A systematic review of physical activity policy recommendations and interventions for people with mental health problems in Sub-Saharan African countries

South African mental healthcare providers' views about exercise for people with mental illness

Background

People living with mental illness (PWMI) have significantly reduced life expectancy compared to the general population, yet mental healthcare providers (MHCPs) do not regularly prescribe exercise, despite its proven health benefits.

Aim

This study aimed to evaluate South African MHCPs' views regarding exercise for PWMI.

Setting

A cross-sectional descriptive study conducted across five public sector specialised psychiatric units in Gauteng.

Methods

Mental healthcare providers were surveyed using the Exercise in Mental Illness Questionnaire - Health Professionals Version.

Results

Most participants were nurses (49.1%) and doctors (26.2%) and reported no prior formal training in exercise prescription (79.4%). The vast majority (up to 89.7%) agreed regarding the physical benefits of exercise, particularly cardiometabolic benefits. The most common barriers, as perceived by MHCPs, to exercise participation for PWMI were: stigma (56.5%) and medication side effects (56.5%). The majority (76.2%) reported prescribing exercise for PWMI at least 'occasionally'. The method most frequently used was personal discussion (77.3%) and aerobic exercise was most frequently recommended (81.0%). Specific instructions regarding physical activity recommendations however were often not provided. Regarding MHCPs personal exercise habits, only a third (34%) met physical activity guidelines. Most MHCPs (92.1%) indicated an interest in further training regarding exercise for PWMI.

Conclusion

Mental healthcare providers were supportive of exercise for PWMI. Strategies to address the stigma around mental illness and medication side-effects, to improve training regarding exercise prescription, as well as the exercise habits of MHCPs themselves, and collaboration with exercise professionals and organisations are recommended.

Contribution

This study provides insight into the views of South African MHCPs regarding exercise for PWMI.

Physical activity and sedentary behavior levels among individuals with mental illness: A cross-sectional study from 23 countries

People with mental illness tend to present low levels of physical activity and high levels of sedentary behavior. The study aims to compare these levels in mental illness patients, exploring the role of socioeconomic development and treatment setting. This cross-sectional study used accelerometers and the Simple Physical Activity Questionnaire (SIMPAQ) to assess physical activity and sedentary behavior in mental illness individuals living in 23 countries. Two-way ANOVAs were used to evaluate the interaction between socioeconomic development and the treatment settings on physical activity and sedentary behavior. A total of 884 (men = 55.3%) participants, mean age of 39.3 (SD = 12.8), were evaluated. A significant interaction between socioeconomic development and treatment settings was found in sedentary behavior (F = 5.525; p = 0.019; η2p = 0.009; small effect size). Main effects were observed on socioeconomic development (F = 43.004; p < 0.001; η2p = 0.066; medium effect size) and treatment setting (F = 23.001; p < 0.001; η2p = 0.036; small effect size) for sedentary behavior and physical activity: socioeconomic development (F = 20.888; p < 0.001; η2p = 0.033; small effect size) and treatment setting (F = 30.358; p < 0.001; η2p = 0.047; small effect size), showing that HIC patients were more active, while MIC patients were more sedentary. Moreover, despite of inpatients had presented higher levels of physical activity than outpatients, they also spent more time sitting. Socioeconomic development plays an important role in sedentary behavior in patients with mental disorders, warning the need to develop new strategies to reduce these levels in this population.

The Physical Activity Vital Sign and associations with cardiometabolic risks in people with bipolar disorder in a low-income country

BACKGROUND

The mortality gap compared with the general population is with 29 years of potential life lost for people with bipolar disorder (BD) highest in Africa. The most significant contributor to premature mortality are preventable cardiovascular diseases due to an unhealthy lifestyle. This study investigated if the Physical Activity Vital Sign (PAVS), i.e. two questions which clarify if someone meets the recommended 150 min of physical activity (PA) per week, can identify patients with BD at higher risk of cardiometabolic abnormalities and mental health symptoms in a low-income country from Sub-Sahara Africa.

METHODS

99 (54♀) Ugandan in- and outpatients (mean age = 34.5 ± 9.4 years) with BD completed the PAVS and Brief Symptoms Inventory-18. Participants were screened for abdominal obesity (waist circumference > 90 cm), overweight (body mass index≥25) and hypertension (systolic pressure ≥ 140 mmHg and/or diastolic pressure ≥ 90 mmHg).

