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Jump step - a community based participatory approach to physical activity & mental wellness Sims-Gould, Joanie; Vazirian, Sara; Li, Neville; Remick, Ronald; Khan, Karim Aug 31, 2017

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RESEARCH ARTICLE Open AccessJump step - a community basedparticipatory approach to physical activity& mental wellnessJoanie Sims-Gould1* , Sara Vazirian2, Neville Li3, Ronald Remick4 and Karim Khan5AbstractBackground: There is a physical inactivity pandemic around the world despite the known benefits of engaging inphysical activity. This is true for individuals who would receive notable benefits from physical activity, in particular thosewith mood disorders. In this study, we explored the factors that facilitate and impede engagement in physical activity forindividuals with a mood disorder. The intent was to understand the key features of a community based physical activityprogram for these individuals.Methods: We recruited and interviewed 24 participants older than 18 with Major Depressive Disorder or Bipolar II. Theinterviews were conducted by peer researchers. The interviews were transcribed and analyzed using NVivo 10™. Thematicanalysis was used to analyze the data.Results: The facilitators to physical activity include being socially connected with family and friends, building a routinein daily life, and exposure to nature. The barriers to physical activity include the inability to build a routine owing to amood disorder, and high cost. The ideal exercise program comprises a variety of light-to-moderate activities, offers theopportunity to connect with other participants with a mood disorder, and brings participants to nature. The averageage of our participants was 52 which could have influenced the preferred level of intensity.Conclusion: The individuals in this study felt that the key features of a physical activity program for individuals with amood disorder must utilize a social network approach, take into account the preferences of potential participants, andincorporate nature (both green and blue spaces) as a health promotion resource.Keywords: Physical activity, Depression, Anxiety, Mental health, Group medical visits, ExerciseBackgroundGlobally, physical inactivity is “pandemic” [1]. Exercise orregular physical activity is often described as a “polypill” [2]– a single treatment with at least 13 documented healthbenefits. Only 150 min a week of moderate exercise is re-quired to receive the health benefits of physical activity, yetglobally around 31% of adults aged 15 and over were re-ported to be insufficiently active in 2008 (men 28% andwomen 34%) with approximately 3.2 million deaths eachyear linked with insufficient physical activity [3]. Physicalactivity is relatively free of adverse side effects and can be alow-cost treatment, especially when compared topharmaceutical agents. It is known that the promotion ofphysical activity is complex with a myriad of influential fac-tors at play, including patient activation, the built environ-ment, and one’s socioeconomic and demographic status toname just a few [4–9].Mood disorders (e.g., depression, anxiety) are a world-wide health epidemic resulting in significant morbidityand mortality [10, 11]. The rate of physical inactivity iseven higher in these individuals as compared to the gen-eral population putting them at a higher risk of cardiovas-cular events [12]. Nearly two thirds of people sufferingfrom Major Depressive Disorder (MDD) do not meet thephysical activity recommendations [13]. The evidence isunequivocal that in terms of treating a mood disorder,regular physical activity can be as effective as either of themore widely known and used treatments – antidepressant* Correspondence: simsg@mail.ubc.ca1Department of Family Practice, University of British Columbia, 793-2635Laurel Street, Vancouver, BC V5Z 1M9, CanadaFull list of author information is available at the end of the article© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Sims-Gould et al. BMC Psychiatry  (2017) 17:319 DOI 10.1186/s12888-017-1476-ymedication and/or cognitive psychotherapy [14, 15]. Infact, a large Cochrane review of exercise as a treatment fordepression [14] recommended that future research movebeyond efficacy studies and begin to examine what typesof exercise and the number and duration of sessions are ofmost benefit to patients with depression. There is recentresearch showing that individuals with depression preferto be in a walking program multiple times a week [16],and researchers trying to find effective ways to promotephysical activity as an intervention for individuals withpsychosis [17]. A qualitative study with individuals withdepression finds that they view physical activity as an ef-fective treatment, but the desired format of the exerciseand the barriers to participation are varied [18]. To thatend we completed a pilot study of a group based interven-tion for patients with depression (14 weekly 2 h sessions,combining 1 h of physical activity led by a personal