Barriers and Facilitators to Health Behavior Change: Perspectives of Individuals with Serious Mental Illness in Health-Promoting Interventions – A Systematic Review of Qualitative Evidence

Barriers and Facilitators to Health Behavior Change: Perspectives of Individuals with Serious Mental Illness in Health-Promoting Interventions – A Systematic Review of Qualitative Evidence | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Barriers and Facilitators to Health Behavior Change: Perspectives of Individuals with Serious Mental Illness in Health-Promoting Interventions – A Systematic Review of Qualitative Evidence Gesa Pult, Fabian Frank This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4793963/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background: Physical health-promoting interventions for individuals with serious mental illness (SMI) have been shown to be clinically effective in improving health outcomes, yet often fall short in meeting participants’ needs, as reflected in high dropout rates.However, studies indicate that individuals with SMI want to improve their physical health. To address this need, a detailed understanding of the barriers to and facilitators of health behavior change for individuals with SMI participating in health-promoting interventions is crucial. Methods: To identify barriers to and facilitators of health behavior change for individuals with SMI in health promoting interventions, a systematic review of qualitative evidence was conducted. Medline, PsycINFO, CINHAL, and SSCI databases were searched for qualitative studies reporting perspectives on health behavior changes among individuals with SMI (18 +) who participated in health-promoting interventions. Health-promoting interventions were defined as those that included at least two aspects of physical health (such as diet and physical activity). The Critical Appraisal Skills Programme (CASP) tool was utilized to assess the quality of the studies. Data were extracted, thematically analyzed, and mapped to the capability, opportunity and motivation for behavior change (COM-B) model. Results: A total of 4242 references were identified and 27 studies, including 547 individuals with SMI, met the eligibility criteria. Informed by the COM-B model, individuals with SMI reported physical and psychological capabilities that led to improvements in physical and mental health as a result of participating in a health-promoting intervention. Physical and social opportunities, such as clear and coherent intervention content or support from trained professionals, were identified as facilitator of behavior change. Additionaly motivation played a crucial role in sustaining health behavior changes among individuals with SMI. Conclusion: This review identifies key factors shaping health behavior change among individuals with SMI, emphasizing that change often depends more on external opportunities than on individual motivation alone. These findings highlight the importance of accessible, inclusive, and socially supportive interventions, and contribute to the development of integrated, person-centered frameworks for research and practice. serious mental illness physical health health promotion qualitative evidence synthesis COM-B model barriers facilitators Figures Figure 1 Figure 2 1 Background Serious mental illness (SMI) – including schizophrenia, bipolar disorder, and major depression – is defined as a mental, behavioral, or emotional disorder that results in substantial functional impairment and limits one or more major life activities (1). Individuals with SMI face a life expectancy up to 25 years shorter than the general population (2–5), largely due to a higher incidence of cardiovascular diseases (3,6,7), which are often driven by modifiable lifestyle factors (8). Obesity is significantly more common in this population (9,10), partly because of metabolic side effects of antipsychotic medications (11–13). Additionally, individuals with SMI often have poor dietary patterns – low in fruits, vegetables, and fiber, and high in processed foods and sugars (14–17) – and are less physically active, frequently leading sedentary lifestyles (8,18,19). Smoking rates remain disproportionately high among individuals with SMI, with nicotine often used as a coping strategy, despite its contribution to cardiovascular and respiratory disease risk (20,21). Also fragmented healthcare systems in which physical symptoms are often misattributed to psychiatric conditions, lead to delayed recognition and treatment of physical illnesses (6,22–25). In response to these disparities, international calls have been made to develop interventions that specifically address the physical health of individuals with SMI (26–30). Health-promoting interventions – structured programs aimed at improving physical and mental well-being through healthier behaviors (31) – are a promising approach to reducing risk factors and improving long-term outcomes in this population. Studies have demonstrated the