RESULTS

49.5 % (n = 49) met the PA recommendation. 43.4 % (n = 43) were overweight, 43.3 % (n = 43) had abdominal obesity and 20.2 % (n = 20) hypertension. Those who did not meet the PA recommendation were older (37.1 ± 10.4 versus 32.2 ± 7.7 years, p = 0.009), had a higher BSI-18 somatisation score (13.7 ± 4.5 versus 10.4 ± 4.2, p = 0.026), and a higher risk for overweight [relative risk (RR) = 2.99, 95 % confidence interval (CI) = 1.69-5.29], abdominal obesity (RR = 1.92, 95%CI = 1.19-3.09), and hypertension (RR = 2.23, 95%CI = 1.02-4.88).

CONCLUSIONS

The PAVS might be an important risk identification tool in patients with BD in low-income countries such as Uganda. The low-cost and brevity of the PAVS may help promote the importance of PA assessment and prescription as a core part of the treatment of patients with BD in low-income settings.

Translation of the mental health literacy questionnaire for young adults into Chichewa for use in Malawi: preliminary validation and reliability results

BACKGROUND

Mental Health Literacy (MHL) is the ability to recognise mental disorders, have knowledge of professional help available, effective self-help strategies, skills to give support to others, and knowledge of how to prevent mental disorders. Sufficient MHL is linked to better help seeking behaviour and management of mental illness. Assessing MHL importantly helps identify knowledge gaps and inaccurate beliefs about mental health issues, whilst informing development and better evaluation of MHL interventions. This study aimed to translate the English version of a self-reporting Mental Health Literacy questionnaire (MHLq) for young adult populations (16-30 years-old) into Chichewa for use in Malawi and evaluate the psychometric properties of this Chichewa version.

METHODS

An established translation methodology was employed, involving back-translation, comparison, forward-translation, comparison, and piloting. The translated Chichewa questionnaire was initially piloted with 14 young adults in a Malawi university, then subsequently administered to 132 young adults in rural community settings across Malawi.

RESULTS

Overall internal consistency of the Chichewa translated MHLq was good (Cronbach's alpha = 0.67) although subscales' scores ranged from acceptable (factor 1 and 3) to unacceptable (factor 2 and 4). Confirmatory factor analysis found Factor 1 (Knowledge of mental health problems), Factor 3 (First aid skills and help seeking behaviour) and Factor 4 (Self-help strategies) of the Chichewa version fit very well with related factors of the original English MHLq. For Factor 2 (Erroneous beliefs/stereotypes), 5 out of its 8 items correlated well with the original version. This suggests a four-factor solution is a reasonably good fit to the data.

CONCLUSIONS

Use of the Malawian MHLq among Chichewa speaking young adult populations is well supported for factors 1 and 3 but not for factors 2 and 4. More psychometric testing with a larger sample is vital to further validate the questionnaire. Further research is needed to carry out test/re-test reliability statistics.

A 10-hours workshop improves physical activity prescription for mental illness knowledge and confidence in health care professionals: a nation-wide multicentre study from Uganda

PURPOSE

Lack of knowledge about and confidence in physical activity (PA) prescription for people with mental illness are important barriers for clinical practice in low-income countries. The aim of this study was to evaluate whether a 10-hour workshop improved the knowledge and confidence in PA prescription among health care professionals in 13 regional referral hospitals across Uganda.

MATERIAL AND METHODS

260 health care professionals (age = 40.4 ± 10.8 years; 48% women; 63.8% nurses, 10% social workers, 8.1% psychologists, 7.3% medical doctors, 5.8% psychiatrists, 5% physical or occupational therapists) completed the Exercise in Mental Illness Questionnaire - Health Professionals Version (EMIQ-HP) pre- and post-workshop.

RESULTS

The EMIQ-HP PA knowledge score (3.1 ± 0.7 versus 1.3 ± 1.3, p < 0.001, Cohen's d = 1.28, 95% confidence interval, CI = 1.04-1.52, i.e., large effect) and EMIQ-HP confidence in PA prescription score (3.0 ± 0.8 versus 1.2 ± 1.2, p < 0.001, Cohen's d = 1.14, 95% CI = 0.91-1.36, i.e., large effect) improved significantly following training. Significantly more benefits and fewer barriers to prescribing PA in busy low-resourced settings were reported.