trainerwith an hour of group medical visit led by a psychiatrist)demonstrating improvement in patients’ physical activitylevels as well as decreases in their levels of depression andanxiety [19].In building this pilot study (focused on the effectivenessof physical activity for persons with depression and anx-iety), the next step was to examine individual experiencesto gain a comprehensive understanding of the barriers andfacilitators to physical activity for individuals with a mooddisorder. This is the focus of the present study.MethodsCommunity-based research in public health focuses onsocial, structural, and physical environmental inequitiesthrough active involvement of community members,organizational representatives, and researchers in all as-pects of the research process. Partners contribute their ex-pertise to enhance understanding of a given phenomenonand to integrate the knowledge gained with action tobenefit the community involved [20]. A community basedparticipatory research approach was chosen for this pro-ject as it is a method that increases the relevance of thedata collected by engaging the community members withthe lived experience of the problem under research; it pro-motes the sustainability of the program designed as it hastaken into account the actual needs of the service recipi-ents; and the community members also play a significantrole in the design and execution of the project [20–22].Taking these benefits into account, we recruited partici-pants with a diagnosis of depression and/or bipolar dis-order in this study. These individuals served as advisors inthe design and data collection of the study and as partici-pants as per the participatory approach.Participant overviewA sample of 24 participants (average age 52 years) with aDSM-5 diagnosis of Major Depressive Disorder (MDD)(N = 18) or Bipolar II depression (BPII) (N = 6) [19] wererecruited from the Lower Mainland, British Columbia.The inclusion criteria were: 1) age over 18 years; 2) con-firmed psychiatric diagnosis of MDD and/or BPII; 3)community-dwelling and able to attend Group MedicalVisits (GMVs); 4) able to comply with scheduled visits,treatment plan, and other procedures; 5) fluent in English;6) able to provide signed and dated written informed con-sent; and 7) able to walk independently. The exclusion cri-teria included: 1) active psychotic symptoms; and 2) aprimary, active diagnosis of substance abuse.RecruitmentThe University of British Columbia (UBC) BehavioralEthics Board provided ethical approval prior to thestudy’s commencement. We recruited the participantsvia four methods. First, we displayed posters in the wait-ing area of the Mood Disorders Association of BC(MDABC), the psychiatric service areas of major hospi-tals in the Lower Mainland, areas visible to potential vol-unteers within related service organizations such as theCanadian Mental Health Association (CMHA), coffeeshops, community centres, and YMCAs. Second, weposted an advertisement on the websites and distributeda message via the list-serves of related service organiza-tions such as the MDABC, the BC Psychiatric Associ-ation, BC Mental Health & Addiction Services, HealthAuthority Mental Health Services, and the CMHA.Third, we recruited through word-of-mouth at theMDABC and other service agencies. MDABC psychia-trists and staff verbally informed clients of the opportun-ity to participate with the assurance that participation ornon-participation would not affect their access to or thequality of psychiatric care and other services offered bythe MDABC. Fourth, we posted messages on socialmedia such as Facebook and Twitter.The use of peer researchersThe use of peer researchers was an integral component ofour community based participatory research design. Peerresearchers have been used in a variety of communitybased participatory studies to decrease the power differen-tial often created by the traditional researcher-participantapproach [23, 24]. Peer researchers were recruited andtrained to conduct the participant interviews. In the initialmeetings of our community advisory committee, com-prised of individuals with a mood disorder and re-searchers, it was decided that peer researchers would beable to relate to participants and more likely to elicit au-thentic responses. Peer researchers met the same inclu-sion/exclusion criteria as study participants and wererecruited in the same format. In two half-day workshops,UBC investigators trained the peer researchers on the pur-pose of the study and in interviewing techniques. The peerSims-Gould et al. BMC Psychiatry  (2017) 17:319 Page 2 of 8researchers had the opportunity to practice their interviewskills and receive feedback after each interview conducted.They were paid a small honorarium for their time and re-imbursed for public transport/parking expenses. They re-ceived gift cards and were entered in a draw to win one offour $150 gift cards. The training workshops took place inSeptember 2014 and the interviews occurred between No-vember 2014 and October 2015.Data collectionInterviews were conducted