effectiveness of smoking cessation (32), nutrition (33), and physical activity (34–37). However, most of these studies were conducted in highly controlled settings, and high dropout rates up to 50% among participants were observed (38–45). A meta analysis indicates key factors influencing dropout rates included the qualification of the professional delivering the intervention, continuous supervision and motivational components (46). Studies have shown that individuals with serious mental illness (SMI) are interested in improving their physical health (25,47–54), which indicates that their needs are not yet being adequately addressed. To develop interventions that are truly responsive, it is essential to understand how individuals with SMI perceive the barriers to and facilitators of health behavior change. Qualitative research is particularly well-suited to exploring complex social phenomena, subjective experiences, and the contextual factors that shape health behaviors (55). As such, qualitative studies are ideal for gaining deeper insight into the lived experiences of individuals with SMI as they attempt to change their health behaviors through participation in health-promoting interventions. Although several qualitative studies have explored these experiences of individuals with SMI in health-promoting interventions, their perspectives have not yet been systematically reviewed or synthesized. A synthesis of this existing qualitative evidence provides an opportunity to learn from their lived experiences and to identify common patterns and context-specific insights. This review aims to fill that gap by conducting a systematic review and thematic synthesis of qualitative studies with the goal of identifying perceived barriers to and facilitators of health behavior change among individuals with SMI. The findings are intend to support the development of more accessible, effective, and person-centered health-promoting interventions for this population. To guide this aim, the study addresses the following research question: What barriers and facilitators to health behavior change do individuals with serious mental illness report when participating in health promotion interventions? 2 Methods A systematic review and thematic synthesis of qualitative studies were conducted following the recommendations for systematic reviews of qualitative evidence by the Johanna Briggs Institute (JBI) (56) and the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) (see Additional file 1) (57). These frameworks provide guidelines for developing and synthesizing qualitative research and ensuring the quality and rigor of reviews. The objectives, inclusion criteria, and methods were specified and documented in a protocol published in the Open Science Framework (OSF) (58). 2.1 Inclusion Criteria The inclusion and exclusion criteria for which studies are considered should be clear and unambiguous concerning the population and phenomena of interest, the context, and the types of studies (56). The criteria were determined a priori. The population of interest included adult individuals with severe mental illnesses. In this study, SMI is understood as a diagnosable mental, behavioral, or emotional disorder that results in serious functional impairment and substantially interferes with or limits one or more major life activities, such as schizophrenia, bipolar disorder or major depression (1). Individuals with neurological disorders, such as dementia; nonchronic mental illnesses, including perinatal depression; or physical illness in the foreground, such as cancer, were excluded. The phenomenon of interest was how the individuals with SMI evaluates health-promoting interventions they were participating in or had completed. Health-promoting interventions (59) were defined as those that included at least two aspects of physical health (such as diet and physical activity). The aim was to identify barriers and facilitators that made health behavior changes easier or more difficult. In this context, "barriers" were defined as any physiological, psychological, or socioecological condition negatively affecting a person’s health behavior change in a health-promoting intervention (54). Therefore, "facilitators" were defined as any physiological, psychological, or socioecological condition that positively affects a person’s health behavior change in a health-promoting intervention (54). Concerning the context , studies were included regardless of the setting where the interventions took place, such as community-based, supportive housing, inpatient or outpatient clinics. Interventions were included if they addressed at least two physical health factors: (e.g. physical activity and nutrition). Single interventions, such as smoking cessation only, were excluded. Interventions delivered exclusively via telephone or internet were excluded if they did not involve structured, interactive components supporting self-management, as the focus was on interventions with more comprehensive