CONCLUSIONS

Training in PA counselling improved the knowledge and confidence in PA prescription in Ugandan health care professionals. Future research should investigate whether PA uptake in people with mental illness can be improved via additional training of health care professionals.IMPLICATIONS FOR REHABILITATIONThe majority of mental health professionals never recommend physical activity to their patients in low-resourced settings and increased awareness is needed to improve rehabilitation programs.Training in prescribing physical activity using the 5A framework improves knowledge about physical activity prescription in mental health professionals at all levels of care.Training in prescribing physical activity using motivational interviewing improves confidence in physical activity prescription in rehabilitation programs.Training in prescribing physical activity reduces perceived barriers for prescribing in rehabilitation programs in low-resourced settings.

Impact of exercise training on symptoms of depression, physical activity level and social participation in people living with HIV/AIDS: a systematic review and meta-analysis

BACKGROUND

Symptoms of depression are prevalent in people living with human immune deficiency virus/acquired immune deficiency syndrome (PLWHA), and worsened by lack of physical activity/exercises, leading to restriction in social participation/functioning. This raises the question: what is the extent to which physical exercise training affected, symptoms of depression, physical activity level (PAL) and social participation in PLWHA compared to other forms of intervention, usual care, or no treatment controls?

METHOD

Eight databases were searched up to July 2020, according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) protocol. Only randomised controlled trials involving adults who were either on HAART/HAART-naïve and reported in the English language, were included. Two independent reviewers determined the eligibility of the studies, extracted data, assessed their quality, and risk of bias using the Physiotherapy Evidence Database (PEDro) tool. Standardised mean difference (SMD) was used as summary statistics for the mean primary outcome (symptoms of depression) and secondary outcomes (PAL and social participation) since different measuring tools/units were used across the included studies. Summary estimates of effects were determined using a random-effects model (I2).

RESULTS

Thirteen studies met the inclusion criteria with 779 participants (n = 596 participants at study completion) randomised into the study groups, comprising 378 males, 310 females and 91 participants with undisclosed gender, and with an age range of 18-86 years. Across the studies, aerobic or aerobic plus resistance exercises were performed 2-3 times/week, at 40-60 min/session, and for between 6-24 weeks, and the risk of bias vary from high to low. Comparing the intervention to control groups showed significant difference in the symptoms of depression (SMD = - 0.74, 95% confidence interval (CI) - 1.01, - 0.48, p ≤ 0.0002; I2 = 47%; 5 studies; 205 participants) unlike PAL (SMD = 0.98, 95% CI - 0.25, 2.17, p = 0.11; I2 = 82%; 2 studies; 62 participants) and social participation (SMD = 0.04, 95% CI - 0.65, 0.73, p = 0.91; I2 = 90%; 6 studies; 373 participants).

CONCLUSION

Physical exercise training could have an antidepressant-like effect in PLWHA but did not affect PAL and social participation. However, the high heterogeneity in the included studies, implies that adequately powered randomised controlled trials with clinical/methodological similarity are required in future studies.

TRAIL REGISTRATION NUMBER

INPLASY202040048.

Psychosocial rehabilitation of individuals with schizophrenia: a scoping review protocol

BACKGROUND

The psychosocial rehabilitation of an individual with mental illness is an evidence-based approach to reducing the burden of the illness and the associated stigma globally. Specifically, in Africa, it has promising scope for African life and the African economy. Psychosocial rehabilitation is described as a set of approaches that aim to assist an individual in achieving restoration from a state of dependency caused by schizophrenia to a state of being an independent decision-maker. However, there seems to be a dearth of literature and implementation of psychosocial rehabilitation in Africa. Therefore, it is necessary to map studies on how psychosocial rehabilitation is conducted for people living in Africa with the most chronic form of mental illness, schizophrenia.

METHODS

This study will adopt the Arksey and O'Malley scoping review framework to search and compile relevant studies. This process will involve three steps: title screening, to be performed solely by the principal investigator, followed by abstract and full-text screening, to be performed independently by two reviewers (the principal investigator and co-investigator). Rayyan QCRI, a systematic reviews web app, will be used for tracking the screening records, and data charting form will be used to extract basic data of included studies. The risk of bias in the articles identified for screening will be assessed by the Mixed Method Appraisal Tool (MMAT). Finally, the content analysis of the screened studies will be performed with NVivo.