one-on-one in a privateinterview room at a UBC senate approved research facil-ity (Center for Hip Health and Mobility (CHHM)) andlasted between 90 and 120 min. Three interviewers werepresent at each interview - two peer researchers and oneresearch assistant (who assisted with note taking). Theinterview guide was designed by UBC investigators andpeer researchers and focused on participant’s historywith physical activity and perceived facilitators and bar-riers to being physically active. Table 1 gives an exampleof the types of questions in the interview guide.Participant demographicsTable 2 highlights key demographic characteristics ofour participants.Data analysisInterviews were audio recorded and transcribed verba-tim using a professional transcription service. We thenremoved participant identifiers and replaced real nameswith pseudonyms. Two members read the transcripts tocome up with a coding framework. They then had a dis-cussion of the frameworks and drafted a preliminaryframework. It was passed along to four other investiga-tors for feedback and suggestions. A final coding frame-work was developed and then one team member codedall 24 transcripts using NVivo 10™ software. We usedthematic analysis [25] and in order to enhance rigor, theteam met repeatedly to discuss emerging themes and toprovide feedback. Peer researchers were also consultedin the process. We also conducted member checking bypresenting the results to a group of peer researchers andparticipants and solicited feedback to “stay true to thedata.” We adhered to COREQ guidelines in this study.ResultsThree main questions we were trying to answer were:facilitators and barriers to physical and mental health;personal strategies to improve health and quality of lifeand the features of an ideal physical activity program forindividuals with mood disorders. The themes thatemerged as a response to our main questions are dis-cussed below in more details.Table 1 Sample interview questionsA - Examples of questions regarding physical activity1. Describe what a typical day looks like for you? Is physical activity apart of your typical day?2. How much time per week are you in nature/the outdoors? Why orwhy not?B - Examples of questions regarding participants’ coping strategies1. What are you currently doing to deal with your anxiety/mooddisorder? Is physical activity a part of it?2. How effective do you find your current treatment options inimproving your quality of life? Why or why not?C - Examples of questions regarding barriers/facilitators to becomingmore physically active1. Is physical activity part of your ideal day? Why or why not? Whatare some of the barriers or facilitators to be physically active?D - Examples of questions regarding ideal physical activity program1. If you were to design the PERFECT physical activity program forYOU, what would it look like and feel like?2. What would some key features be in terms of time, location,duration, types of physical activity, etc.?Table 2 Participant demographicsParticipant Age Gender (Male/Female)Daily AverageSteps001 43 M 4176002 44 F 4461003 52 F 4946004 45 F 8597005 58 F 11,343006 59 F 7255007 56 M 2165008 46 M 7136009 61 M 1562010 54 F 3125011 53 F 2952012 66 F 2297013 55 F 752014 50 M 3131015 47 M 8396016 52 F 4130017 54 F 8118018 66 M 6126019 75 F 6262020 57 M 3450021 53 F 4563022 20 F 3592023 45 F 8562024 50 F 5045Average = 52.5 M = 8F = 16Average = 5089Sims-Gould et al. BMC Psychiatry  (2017) 17:319 Page 3 of 8Facilitators and barriers to physical and mental healthParticipants discussed at length facilitators and barriersto their physical and mental health. Facilitators to posi-tive physical and mental health included the availabilityand presence of social support and the opportunity toengage in social activities. All participants identifiedtheir mood disorder diagnosis as being a threat to boththeir physical and mental health. Participants also spokeabout barriers to engaging in physical activity despiteunderstanding the benefits of being active.FacilitatorsThe most common themes are 1) support from spouse,family or friends, and 2) social activities.Support from spouse, family or friends The vast ma-jority of participants said that their family and friendsgave them the support, encouragement, and practicalhelp around daily tasks so that they could improve theirown health. For example,My husband is very supportive. For a long time he wasmaking almost all the meals and stuff like that. But hehas a really busy job, and the advantage of [for] me? Ican be at my best, or close to. If I could be fullyfunctioning and doing a bunch of stuff that makes hislife better too. (P003, Female, 52)Social activities Among the participants, getting in-volved in social activities with other people, as opposedto spending the day by oneself, was a desired way to im-prove their own health.Q: Do you see that as a part of your treatment, theexercise?A: Oh, yeah, definitely. Definitely helps. Socializingwith people. It helps.Q: And you see socialization as part of your treatment,right?A: Yeah, I think socializing is just a part of life. (P009,Male, 61)BarriersThe emergent theme in this regard is the mood disorderas a formidable barrier in itself creating a vicious cycle:Getting out of bed is hard. I wake up and I feel almostdrugged, and it’s sort of…pulling myself out of theswamp. It’s a comfortable swamp of semi-consciousness. So if I can make myself get up, I’m fine.