all causes, and suicide are also elevated among individuals diagnosed with a mental illness (Chesney, Goodwin, & Fazel, 2014). Walker, McGee, and Druss (2015) * Corresponding author. Kermanshah, Dovlat Abad Blvd, Farabi Hospital, Sleep Disorders Research Center, Kermanshah University Of Medical Sciences, Kermanshah, Iran. E-mail addresses: [email protected] (L. Rezaie), [email protected] (N. Shafaroodi), [email protected] (D. Philips).

reported that 8 million deaths each year can be attributed to mental illness. Studies suggest that the increased mortality rate in these patients is not solely due to higher risk of suicide; rather, cardiovascular diseases (CVD), such as myocardial disease, are among the most common causes of mortality in this group (Miller & Bauer, 2014; Ringen, Engh, Birkenaes, Dieset, & Andreassen, 2014). Researchers have reported that CVD accounts for 40e50% of deaths among individuals diagnosed with schizophrenia (Ringen et al., 2014), and 35e40% of deaths among individuals diagnosed with a bipolar disorder (Miller & Bauer, 2014). Factors such as obesity, tobacco smoking, diabetes, hypertension, lack of physical activity, the use of second-generation antipsychotic medications (associated with the risk of weight gain and metabolic syndrome), and the lack of access to health systems contribute to the higher risk of CVD among individuals with SMI (Baxter, Charlson, Somerville, & Whiteford, 2011; Carliner et al., 2014; Scott,

https://doi.org/10.1016/j.mhpa.2017.09.008 1755-2966/© 2017 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Rezaie, L., et al., The barriers to participation in leisure time physical activities among Iranian women with severe mental illness: A qualitative study, Mental Health and Physical Activity (2017), https://doi.org/10.1016/j.mhpa.2017.09.008

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Platania-Phung, & Happell, 2012). Concerns about the physical health of these patients have prompted the creation and implementation of lifestyle interventions that have become one of the pillars of the recovery process (Silverstein & Bellack, 2008). Participation in physical activities, weight control, healthy and balanced diets, and participation in health-promoting activities are
ndez-Santhe main components of these interventions (Ferna Martín et al., 2014; Verhaeghe, De Maeseneer, Maes, Van Heeringen, & Annemans, 2011). The present study focuses on physical activity in particular. Multiple categories of physical activity have been identified, including occupational physical activity (i.e., activity completed in the course of one's occupation), incidental activity, commuting activity, and leisure-time physical activity (LTPA), which is the focus of the present study. LTPA includes all forms of aerobic activities, structured endurance exercise programs, resistance-training programs, and sports (Howley, 2001). LTPA is considered a main component of a healthy lifestyle and its positive health effects (i.e., improved cardiovascular function, increased respiratory capacity, weight control, depression prevention, and reduced psychiatric symptoms (Hamasaki, 2016; Takahashi et al., 2012) have been demonstrated. As suggested above, evidence indicates that patients with SMI tend to have sedentary lifestyles and experience significant barriers to participation in LTPA (Faulkner, Cohn, & Remington, 2006; Vancampfort, Probst, Knapen, Carraro, & De Hert, 2012b; Vancampfort et al., 2011), despite evidence that exercise is safe and improves health outcomes among individuals with SMI (Mason & Holt, 2012; Richardson, Avripas, Neal, & Marcus, 2005; Stanton & Happell, 2014). Several researchers have investigated the reasons for inactive lifestyles among patients with SMI. Roberts and Bailey (2011) conducted a narrative review of quantitative, qualitative, and mixed method studies, and reported that lack of support, symptom illness, treatment effect, and negative staff attitudes are common barriers. Vancompfort and colleagues (2012a) also reported that side-effects of antipsychotic medications, negative psychiatric symptoms, lack of knowledge about cardiovascular risk factors, disbelief in the positive effects of physical activity, and social isolation reduce physical activity among individuals with SMI. Recently, Firth et al. (2016) conducted a meta-analysis of motivating factors and barriers to exercise among patients with SMI. Low mood, stress, and lack of support were the most common barriers. The authors concluded by emphasizing the critical role of providers in reducing barriers and maintaining patient motivation (see also Soundy, Kingstone, & Coffee, 2012). Research on barriers to LTPA is critical for the development of effective interventions, yet to the best of our knowledge, no studies to date have been conducted in Iran as per the review of reliable databases (i.e., Pubmed, Google scholar, Ovid, and Iran doc). Given the unique cultural influences experienced by patients and providers in Iran, research into this area is necessary. Further, females experience unique socio-cultural barriers, thus research focusing on women is warranted (Joseph, Ainsworth, Keller, & Dodgson, 2015; Persson, Mahmud, Hansson, & Strandberg, 2014). Lastly, the use of qualitative methods are well suited for capturing and exploring barriers to participation because non-participation in LTPA is a subjective experience that can be affected by many factors. Therefore, the present study was conducted using a qualitative approach to elucidate the barriers to participation in LTPA among females with SMI being treated in Iran. 2. Methods 2.1. Study setting and participants Participants (N ¼ 32) consisted of adult females diagnosed with