formats aimed at facilitating behavior change through engagement and support. Only qualitative studies were included to understand the complex social phenomena, subjective meanings, and the contextual factors that shape health behaviors, and in-depth insights that quantitative studies cannot offer (55). Studies were included when they involved the perspectives of the individuals with SMI who were participating or had completed a health-promoting intervention and reported barriers or facilitators concerning health behavior change. Mixed method studies were included if their qualitative data were congruent with the research question. If a study included other groups of individuals, including professionals, the results referring to these groups were not included. 2.2 Search Strategy An initial limited search in PsycINFO was undertaken to identify studies on the topic. The text words in the titles and abstracts of relevant articles, including the index terms used to describe the articles, were used to develop an entire search strategy for PsycINFO. The reference lists of identified studies were hand-screened for further relevant data. The search strategy, including all identified keywords and index terms, was then adapted for each database (see Additional file 2). To ensure comprehensive and interdisciplinary coverage of the topic, we purposefully selected databases representing key relevant disciplines. Medline (via PubMed) was included for its extensive focus on medical and clinical literature, PsycINFO for psychological research, CINAHL for nursing and allied health studies, and the Social Sciences Citation Index (SSCI) for research in sociology, education, and related social sciences. This strategy allowed to capture diverse perspectives relevant to health behavior interventions. While databases such as Web of Science were considered, SSCI – also part of the Web of Science Core Collection – was chosen specifically for its focused indexing of the social science literature most pertinent to our research objectives. The databases were searched between August 29, 2023, and June 1, 2024. No time limit or language was set for inclusion An example of the search strategy used is displayed in Table 1. Table 1: Example search string PsychInfo PsycINFO DE "Serious Mental Illness" OR MM "Mental Disorders" OR DE "Schizophrenia" OR DE "Anxiety Disorders" OR DE "Major Depression" OR DE "Bipolar Disorder" OR DE "Borderline Personality Disorder" AND DE "Physical Activity" OR DE "Physical Fitness" OR DE "Activity Level" OR DE "Actigraphy" OR DE "Active Living" OR DE "Exercise" OR DE "Aerobic Exercise" OR DE "Dietary Treatment" OR DE "Diets" OR DE "Healthy Eating" OR DE "Obesity" OR ""Dietary Intervention*" OR "Physical Health" OR exercis* AND DE "Treatment Refusal" OR DE "Treatment Barriers" OR DE "Treatment Compliance" OR DE "Client Participation" OR DE "Client Attitudes" OR barriers OR facilitators" OR enabl* OR promot* 2.3 Study Screening The identified records were imported into the systematic review tool Covidence (60). Duplications were removed, and the first author screened the titles and abstracts to exclude records irrelevant to the research question. All remaining full texts were then assessed for eligibility by the first and second author independently. Discrepancies occurred in a small number of cases and were resolved through discussion to reach consensus. For example, there were occasional disagreements about whether studies focusing solely on one behavioral domain (e.g., diet or physical activity) met the criteria for inclusion. Reasons for exclusion were documented for all full-text articles at this stage. 2.4 Data Extraction The studies included were extracted by the first author. A data extraction table was used, which included the author, year, country, study objectives, study participants, data collection, data analysis, and health-promoting intervention components. The first author completed the data extraction. The second author independently checked 20% of the data for consistency. Any discrepancies were discussed. 2.5 Quality Appraisal The quality of the studies was appraised using the Qualitative Checklist for Qualitative Studies (CASP) (61). Therefore, the CASP provides criteria concerning the validity of results, methodology, research design, recruitment, data collection, analysis, and ethical issues taken into consideration. The first author appraised all studies against quality. The second author independently appraised 20% of those studies. Any discrepancies were discussed. 