EXPECTED OUTCOME

This study has the likelihood of revealing a research gap in psychosocial rehabilitation approaches and methods. The review results will constitute part of the available evidence that the researchers aim to adopt in the broader part of the project, which aims to develop implementation strategies for the psychosocial rehabilitation of chronic mental illnesses, specifically schizophrenia, in Sub-Sahara Africa. The implementation process also encompasses disseminating the findings of this review to stakeholders, which will enhance their knowledge of the current state of Sub-Saharan Africa and may stimulate support for the implementation of rehabilitation strategies.

Test-retest reliability, concurrent validity and correlates of the two-minute walk test in outpatients with alcohol use disorder

We investigated the test-retest reliability of the 2-min walk test (2MWT) and its concurrent validity with the 6-min walk test (6MWT) in Ugandan outpatients with alcohol use disorder (AUD). We also explored practice effects, and assessed the minimal detectable change (MDC) and correlations with the 2MWT. Fifty outpatients [7 women; median age = 32.0 years] performed the 2MWT twice, the 6MWT once, and completed the Simple Physical Activity Questionnaire, Brief Symptoms Inventory-18 (BSI-18), and Alcohol Use Disorders Identification Test. The median (interquartile) 2MWT score on the first and second test were 162.0 (49.0) meters and 161.0 (58.0) meters, respectively, without significant difference between the two trials (p = 0.20). The intraclass correlation between the two 2MWTs was 0.96 (95% confidence interval = 0.94-0.98). The Spearman Rho correlation between the second 2MWT and the 6MWT was 0.91 (p < 0.001). The MDC for the 2MWT was 18 m. There was no evidence of a practice effect. Variance in BSI-18 depression and the presence of leg pain following the 2MWT explained 18.7% of 2MWT score variance. The 2MWT is a reliable and valid fitness test, which can be conducted without any special equipment or substantial time demands in outpatients with AUD.

Test-retest reliability and correlates of the Simple Physical Activity Questionnaire in Ugandan out-patients with psychosis

BACKGROUND

In order to facilitate people with psychosis to increase their physical activity (PA) levels, a reliable measurement of these levels is of relevance.

OBJECTIVES

The primary aim of current study was to explore the test-retest of the Simple Physical Activity Questionnaire (SIMPAQ) in Ugandan outpatients with psychosis. A second aim was to explore correlates of the SIMPAQ, including demographic variables and antipsychotic medication dose.

METHODS

Thirty-four women (33.9±8.0 years) and 21 men completed the SIMPAQ twice in a day. The test-retest reliability was assessed using Spearman Rho correlations coefficients. Differences in subgroups were analysed with Mann Whitney U tests.

RESULTS

The SIMPAQ showed a good test-retest reliability with correlates ranging from 0.78 (P<0.001) for structured exercise to 0.96 (P<0.001) for walking. Women, non-smokers and those without HIV/AIDS showed higher incidental PA than men, smokers and those with HIV/AIDS.

CONCLUSION

The SIMPAQ is a reliable tool to assess PA and sedentary levels in Ugandan outpatients with psychosis. Men, smokers and those with HIV/AIDS appear to be at risk for lower incidental PA.

Test-retest reliability, validity, and correlates of the 2-min walk test in outpatients with depression

OBJECTIVES

A reason for the lack of interest in physical fitness testing in mental healthcare is limited time among existing staff. This cross-sectional study investigated the test-retest reliability of the 2-min walk test (2MWT) and its concurrent validity with the 6-min walk test (6MWT) in Ugandan patients with depression. We also explored practice effects and assessed the minimal detectable change (MDC) and clinical correlates with the 2MWT.

METHODS

This is a cross-sectional study executed in Butabika National Referral Hospital in Kampala, Uganda. Fifty Ugandan patients with depression (15 women; median age = 29.0 years) performed twice a 2MWT, once a 6MWT, and completed the Simple Physical Activity Questionnaire (SIMPAQ), and Brief Symptoms Inventory-18 (BSI-18).