SMI being hospitalized in the women's psychiatric wards of Farabi Teaching Hospital in Kermanshah, Iran, from September 2015 to March 2016. At this hospital, patients are admitted for treatment during periods of acute symptom presentation for a maximum of 2 months. Patients return to their respective communities after remission. Individuals were recruited using purposeful sampling and sample size was based on the principles of data saturation (Palinkas et al., 2015). The inclusion criteria consisted of a diagnosis of SMI made by a psychiatrist based on a set of psychiatric evaluations, willingness to participate in the study, and stabilization of psychiatric symptoms (i.e., the symptoms of illness had subsided and the patient was ready for discharge as confirmed by the psychiatrist). The exclusion criteria consisted of having received electroconvulsive therapy in the past three months because it can interfere with recall, symptoms of paranoia because they can impact group attendance/participation, and debilitating medication side effects (i.e., alogia, dizziness and drowsiness) that can interfere with active participation. It is estimated that approximately 40 patients were excluded, though the exact number was not recorded. Table 1 presents participant demographic characteristics. This research was carried out with the approval of the research council of Kermanshah University of Medical Sciences after obtaining permission from the ethics committee of the university. The participants were given full and clear explanations about the study objectives and the confidentiality of their data/identity. All participants provided their verbal consent to the researcher. 2.2. Data collection Data were collected through focus group discussion sessions held in the women's ward's occupational therapy unit. Focus group discussion is a qualitative data collection method that leverages group dynamics to promote a candid discussion of topics (Napolitano, McCauley, Beltran, & Philips, 2002). In this study, four focus group discussion sessions were held, each with 8 participants in attendance. The first author, who had sufficient experience in holding focus group discussions, facilitated these sessions. At each meeting, the participants were first briefed on the study objectives, the group members were introduced to each other, and questions were then posed in accordance with the research objectives. These questions had already been established by the

Table 1 Participants’ demographic characteristics. Variable

N

Age Duration of Illness (years) Marital Status Single Married Divorced Education Illiterate Primary school education Below high school diploma High school diploma Advanced diploma and above Occupation Housewife Corporate employee Unemployed (Non-students) Diagnosis based on the Patient's Records Schizophrenia Schizoaffective disorder Chronic bipolar disorder Major depression

42 (M; SD ¼ 8.7) 9 (M; SD ¼ 2.1) 8 17 7 7 5 12 4 4 22 3 7 8 10 8 6

Please cite this article in press as: Rezaie, L., et al., The barriers to participation in leisure time physical activities among Iranian women with severe mental illness: A qualitative study, Mental Health and Physical Activity (2017), https://doi.org/10.1016/j.mhpa.2017.09.008