(P006, Female, 59)In addition, participants spoke about barriers to en-gaging in physical activity despite the known benefits.The most common barrier to engaging in activity wascost. Participants spoke about disruptions to income andlack of financial means to engaging in activity. One par-ticipant stated:A: But– ‘cause I was really enjoying going to yoga, butI’ve taken, like, I’ve paused my membership becauseI have no income right now.Q: So finances are definitely–A: Finances are a huge stressor at the moment. (P024,Female, 50)Personal strategies to improve health and quality of lifeDespite challenges to physical and mental health and en-gagement in physical activity, participants devised a num-ber of ways to improve their own health. These strategieswere highly personal and diverse. However, there werecertain common themes which included getting out of thehouse; building a routine; and, connecting with nature.Getting out of the home/houseA consensus among participants was that not being con-fined to the home was very important. They often men-tioned being “overly-stimulated” and “overwhelmed” bythe outside world because of the number of people,noise and even daylight. Consequently, many partici-pants stayed home most of the time. Participants recog-nized this as a vicious cycle that worsens their mentalhealth, turning something as simple as going outside ofthe house a coping strategy.Q: What do you believe are the most important thingsyou could be doing to improve your mental health?The most important things. So not everything. Justthe most important you could do.A: Just trying to get out. Trying to get out every dayprobably, trying to put some more structure inwithout overdoing it, like, without committing totoo much. (P003, Female, 52)Building a routine/structure in daily lifeSome participants mentioned that having a routine withexpected activities helped them manage their health.Typically, many of these routines involve getting out ofthe house for seeing friends and buying groceries:Getting up every day and kind of having a little bitof a plan for what I need to accomplish. And alsojust, like, having a certain built-in structure of myson goes to school. I can’t let my own depression,anxiety, mental health issues affect his life. … Ineed to make sure that his day is structured, butbecause I need to do this, it gives me a structurefor my day. (P005, Female, 58)Sims-Gould et al. BMC Psychiatry  (2017) 17:319 Page 4 of 8Connecting with natureWhen probed about their relationship with nature, a num-ber of participants said that nature calmed their nerves:I love nature. We’ve got– as I say, we have a mountaincabin. I love being up there. … Breathing room, freshair, peace and quiet. And then the types of activitiesoutside, things like for me, chopping wood, buildingprojects, handyman type work. Taking care of the boat,those sorts of things I enjoy. (P007, Male, 56)Closely related to the enjoyment and serenity that naturebrings, some participants described nature as “natural” forhuman beings. In other words, humans ought to be out-doors in nature more to achieve a natural state of mind:A: Yeah. And nature’s great ‘cause you getdifferentIt’s [nature’s] good for you. I actuallyhappen to like broccoli and I enjoy it. But Iactually really think that people need to get outof an urban environment and into nature– ‘causesometimes I think it’s really unnatural foreverybody to live so shoulder to shoulder.Q: So nature also includes space for everybody.A: Yeah. And nature’s great ‘cause you get differentsmells. You get, like, rich organic smells and you getcrisp smells and you’re not smelling toxins anddiesel. (P005, Female, 58)Participants also noted that connecting with nature in-creased the likelihood of engaging in physical activity:But also because quite often when I’m in the outdoorsI’m being physically active. Like, I’m not just– I’m notbeing rolled to a park and sat there or something. Soit’s usually connected with activity. And just– I find it’svery serene to the point where something like a cell-phone call or something just seems to disrupt the se-renity of– yeah, of the moment. (P008, Male, 46)Features of an ideal physical activity programBased on participant’s discussions of physical activity,facilitators and barriers to physical activity we were ableto distill a list of key features of an ideal physical activityprogram for individuals with mood disorders. These keyfeatures included: the importance of peer support (acommunity of individuals with similar diagnoses); variedactivities; and recommendations on intensity, durationand time of day, and cost.Peer supportParticipants spoke at length about the importance of be-ing part of a caring community