RESULTS

The median (interquartile) 2MWT score on the first and second test were 125.5 (59.2) meters and 131.0 (57.0) meters (p = .28). The intraclass correlation was.96 (95% confidence interval [0.94, 0.98]). The MDC was 23.5 m for men and 23.4 m for women. There was no evidence of a practice effect. Scores on BSI-18 depression, SIMPAQ walking, and SIMPAQ incidental physical activity explained 66.3% of 2MWT score variance.

CONCLUSION

The 2MWT is a reliable test, which can be conducted without any special equipment or substantial time demands, to provide a valid assessment of the functional exercise capacity in outpatients with depression.

A quantitative assessment of the views of mental health professionals on exercise for people with mental illness: perspectives from a low-resource setting

Background

Exercise is nowadays considered as an evidence-based treatment modality in people with mental illness. Nurses and occupational therapists working in low-resourced mental health settings are well-placed to provide exercise advice for people with mental illness.

Objectives

We examined the current exercise prescription practices employed by Ugandan health care professionals when working with people with mental illness, and identified perceived barriers to exercise prescription and exercise participation for people with mental illness.

Methods

In this study, 31 Ugandan health care professionals 20 men; 31.2 ± 7.1 years completed the Exercise in Mental Illness Questionnaire- Health Professionals Version EMIQ-HP.

Results

The vast majority of the respondents 29/31, 94% reported they prescribed exercise at least “occasionally” to people with mental illness. Exercise-prescription parameters used were consistent with those recommended for people with mental illness. Regarding barriers to exercise participation, coping with side effects of psychotropic medication at the individual level and reducing stigma at community level should be prioritized.

Conclusion

A health care reform to enable collaboration with exercise professionals, such as exercise physiologists or physiotherapists, might increase exercise uptake for people with mental illness, thereby improving health outcomes for this vulnerable population.

Sedentary Behavior and Quality of Life in People with Psychotic Disorders from a Low Income Country: A Study from Uganda

The current study examined the impact of sedentary behaviour (SB) on quality of life (QoL) in people with psychotic disorders. Thirty-six Ugandan women (mean age = 33.9 ± 8.0 years) and 23 men (37.4 ± 11.8 years) with a DSM 5 diagnosis of psychosis completed the World Health Organization Quality of Life-Brief version and Simple Physical Activity Questionnaire (SIMPAQ). Medication use, physical co-morbidities, weight, height, blood pressure and smoking habits were recorded. Multiple regression analyses were undertaken. Variability in SIMPAQ sedentary and walking scores explained 56% of the variability in psychological QoL, while variability in SIMPAQ walking explained 46% of the variability in physical QoL. Health care professionals should not only consider increasing physical activity but also reducing SB to improve QoL in their patients.

Correlates of Physical Activity Among Middle-Aged and Older Adults With Hazardous Drinking Habits in Six Low- and Middle-Income Countries

We investigated physical activity (PA) correlates among middle-aged and older adults (aged ≥50 years) with hazardous drinking patterns in six low- and middle-income countries. Cross-sectional data were analyzed from the World Health Organization's Study on Global Ageing and Adult Health. Hazardous drinking was defined as consuming >7 (females) or >14 (males) standard drinks per week. Participants were dichotomized into low (i.e., not meeting 150 min of moderate PA/week) and moderate-high physically active groups. Associations between PA and a range of correlates were examined using multivariable logistic regressions. The prevalence of low PA in 1,835 hazardous drinkers (60.5 ± 13.1 years; 87.9% males) was 16.2% (95% confidence interval [13.9%, 18.9%]). Older age, living in an urban setting, being unemployed, depression, underweight, obesity, asthma, visual impairment, poor self-rated health, and higher levels of disability were identified as significant PA correlates. The current data provide important guidance for future interventions to assist older hazardous drinkers to engage in regular PA.

Correlates of sedentary behaviour among adults with hazardous drinking habits in six low- and middle-income countries

Sedentary behaviour is associated with poor mental health, diabetes and cardiovascular disease, all of which are a concern among hazardous drinkers. Little is known about sedentary behaviour and it's correlates in hazardous drinkers, particularly in low- and middle-income countries. We investigated correlates of sedentary behaviour among community-dwelling adults aged ≥18 years with hazardous drinking patterns in six low- and middle-income countries. Cross-sectional data were analyzed from the World Health Organization's Study on Global Ageing and Adult Health. Hazardous drinking was defined as consuming >7 (females) or >14 (males) standard drinks per week. Associations between time spent sedentary and a range of correlates were examined using multivariable linear and logistic regression. The mean time spent sedentary in 2142 individuals with hazardous drinking patterns (mean age = 45.7 years; 13% female) was 216±135min/day. Nine percent (95%CI=6.1-13.2%) were sedentary for ≥8h per day. Living in an urban setting and unemployment were strong sociodemographic correlates of being sedentary for ≥8h per day. From a health-related perspective, weak grip strength, stroke and disability were associated with increasing time spent sedentary. The current data provides important guidance for future interventions across low- and middle-income countries to assist hazardous drinkers to reduce sedentary behaviour.