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research team and given to the group director as an interview guide (see Appendix 1). The sessions began with one of the predetermined prompts (e.g. Please talk to us about your experiences of participating in leisure time physical activities) and continued with follow-up questions to promote discussion (e.g., Please elaborate or Give us an example). Tea and cake were served at the end of each session. The sessions lasted 60 min each. The first author directed all the sessions, which were audio recorded. An assistant therapist with shorthand skills attended and took notes. 2.3. Data analysis The present study used qualitative content analysis in which data are collected from the participants and codes and categories are extracted directly from the crude data using an inductive method (Speziale & Carpenter, 2007; Strauss & Corbin, 1990). Predetermined categories as well as the researcher's theoretical perspective are not imposed on the data. Specifically, data were analyzed using the following method proposed by Graneheim and Lundman (2004). First, the first author transcribed the recorded group discussions verbatim. Then, the transcribed text was reviewed several times and a general understanding of it was written down. Next, both the first author and second author re-read the transcribed text line-by-line, underlining key statements and identifying the meaning units (i.e., emergent themes and ideas). Then, relevant codes were assigned to these units. The extracted codes were organized into subcategories according to similarities. Then subcategories with at least one common feature were placed into a broad category. This produced homogeneity within categories and heterogeneity between categories (Graneheim & Lundman, 2004; Hsieh & Shannon, 2005). To ensure the trustworthiness and rigor of the data analysis, prolonged engagement with the data, peer check, member check, and external check were used as key strategies in the study (Lincoln, 1995). The transcripts and the extracted codes were reviewed several times and the research team debated the results of the data analysis during its weekly meetings. In addition, some of the participants reviewed the transcripts and analyses and provided feedback. The research data and their analysis were also distributed to another qualitative researcher, not involved in data gathering, for external critical evaluation. 3. Results Two main categories were extracted during data analysis: Personal experience of disease and Non-supportive context. Each primary category was comprised of multiple related, yet distinct subcategories, which too were comprised of particular codes. Table 2 presents the categories, subcategories, and codes. The following sections describe each category and their constituent components. 3.1. Personal experience of disease Personal experience of disease refers to factors that are directly related to the effects of SMI on the participants’ psychological and physical health status. This category is comprised of three subcategories: Stigma of disease, Signs and symptoms of disease, and Medication side effects. Each subcategory is described in the following sections. Stigma of disease. Participants reported that negative public perceptions of mental illness (i.e., mental-health stigma) contribute to a loss of motivation and unwillingness to participate in LTPA. They indicated that being labeled a psychiatric patient impacted their sense of self-value. One participant explained:

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Table 2 Extracted codes, subcategories, and categories. Categories Personal experience of disease Subcategories and Codes Stigma of disease Label of psychiatric patient Judgment of others Fear from rejection Signs and symptoms of disease Loss of energy Fatigue Hopelessness Medication side effects Confusion Increased appetite Sleepiness

Non-supportive context Subcategories and Codes Cultural barriers Non-acceptance of women exercising Non-acceptance of group exercise Environmental barriers Lack of facilities Occupational demands Non-supportive family Lack of support Lack of value for physical activity No budget for physical activity Non-supportive medical staff Not included in treatment No recommendation from psychiatrist

Note: bold font indicates categories and subcategories; indentation within subcategories indicates constituent codes.

“Being labeled as mentally ill makes you feel worthless. You lose all your hope in the future and have no motivation to exercise” (P5). The participants also stated that they could not attend gyms because they were concerned about people's judgment and potential rejection. One participant said: “Well, one has to go to the gym, but I always feel that people look at me differently and may not accept me. So, I prefer not to sign up for the gym” (P12). Signs and symptoms of disease. Participants consistently cited the symptoms of their psychiatric diagnoses as primary barriers to LTPA. This subcategory is comprised entirely of negative psychiatric symptoms, including amotivation, apathy, malaise, fatigue and lack of energy. Notably, one participant said: “This illness tires you out and deprives you of energy, so you always want to be alone and have no energy to do anything or exercise” (P17). Another participant stated that: “I think it is the nature of the illness. When you are ill, you became very indifferent to everything, to your life, to your health. So you did not have the desire to do anything such as exercise ” (P3). Participants reported that low self-confidence and hopelessness, common symptoms of SMI, also served as barriers to physical activity engagement, especially in public. One woman stated: “I feel embarrassed to go to the gym, and I can't exercise alone at home. I have no self-confidence, and this prevents me from exercising, even though it is so good for me” (P2). Medication side effects. The participants reported that they were unable to take part in LTPA due to the side effects of their medications. One participant explained: “The medications we take make us dizzy and drowsy and increase our appetite. I get up at eleven, and it's already noon by then, so I don't get to do anything, let alone exercise. Then we see we've gained weight and can't do anything about it” (P7). Another participant explained medication side effects this way:

Please cite this article in press as: Rezaie, L., et al., The barriers to participation in leisure time physical activities among Iranian women with severe mental illness: A qualitative study, Mental Health and Physical Activity (2017), https://doi.org/10.1016/j.mhpa.2017.09.008

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“Our medications make us good, but it makes us like a robot. We cannot move very easy, we cannot talk easy. Because of this exercise is a difficult task for us” (P11). 3.2. Non-supportive context Non-supportive context refers to socio-cultural factors that prevent participation in LTPA. This category is comprised of four subcategories: Cultural barriers, Environmental barriers, Nonsupportive family, and Non-supportive medical staff. Each subcategory is described in the following sections. Cultural barriers. Exercise among women, especially group exercise in public places, was not viewed as culturally acceptable. Participants reported that this lack of acceptance makes women uncomfortable about taking part in physical activities, regardless of mental health status. One participant stated: “I think culture has a great influence, and in our culture, there is no room for women's exercise. There are a lot of women with no psychiatric illness who do not exercise either. Exercise is not a part of life for women in this culture ” (P19). Relatedly, participants reported that physical activity is not valued among women in Iran, and that this is an intergenerational phenomenon. One participant said: “In our culture, a daughter learns all important things from her mother in childhood. My mother herself, did not exercise, and did not tell me. Perhaps it is not important in our culture” (P18). Another participant also said: “In our culture, which is a traditional culture, we did not have a proverb, an example to value female exercise. I learned that a woman who works well at home is an ideal woman. I think our culture should consider the value of exercise for women” (p27). Environmental barriers: The participants reported that their living environment and the lack of access to recreational facilities also affect participation in LTPA. According to the data, participants came from rural settings that demand time consuming labor (e.g., farming land) and have limited facility resources. One participant said: “We are livestock farmers and agricultural workers in our village, and are so busy on the land and farm that we have no time for anything else. We have to do both the house chores and work on the farm. Besides, we don't have parks or gyms to exercise in, it's not like cities” (P21). Another participant reported: “I think the possibilities are important. In a city there are parks with devices for exercise, and both men and women go to the parks and do exercise. Perhaps, if there were parks, we would also find a little time to exercise” (P14). Non-supportive family: Participants consistently reported that their families do not support female participation in LTPA. They clarified that other family-centered obligations consistently take precedence. One participant stated: “The family expects me to look after my life, take care of the children and, prepare the meals rather than exercise. My husband says that I should look after my life, and he asks, what good is exercise going to do for us?” (P16).

The participants also explained that they do not receive financial or social support to participate in LTPA. One participant said: “Exercise has had no place in our family from the start. They won't give me any money if I decide to go to the gym. Even if I ask my mother to join me on a walk, she won't cooperate” (P3). Furthermore, participants with no background in LTPA reported that their families would likely pathologize their behavior. One participant explained: “We were never the exercising type from the start, so, if we are to begin exercising now, they'll think, she's not well, we should have her hospitalized” (P14). Non-supportive medical staff. Participants consistently reported that their treatment regimens did not encourage physical activity. They stated that medical staff, especially psychiatrists, do not particularly emphasize LTPA. Therefore, there is no motivation to overcome barriers to participation. One participant said: “I have been hospitalized many times, and this is the first time I have heard about the importance of exercise in here. My doctor only advises me to take my medications. And I do. Perhaps I would have done that too, had he said anything about it. After all, doctors know better than we do” (P30). Another participant also stated: “I think psychiatrists' statements are important and nursing staffs' statements are also important. They obligate themselves to give us the medication. It would be better if they advised us to do physical activity” (P19). 4. Discussion The present study was conducted to explore the barriers to LTPA participation among females with SMI being treated in Iran. The two primary barrier categories, Personal experience of disease and Non-supportive context, were extracted from participant statements. These findings concur with the results of other studies conducted on this subject (Corrigan, Rafacz, & Rüsch, 2011; Corrigan, Watson, & Barr, 2006; Faulkner et al., 2006; Tsang, Fung, & Chung, 2010; Vancampfort et al., 2011, 2012a) and provide clinically useful information. In particular, the Personal experience of disease category highlights the direct effect that SMI has on LTPA engagement. Within this category, participants cited the stigma of illness as a factor that depletes motivation to perform physical activities. Moreover, participants reported an internalization of mental health stigma (i.e., ‘self-stigmatization’), which is consistent with prior findings (Corrigan et al., 2006). Researchers have consistently found that self-stigmatization is associated with poor self-confidence, dysphoria, social isolation, and affects the process of treatment in psychiatric illnesses (Corrigan et al., 2011; Tsang et al., 2010). It is therefore essential to implement strategies to alleviate self-stigma. Consumer-based stigma reduction programs in which patients with SMI and mental health providers receive information about stigma and its treatment have been suggested (Michaels et al., 2014). Similarly, shared engagement in physical activity programs by medical staff and patients is another practical strategy likely to reduce stigma and increase activity levels. Disease symptoms such as lack of energy, malaise, and fatigue were also identified, which is consistent with prior research.