2.6 Analysis and Synthesis The data were extracted to MAXQDA (62) a qualitative data software tool, and the study results were analyzed using a framework analysis (63) informed by the COM-B model (64). As part of the behavioral change wheel (BCW), the COM-B model conceptualizes behavior as the result of an interaction between three core components: Capability (both physical and psychological), Opportunity (both physical and social), and Motivation (both reflective and automatic) (64). We used the COM-B model to guide our findings by mapping factors associated with health behavior change to these subcomponents using a coding guide developed by Michie et al. (64,65). For example, participants’ knowledge and mental skills were coded under psychological capability , while access to supportive environments or resources was coded under physical opportunity . Distinct from the concept of automaticity in cognitive science automatic motivation refers to emotional responses, impulses, and habits that influence behavior . The COM-B model approach allowes to systematically identify barriers and facilitators to health behavior change and to generate practice-oriented intervention points. The first author coded all studies. The second author independently coded 20% of the studies to ensure consistency. Any discrepancies were discussed. Themes were continuously compared and contrasted during the data synthesis process to promote the accuracy and validity of translation and interpretation. The factors assigned to the six subcomponents of the model are discussed separately below. The included studies were summarized. 3 Results 3.1 Results of the research The literature search occurred between August 29, 2023, and June 1, 2024. A total of 4242 studies were found, of which 850 were identified as duplicates and removed. A total of 3392 studies were screened with titles and abstracts. For full-text review, a total of 47 studies were selected. A total of 27 studies (66–92) were eligible for the systematic review of qualitative evidence (see Figure 1). Figure 1: Flowchart 3.2 Characteristics of the included studies The following summary describes the characteristics of the included studies and interventions in which the individuals with SMI participated (see Table 2). A total of 13 studies were conducted in the USA (66–68,72–74,76,80,81,84,85,87,92), four in the UK (69,71,77,83) and three in the Netherlands (70,88,89), two in Sweden (90,91) and Australia (79,82), and one in Denmark (75), Canada (78), and Israel (86). Studies were published between 2008 and 2022. Data collection was carried out using semistructured interviews (68,70–76,78–82,84–91,93), but qualitative interviews (84,92) or focus groups (66,67,69,77,80) were not further described. Thematic analysis was predominantly used for data analysis (66–68,70,72–74,76,77,81–83,85,87–89,92), some with a predominantly existing framework (78,79,91). Other studies used content analysis (80,90), one grounded theory methodology (86), a pragmatic approach (69), and a secondary inductive approach (71). The samples varied in size between two (84) and 84 (86) individuals with SMI. In total, 547 indivduals with SMI provided their perspectives on barriers to and facilitators of health behavior change in the context of health-promoting interventions. Jimenez et al. (72–74), Walburg et al. (88,89), and Wärdig et al. (90,91) published different studies with the same sample. The interventions mainly took place in community mental health services (66–69,72–74,76,79,81–85,88,89,92), two in supportive housing or community residentials (80,86), one in a long-term inpatient facility (70), a primary care setting (71) and two in a psychiatric outpatient setting (75,87), one of which had additional substance use (75). Concerning the intervention components, 12 interventions were group-based (66,68,69,79,80,82–84,86,90–92). Furthermore, nine studies were conducted in a one-on-one setting (67,71–74,76–78,85), and six were conducted partly in a one-on-one setting and partly group-based (70,75,81,87–89). Guidance was predominantly provided by a trained specialist (66–77,80–82,84–86,88–92), such as a health professional, mental health professional, physical therapist, nutritionist, or fitness trainer. Trained peers were involved in the implementation of three interventions (66,80,81). The total duration of the interventions ranged from 12 weeks (82) to 24 months (92), with the majority of interventions lasting 12 months (67,69,72–74,76,80,85,88,89). All interventions involved theoretical input related to healthy eating and physical activity. The physical activity started at a beginner level and gradually increased in intensity and duration over time, including exercises to music, walking, and other activities (66–68,73,85,86,90,91). The diet component emphasized a balanced diet rich in vegetables, fruits, whole grains, and low-fat dairy, with a focus on calorie and fat reduction. Participants were taught strategies for healthy eating, meal planning, and overcoming barriers, often using self-monitoring tools like food logs (66,73,86,87,92). In 21 interventions, behavioral change techniques(66–70,72–76,80–82,84,85,87–92), such as motivational interviewing or goal setting, were shown. In 12 interventions, practical interventions such as physical activities or cooking classes were applied (67,70,72,72,74,76,77,82,83,85,87–92), and two optional fitness sessions were offered (66,68). The frequency