with encouragement as acentral tenet. One participant stated:If there was…if I was part of a group, to see thatI’m– or giving me encouragement, whether it bepeople that you’re working out with, or aninstructor, coach type thing, positive … positivereinforcement. (P002, Female, 44)In addition to a caring community, participants alsoidentified that a program specifically for individuals witha mood disorder would have the potential to create asense of community and sharing with other people whowere “in the same boat”. One participant summarizedthis by stating:To share the place with other people with the sameillness like me. Because they don’t go ah, they don’t[sic] going to judge me. And I am not going to judgethem. So we are in the same boat, and we are tryingto get the same reach. (P013, Female, 55)Varied activitiesTo pique participants’ interest and to offer the greatesthealth benefits, a number of participants suggested anall-around fitness program that would include a cardiocomponent, weight training, and activities deemed en-joyable, such as yoga. Another key factor of a perfectprogram is to take the attendees’ interests into account.Many participants mentioned walking, yoga, swimming,and weight lifting as the most desired exercise optionsbecause they were fun, economically feasible, and activ-ities they had done previously.Yeah, you can’t pigeonhole people into something.Doesn’t work. If you try to get somebody who doesn’tlike working out, working out to try and find out if it’sgoing to improve their mental health, they’re going totell you … why are you making me do this? I don’twant to do in the first place. (P015, Male, 47)Intensity, duration, time, costParticipants also offered advice on the structure of a per-fect physical activity program, despite personal prefer-ences; there are general commonalities across all theresponses. The preferred frequency of an ideal programis 2–3 times per week; the intensity is typically light tomoderate; with a duration of 30–60 min. We understandthat the average age of our participants might have influ-enced their preference in terms of their preferred inten-sity. Most participants prefer a session between morningand early evening, with no participant saying that theywant a program offered at night. As identified, lack of fi-nancial resources is a barrier to participation in physicalactivity. Therefore, it is not surprising to hear from par-ticipants that the availability of a free or low-cost pro-gram would go a long way to ensuring program success.Sims-Gould et al. BMC Psychiatry  (2017) 17:319 Page 5 of 8The ideal scenario is that a program would be offeredfree-of-charge.I mean, if it was set up on a six-month program at afairly reasonable cost to get me started, something likethat. Money is always a barrier, but in my case, it’s a– itmight be a barrier, but it’s not an excuse. (P020, Male, 57)DiscussionThe goals of this study were to understand the engage-ment in physical activity among individuals with a mooddisorder, the facilitators and/or barriers for them to be-come physically active and the key features of a physicalactivity program specific to their needs.The majority of the participants were not content withtheir current level of physical activity. There was a generalunderstanding of the importance of physical activity andits positive impact on their mental as well as overallhealth. Some participants did consider it one of the copingstrategies and even regarded it as a part of their treatment.The facilitators of and barriers to physical and mentalhealth closely resembled participants’ discussions of en-gagement in physical activity. For example, participantsspoke at length about the importance of social support;they also discussed supportive features as being key to thesuccess of a physical activity program. This emphasis onsocial support is in alignment with qualitative research onpeople with first-episode psychosis, in which persons withpsychosis are more engaged in moderate-to-vigorous exer-cise with a social network [26]. Participants were veryclear about strategies they employed to promote and im-prove their own health and to enhance their quality of life.These strategies included building a daily routine to “getout of the house” such as walking their children to school.These results echo the findings from a recent study on in-dividuals with longer-term depression. In the study,Chambers et al. [27] found that an individualized modelwith more choices and control facilitates self-managementof depression. Our participants also benefited from theirown choice of physical activity and daily exercises.Levula et al. [28] stated in their study that social net-work factors are associated with mental health acrossthe three life stages of adolescence, adulthood and oldage, and that their findings have implications for mentalhealth intervention design. Many of our participants’coping strategies were related to building a social net-work to avoid social isolation and other negative effectsof mental illnesses. Their established strategies providedkey