Please cite this article in press as: Rezaie, L., et al., The barriers to participation in leisure time physical activities among Iranian women with severe mental illness: A qualitative study, Mental Health and Physical Activity (2017), https://doi.org/10.1016/j.mhpa.2017.09.008

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Vancompfort and colleagues (2012a) reported that symptoms of SMI are common barriers to participation in physical activities, and negative symptoms in particular have been shown to reduce activity levels (Cella, Edwards, & Wykes, 2016). These findings suggest that the assessment and treatment of negative symptoms are essential components of effective physical activity interventions. The present study and prior research (Roberts & Bailey, 2011; Vancampfort et al., 2012a) have also identified medication side effects (e.g., dizziness, drowsiness, and increased appetite) as barriers to LTPA. Patients frequently experience medication side effects that may lead to low activity, weight gain, and increased appetite. Moreover, these symptoms are interrelated in nature, such that weight gain reduces physical activity, which in-turn leads to weight gain. Although the importance of taking medications cannot be overlooked in these patients, their doses should be carefully managed in accordance with their symptoms. Providing patients with information about proper nutrition and weight control strategies may also be effective in the management of weight gain and its associated sedentary lifestyle. The present study also identified multiple socio-cultural contextual barriers that impact LTPA participation. These included cultural, environmental, family, and treatment related barriers. Cultural barriers refer to cultural constraints on women's decisions to exercise in public places. Multiple women reported that female exercise in public is culturally taboo in Iran. This finding is consistent with other evidence that Iranian women's mental health suffers as a consequence of cultural taboos (Khankeh, Hosseini, Rezaie, Shakeri, & Schwebel, 2015; Rezaie et al., 2014). Participants also reported and that women simply do not value LTPA. The broad lack of interest in LTPA among women in Iran may be a core barrier. Therefore, it is recommended that authorities (e.g., public health administration, and municipalities) address these taboos by promoting cultural awareness about the positive health effects of LTPA and devising public health initiatives that encourage physical activity engagement among women, irrespective of mental health status. In particular, the construction of dedicated spaces for women's exercise may be very effective in shifting community and cultural views. Environmental barriers refer to occupational obligations common in rural communities, which include women's participation in agricultural and livestock farming. This subcategory also refers to the general lack of exercise facilities in villages. These factors have not been identified or discussed in previous studies. Although agricultural work and livestock farming require motor activities, they do not qualify as LTPA because they are mandatory and may not produce the positive health effects garnered from LTPA
rrez-Fisac et al., 2002; King et al., 2001). Building exercise (Gutie facilities in rural areas would allow easy access to LTPA spaces and may promote participation in physical activities throughout the community. Lack of family support was also identified as a barrier to LTPA. Participants reported that their families do not prioritize physical activities and do not invest time/money on such activities. These findings are consistent with Aschbrenner et al. (2013) who noted that families play a key role in encouraging or discouraging healthy behaviors related to diet and exercise. Given the central role of the family, public health and therapy interventions aimed at educating families about the importance of LTPA are imperative. Promoting LTPA among all family members as a part of treatment may reinforce physical activity, limit stigma associated with sudden behavior change, and enhance family wellbeing. Finally, Non-supportive medical staff was a barrier to participation in LTPA. Participants reported that their medical team members, especially psychiatrist, do not emphasize the therapeutic effects of participating in physical activity. This relationship is likely