of intervention units was monthly in one intervention (78), daily in two interventions (70,77), and weekly in seven interventions (80–82,84,87,90,91). In 12 interventions, the frequency differed through intervention time, with reduced meetings at the end (66–69,72–74,85,86,88,89,92). The duration of an intervention session was up to 60 minutes in seven interventions (67,72–74,76,80,82) and up to 120 minutes in three interventions (69,90,91). Six studies referred to the SHAPE intervention (67,72–74,76,85). This motivational health-promoting intervention aimed to improve physical fitness through dietary changes and increased physical activity. Each participant with SMI received a one-year membership to a local fitness facility and ongoing support from a health mentor. Six interventions were adopted from diabetes programs (66,68,69,80,84,86), and one was an obesity and diabetes treatment intervention in a primary physical health service (78). 3.3 Qualitative assessment The overall quality of the included studies against the CASP Qualitative Checklist (61) was variable. Although all studies were included regardless of CASP score, the quality ratings were taken into account during synthesis, with lower-quality studies interpreted more cautiously. Five studies met all 10 of the evaluation criteria (68,75,83,87,92). A total of 11 studies met nine criteria (66,67,71–74,76,78,79,82,85) because the relationship between participants and researchers, recruitment strategy, or data analysis was not clear. Three studies met eight evaluation criteria (70,80,86) because the relationships between participants and researchers, data analysis, findings statements, or ethical considerations were not clear. Two studies met seven (69,81), one study six (84), and one study five (77) evaluation criteria, with unclear research design, data collection, the relationship between participants and researchers, ethical issues, or data analysis (see Table 2). Table 2: Critical appraisal and characteristics of the included studies and interventions 3.4 Data Synthesis with the COM-B Model The results of the studies were mapped into the COM-B model of behavior change with its six subcategories. Categories, definitions of the categories and subcategories, and example quotes are presented in Table 3. A total of 63 facilitators and 36 barriers to health behavior change were identified in this systematic review (Figure 2). Table 3: COM-B model: categories, definitions, and example quotes COM-B model Definition Subcategories Example quote Capability Individual's psychological and physical capacity to engage in the activity concerned. It includes having the necessary knowledge and skills. Physical capability Facilitator: Before I started the sugar was all high and now when they test it`s down in the normal range. ( Vazin et. al. 2016, p.14) Barrier: The trainer was a big encouragement. It´s like I need more than a year. I wasn`t ready for my year to end. (Lesley & Livingood 2015, p. 6) Psychological capability Facilitator: “I was like Ì’ll never be able to get into a group of people’ [...] and it showed that I could actually put on a real conversation with somebody outside the family [...] I wasn’t afraid, which was cool ” (Shiner et al 2008, p.8) Barrier: '' 'One plate isn’t going to hurt you,' but the plate is like this [gestures] big, and it’s all mounded, it’s huge, and then everyone had to have a drink, and I’m like, 'I don’t drink anymore' " (Aschbrenner et al. 2013) Opportunity All factors that lie outside the individual and make the behavior possible or prompt it. Physical opportunity Facilitator: I think the greatest help has just been the repetition and just kind of instilling that in my mind. ( Yarborough et al. 2016, p. 8) Barrier: I didn`t go because I ended up feeling very overwhelmed with other appointments in general. (Melamed et al. 2019, p. 6) Social opportunity Facilitator: Because they are in the same boat, they know exactly what you mean and how you feel. (Aschbrenner et al. 2016, p.14) Barrier: The atmosphere was really like an assembly line. It wasn`t a place of compassion and the empathy or personal touch wasn´t there with the care (Melamed et al. 2019, p.4) Motivation Brain processes that energize and direct behavior, not just goals and conscious decision-making. It includes habitual processes, emotional responding, as well as analytical decision-making. Reflexive motivation Facilitator: They`ll tell me, ` You need to go to the gym. Think how good you´ll feel afterwards ´ . (Aschbrenner et al. 2013, p. 3) Barrier: The atmosphere was really like an assembly line. It wasn`t a place of compassion and the empathy or personal touch wasn´t there with the Automatic motivation Facilitator: I´m having fun with a group of people and I´m exercising and it makes it all worthwhile. (Vazin et al. 2016, p. 6) Barriers: I was so weak from all medication I was on, I just wanted to sleep, just daydream all day long. (Olmos-Ochoa et al. 2019, p. 17) Table 3 COM-B model: categories, definitions and example quotes Figure 2: COM-B model: identified facilitators of and barriers to health behavior change 3.4.1 Capability Physical Capability Facilitators: Individuals with SMI felt that they could change their health behavior because of the intervention. This was attributed to new health knowledge, such as managing issues with fresh produce or specific ingredients (66,71,74,76,80,82,83,85,87,88,91,92), including newly acquired health skills, such as reading food labels, preparing simple healthy meals (67,76,82,84,85,87,88,91,92). The individuals with SMI reported perceived, primarily minor, improvements in physical health (71,73,85,87,88,90). "Although I was skinny... I could not breathe very well when I was going up and down the stairs. This improved. My clothes were not smelly anymore [...]" (71). Barriers: Health-related behavioral changes were described as impossible if the individuals with SMI reported severe side effects of the medication (74,79,80,86) or, especially at the beginning of the intervention, preexisting physical impairments (76,80,81,85,86). In particular, this was observed when exercises were perceived as too strenuous (66,78,80,81,84,86,88,90). Individuals with SMI reported that the maintenance of health-related behavioral changes after the end of the program or after switching to less close monitoring was particularly challenging (76,77,80,84,88,90,92). "I was not ready for my year to end" (76) . Physical Capabilities Summary: Physical capability influenced participants’ ability to engage in and sustain health-related behavior change. Facilitators included newly acquired health knowledge and skills gained through the intervention, as well as perceived physical health improvements. However, barriers were reported in relation to medication side effects, preexisting physical limitations, and the intensity of certain exercises. Sustaining changes proved particularly difficult once structured support ended. These findings suggest that interventions should accommodate varying physical abilities and include strategies for long-term support. Psychological Capabilities Facilitators: Individuals with SMI stated that they felt ready for a behavior change before participating in the intervention (69,71,74,78,85,89–91). It was seen as helpful that the intervention enabled them to reflect on their own health-related behavior (72,75,85,88,91,92). Constant contact persons and a group setting were perceived as pleasant (66,68,69,79,82–84,87,88,91,92). Reported improvements in mental health were observed in connection with the intervention (73,75,76,83,85,87,88,90–92). “ I was like I`ll never be able to get into a group of people’ [...] and it showed that I could actually put on a real conversation with somebody outside the family [...] I wasn’t afraid, which was cool” (94). Barriers: Individuals with SMI cited symptoms during worse episodes of severe mental illness as a barrier to behavioral change (68,68,70,71,74–76,78,79,81,83,86,88,90,92). Assumptions were expressed that behavior change would be beyond one's capability (71,78,80,90,91) or -in a small number of studies- perceived unnecessary (70,75). Moreover, the individuals with SMI has expressed cultural norms and habits as obstacles to behavioral change (67,72,80,92). '' 'One plate isn’t going to hurt you,' but the plate is like this [gestures] big, and it’s all mounded, it’s huge, and then everyone had to have a drink, and I’m like, 'I don’t drink anymore' " (67) . Psychological Capabilities Summary: Psychological capabilities played a central role in enabling or hindering behavior change among individuals with SMI. Key facilitators included participants’ initial readiness to change, the opportunity for self-reflection within the intervention, and improved mental health outcomes that reinforced motivation. Conversely, barriers stemmed from the symptoms of SMI itself, low self-efficacy, perceptions that change was unnecessary, and cultural habits that conflicted with healthier behaviors. These findings underscore the importance of designing interventions that account for fluctuating mental health status, support self-belief, and address culturally ingrained behaviors. 3.4.2 Opportunity Physical opportunities Facilitators: Facilitators were seen as helpful if activities were offered, particularly various theoretical and practical aspects of health, nutrition, and physical activity (70,83,84,89). In one study, participants with SMI expressed a preference for small group settings of no more than ten individuals, which they found more comfortable (69). Within group environments, repetition of learning content was seen as beneficial, along with the use of worksheets and the opportunity for health measurements (75,83,91,92). In relation to nutrition, some participants reported that tasting sessions (69,83,85), food diaries (82,92), and structured nutrition plans (91) supported their behavior change. Additional supportive elements, such as cooking classes (92) or