insights to the design of an ideal physical activityprogram for individuals with a mood disorder, and theincorporation of different ways for participants to de-velop social connections should not be neglected. Theprogram can borrow the concept of a social network ap-proach in community mental health nursing that hasbeen in practice since the 1970s [29]. In this approach,the clinician utilizes the social network of the personwith mental health issues to solve problems collectively.Applying this strategy to exercise interventions for pa-tients with mood disorders, we can gather the friends,family and acquaintances of an individual with a mooddisorder to plan and solve problems together, tostrengthen a sense of solidarity and to lessen the feelingof aloneness. Specifically, the participants in the programcan act as peer support during both good and challen-ging times, the family or friends can offer encourage-ment and a reminder for the individual with a mooddisorder to engage in consistent physical activity, thesports coaches can contribute their expertise on exercisetechniques and be a source of accountability, and the cli-nicians such as psychiatrists or psychologists can edu-cate the participants on the scientific ways to managetheir symptoms. Previous research findings have pointedto the support of mental health staff and the structure ofthe exercise program to be enabling factors to participa-tion among individuals with a mood disorder [30].Researchers have explored the relationship between nat-ural environments or green environments and mentalhealth in fields ranging from epidemiology [31], psych-ology [32] and geography [33]. All of these studies havedemonstrated that the natural environments, whetherproximity to it and/or engaging in physical activity withinit, are effective in boosting a person’s mental health. Finlayet al. [34] found out that both green (e.g., parks, gardens)and blue (e.g., lakes, oceans) spaces have therapeutic ef-fects on older adults. These “therapeutic landscapes” en-hance their physical, mental and spiritual health andwellbeing as well as elicit feelings of renewal, restorationand spiritual connectedness. The authors suggested thatpublic health strategists and urban planners should deviseways to utilize nature as a health promotion resource. In a2016 study [35], outdoor exercises were proved to providemore affective improvements and enhance psychologicalwell-being than indoor exercises to people with depres-sion. In our study, participants’ accounts confirmed thecathartic effects of nature or the outdoors and an in-creased level of physical activity coming from being in na-ture. From this, we suggest that incorporating nature orthe outdoors in a physical activity program for individualswith a mood disorder is essential.Within the literature there is relatively recent evidencethat physical activity is an effective treatment for mooddisorders as opposed to only as a treatment to improvephysical health [36–38]. Vancampfort et al. [39] devel-oped a list of ten questions for researchers to take intoconsideration when attempting to promote physical ac-tivity (PA) for people with bipolar disorders (BD). Exam-ples of these questions include i) what are the keybarriers to PA among people with BD? ii) what are theSims-Gould et al. BMC Psychiatry  (2017) 17:319 Page 6 of 8most effective motivational strategies for ensuring PA adop-tion and maintenance in BD? and iii) If one treatment goalis increased physical activity, what type of professionals areneeded as part of a multidisciplinary team? Besides the ac-tual physical activity program, other factors may also bepivotal to the successful promotion of PA. For example,one quantitative study conducted in Australia found thatamong middle-aged and older adults, in addition to thephysical activity programs, personal safety, the neighbor-hood environment, and social support from family andfriends also improved mental health-related quality of life[40]. In our study, participants confirmed and extendedthese previous findings and offered detailed information onhow to create a physical activity program that is inclusive,non-stigmatizing, and effective. The most important ele-ments include the absence of a power difference betweenthe program facilitators (e.g., psychiatrists, fitness coaches)and the participants, an inviting environment to share ex-periences without feeling judged, peer-to-peer support, alocation that is close to home, a variety of activity optionsfor different physical levels, and the opportunity to forgesocial connections with the other participants. Those de-signing a physical activity program for individuals with amood disorder should take into consideration these sugges-tions and Vancampfort et al.’s [39] ten questions.Lastly, our findings show that individuals with a mooddisorder appreciate the opportunity of staying engagedwith the community as a strategy to help with theirmental as well as physical health. It is also very import-ant to have access to a stigma-free and non-judgmentalenvironment in order to