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bi-directional given documented reticence toward nonpharmacological treatments among Iranian patients (Khazaie, Rezaie, & de Jong, 2013; Khazaie, Rezaie, Shahdipour, & Weaver, 2016). Therefore, it seems medical staff have an important role in encouraging patient participation in physical activities. Practically, if psychiatrists emphasize LTPA as a central treatment component, patients may perceive it as valuable. The present study identified multiple distinct barriers that impact LTPA participation among women with SMI in Iran. However, these barriers do no operate in isolation. They interact with each other, the environment, and the individual to form a complex psycho-social milieu. Law et al. (1996) offered the PersonEnvironment-Occupational (PEO) model as a way to capture this transactional relationship. In brief, PEO identifies the individual, the environment (including cultural, family, and social elements), and the occupation(s) (i.e., functional tasks and activities completed to meet ones needs for self-maintenance) as conceptual units that interact across the lifespan to influence behavior. PEO highlights that maintenance factors and intervention targets should be considered through a transactional lens. For example, lack of proper facilities (environmental barrier) impacts and is impacted by non-acceptance of group exercise (cultural barrier), which in-turn influences the individual's willingness to engage in LTPA. An intervention aimed at increasing acceptance of group exercise may benefit from the construction/designation of community recreational facilities. It is therefore recommended that providers use a transactional lens, like PEO, when addressing barriers to LTPA at the individual and community level. 4.1. Limitations The present study is the first to analyze barriers to LTPA among women with SMI in Iran. Nonetheless, there are some limitations. First, the research team did not collect information about body mass index (BMI) or physical activity level using a standard questionnaire. This information could have improved our sample description and analyses. Secondly, this study restricted the sample to only female participants with SMI, which limits the generalizability of the findings. Moreover, barriers to participation were not studied from the perspective of medical teams, psychiatrists, or patient families. These sources may have identified additional, important factors affecting LTPA participation. 5. Conclusion and implications Although results cannot be generalized to all patient populations, there are several conclusions and implications warranted by this study. First, the study showed that participation in LTPA among females with SMI is affected by two broad categories of barriers: Personal experience of disease and Non-supportive context. The barriers related to Personal experience of disease refer to factors such as the stigma of mental illness, disease symptoms, and medication side effects. The Non-supportive context related barriers include factors such as family, cultural, environmental, and medical treatment barriers. Per the PEO model, comprehensive interventions should be developed that account for the transactional nature of these broad categories and subcategories. Additionally, further research is needed to explore interactions among barriers, which may influence public policy and clinical treatment. This study also reiterates the unique experience of women, both with and without SMI, living in Iran. Multiple researchers have now identified that women commonly lack family support for engaging in LTPA and have limited access to appropriate facilities (Joseph et al., 2015; Persson et al., 2014). The present study corroborated

Please cite this article in press as: Rezaie, L., et al., The barriers to participation in leisure time physical activities among Iranian women with severe mental illness: A qualitative study, Mental Health and Physical Activity (2017), https://doi.org/10.1016/j.mhpa.2017.09.008

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these findings and emphasizes that Iranian females with SMI are faced with additional barriers related to the personal experience of their diagnosis. Accordingly, community level programs should be developed that target barrier reduction among women in general, but additional services are needed that address illness related barriers, such as stigma reduction, medication management, and provider training programs that emphasize LTPA among patients with SMI. Conflict of interest The authors have no conflict of interest. Acknowledgements Hereby, we would like to express our gratitude to all the participants for sharing their experiences. Appendix 1 Interview guide.  Please describe your experience in participating in leisure time physical activity?  Please describe your understanding about the impact of physical activity on your health?  Please describe the barriers women experience in participation in leisure time physical activity?  Please describe the barriers you experience in participation in leisure time physical activity?  What supports may help you to overcome the barriers?  What supports would encourage your participation in leisure time physical activity?

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Please cite this article in press as: Rezaie, L., et al., The barriers to participation in leisure time physical activities among Iranian women with severe mental illness: A qualitative study, Mental Health and Physical Activity (2017), https://doi.org/10.1016/j.mhpa.2017.09.008