Correlates of physical activity among depressed older people in six low-income and middle-income countries: A community-based cross-sectional study

OBJECTIVE

Despite the benefits of physical activity (PA) in older people with depression, many do not comply with the International PA guidelines. Thus, we investigated what factors influence PA participation among 915 community-dwelling older adults (aged ≥65 years) with depression in 6 low-income and middle-income countries (LMICs).

METHODS

Cross-sectional data were analyzed from the World Health Organization's Study on Global Ageing and Adult Health. The sample was restricted to those with DSM-IV depression or receiving depression treatment in the last 12 months. PA was assessed by the Global Physical Activity Questionnaire. Participants were dichotomized into low (ie, not meeting 150 minutes of moderate PA per week) and moderate-to-high physically active groups. Associations between PA and a range of correlates were examined using multivariable logistic regressions.

RESULTS

The prevalence of low PA was 40.4% (95%CI = 34.8%-46.1%). After adjusting for age, sex, and country, larger household size and unemployment were significant sociodemographic correlates of low PA. Former smoking (vs never), anxiety, mild cognitive impairment (MCI), lower body mass index, bodily pain, asthma, chronic back pain, chronic obstructive pulmonary disease, hearing problems, stroke, slow gait, poor self-rated health, higher levels of disability, and lower levels of social cohesion were identified as significant negative correlates of PA.

CONCLUSIONS

The current data provide guidance for future interventions across LMICs to assist older people with depression engage in regular PA. The promotion of social cohesion may increase the efficacy of future public health initiatives, while from a clinical perspective, somatic co-morbidities, MCI, pain, and slow gait need to be considered.

Sedentary behavior and physical activity levels in people with schizophrenia, bipolar disorder and major depressive disorder: a global systematic review and meta-analysis

People with severe mental illness (schizophrenia, bipolar disorder or major depressive disorder) die up to 15 years prematurely due to chronic somatic comorbidities. Sedentary behavior and low physical activity are independent yet modifiable risk factors for cardiovascular disease and premature mortality in these people. A comprehensive meta-analysis exploring these risk factors is lacking in this vulnerable population. We conducted a meta-analysis investigating sedentary behavior and physical activity levels and their correlates in people with severe mental illness. Major electronic databases were searched from inception up to April 2017 for articles measuring sedentary behavior and/or physical activity with a self-report questionnaire or an objective measure (e.g., accelerometer). Random effects meta-analyses and meta-regression analyses were conducted. Sixty-nine studies were included (N=35,682; 39.5% male; mean age 43.0 years). People with severe mental illness spent on average 476.0 min per day (95% CI: 407.3-545.4) being sedentary during waking hours, and were significantly more sedentary than age- and gender-matched healthy controls (p=0.003). Their mean amount of moderate or vigorous physical activity was 38.4 min per day (95% CI: 32.0-44.8), being significantly lower than that of healthy controls (p=0.002 for moderate activity, p<0.001 for vigorous activity). People with severe mental illness were significantly less likely than matched healthy controls to meet physical activity guidelines (odds ratio = 1.5; 95% CI: 1.1-2.0, p<0.001, I² =95.8). Lower physical activity levels and non-compliance with physical activity guidelines were associated with male gender, being single, unemployment, fewer years of education, higher body mass index, longer illness duration, antidepressant and antipsychotic medication use, lower cardiorespiratory fitness and a diagnosis of schizophrenia. People with bipolar disorder were the most physically active, yet spent most time being sedentary. Geographical differences were detected, and inpatients were more active than outpatients and those living in the community. Given the established health benefits of physical activity and its low levels in people with severe mental illness, future interventions specifically targeting the prevention of physical inactivity and sedentary behavior are warranted in this population.