facilitate fear-free participation.Many participants voiced their concerns of lack of finan-cial resources to enroll in an exercise program, thereforea free or low-cost program will be essential. Overall, weconclude that there is a strong need for a communityphysical activity program for individuals with a mooddisorder and they are best situated to advise on the de-sign and implementation of this program.LimitationsDue to their self-selection for the research study, partici-pants might not be representative of the larger popula-tion who meet the inclusion/exclusion criteria. Theparticipants who volunteered in our study were of anolder age which may have influenced their responses ondifferent aspects of an ideal physical activity program in-cluding their preferred intensity (low to moderate). Par-ticipants were aware that the project was focused onphysical activity and this might have influenced their de-cision to participate and/or their answers. Participantsmight already have an appreciation for and/or previousinvolvement with physical activity, which could have ledto biased responses. To reduce these biases, the researchteam engaged in repeated discussions of the results, usedpeer researchers for the interviews, and conductedmember checking to solicit feedback on the findingsfrom the participants. We believe that the results repre-sent the true needs and perspectives of the participants.ConclusionThis study underscores specific factors that can supportindividuals with a mood disorder to further their healthand to increase engagement with physical activity. Thesefactors are relevant to community mental health care andthe proven benefits of utilizing a social network approachto solve problems related to a mood disorder. Our evi-dence suggests that we need to incorporate the perspec-tives and preferences of the potential participants into thedesign of a physical activity promotion program. Our find-ings also point to the benefits of incorporating nature intosuch a program. The inclusion of opportunities to connectwith nature is also consistent with emerging research onthe benefits of access to blue and green spaces. Our nextstep is to design and implement a physical activity pro-gram with our peer researchers and then to evaluate theoutcomes and effectiveness of the program.AcknowledgementsWe would like to thank David Adams for his assistance in data collection andthe initial analysis of the data.FundingThis research was funded by a grant from the Vancouver Foundation. Dr.Sims-Gould is supported by a Canadian Institutes of Health Research New In-vestigator award and a Michael Smith Foundation for Health ResearchScholar award.Availability of data and materialsThe datasets generated and/or analyzed during the current study are notpublicly available due to ethics and privacy concerns that participants maybe identified but anonymized data are available from the correspondingauthor on reasonable request.Authors’ contributionsDr. JS-G conceptualized and designed the study, drafted the initial manuscriptand approved the final manuscript as submitted. Dr. SV collected the data,carried out the analyses, reviewed and revised the manuscript and approvedthe final manuscript as submitted. Mr. NL collected the data, carried out theanalyses, reviewed and revised the manuscript and approved the finalmanuscript as submitted. Dr. RR conceptualized and designed the study, criticallyreviewed the manuscript and approved the final manuscript as submitted. Dr. KKconceptualized and designed the study, critically reviewed multiple drafts of themanuscript and approved the final manuscript as submitted.Ethics approval and consent to participateEthical approval was obtained from the University of British ColumbiaResearch Ethics Board and all participants provided written informed consentto be involved in the study.Consent for publicationNot applicable.Competing interestsThe authors declare that they have no competing interests.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Sims-Gould et al. BMC Psychiatry  (2017) 17:319 Page 7 of 8Author details1Department of Family Practice, University of British Columbia, 793-2635Laurel Street, Vancouver, BC V5Z 1M9, Canada. 2University of BritishColumbia, Center for Hip Health and Mobility, 2635 Laurel Street, Vancouver,BC V5Z 1M9, Canada. 3University of British Columbia, Center for Hip Healthand Mobility, 2635 Laurel Street, Vancouver, BC V5Z 1M9, Canada. 4MoodDisorders Association of BC, 1450 - 605 Robson Street, Vancouver, BC V6B5J3, Canada. 5Department of Family Practice, University of British Columbia,5950 University Blvd, Vancouver, BC V6T 1Z3, Canada.Received: 17 February 2017 Accepted: 22 August 2017References1. Kohl H, Craig C, Lambert E, Inoue S, Alkandari J, Leetongin G, et al. Thepandemic of physical inactivity: global action for public health. Lancet. 2012;380(9838):294–305.2. Fiuza-Luces C, Garatachea N, Berger NA, Lucia A. Exercise is the real polypill.Physiology. 2013;28(5):330–58. doi:10.1152/physiol.00019.2013.3. 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