grocery shopping activities (82) were mentioned in a limited number of studies. Concerning physical activity, individuals with SMI appreciated structured guidelines for exercise units (66,91), especially if they were not too strenuous or could be as in one study mentioned carried out with music (72). "Doing exercises with music is almost like dancing except that you are working muscles; that’s what I like" (72) . It was considered beneficial if the intervention location was perceived as pleasant (69,83). Concerning the duration of a program unit, the individuals with SMI reported that it should not last longer than two hours and should not occur too early in the day due to the typical symptoms of mental illness with a lack of motivation, especially in the morning (69,83). The provision of light refreshments was reported to be pleasant (69,83). Transportation to the intervention location was essential to enable participation (67,69,79). Having access to professional health workers was reported to be beneficial (82,90). Barriers : Financial aspects were named as barriers to a health behavior change (72,78,80,81,83,86,90); for example, travel costs, implementation of dietary recommendations, or sporting activities with additional expenses. In an inpatient setting, the individuals with SMI were unable to leave the facility unaccompanied, which led to nonparticipation (77). It was also reported that obligations such as caring for family members or a job prevented regular participation (75,78,79,81,83). Intervention locations that were too far away or difficult to reach were cited as barriers (78,79,85). Similarly, the intervention location was perceived as unsafe (80,85) or unpleasant (78). Poor weather conditions, such as rain or cold, were rated in one study as obstacles (92). Within clinical programs, organizational processes are perceived as too complex (78). "There’s been a lot of back and forth with the clinic [...] so it’s kind of hard to manage" (78). It was also felt to be a hindrance if too much advice was given in general or there was no opportunity to actively apply what had been learned (66,80). A sole focus on calories instead of a healthy diet was perceived as unhelpful (66). In one study it was perceived as a barrier if the lessons did not address mental health or the side effects of psychotropic medication (66). A barrier was mentioned when the technologies provided did not work or did not work sufficiently, such as pedometers falling off (66,81). Exercises that were too strenuous were rated as undesirable (72). Physical Opportunities Summary: Physical opportunities strongly shaped participation and engagement in health-promoting interventions. Key facilitators included structured and accessible program formats, and guided physical exercises adapted to participants’ capabilities. A pleasant environment, suitable timing, transport support, and access to professionals were also valued. In contrast, barriers included financial constraints, restrictive institutional settings, logistical challenges (e.g., distant or unsafe locations), and external obligations like caregiving or employment. Participants also noted issues with overly rigid content, poor integration of mental health considerations, and malfunctioning technologies. These insights emphasize the importance of designing low-threshold, flexible, and context-sensitive interventions for individuals with SMI. Social Opportunities Facilitators: Social opportunities were seen in the support provided by professionals (72,76–79,82,83,85,89,89,91,92) and trained peers with whom they described a working alliance (76,84). In several studies, individuals with SMI reported being supported by professionals who demonstrated an open-minded (83,91), humorous (83), interested (79), empathetic (79),or respectful (76,83) attitude. In one study, professionals were also perceived as helpful when serving as role models (66). Trained professionals were valued (83,89), especially when the same professional was available throughout the intervention (69,72). “I had a trainer who I met each week, which was probably one of the reasons I was able to do things because when you meet with someone, it’s easier to hold yourself accountable [...]” (72) . Peer support was also reported to be beneficial (66,68,69,72,79,82,83,88,89,91), as individuals with SMI started seeing in a group the possibility of sharing successes and challenges (68,72,82,83,88,89,91). Doing exercise in the peer group was also seen as helpful and enjoyable (82–84,92). A trusting atmosphere within the group was considered a prerequisite (82–84,92). Therefore, changes in group members were unwanted for this reason (69). Individuals with SMI experience a group as an opportunity for social networking (82,83,88) or for making friends (68,82,83). “You share things with each other, you learn and grow as a person. Making friendships, having bonds, solving problems with each other, and working as a team. That was a lot of fun" (68). Another facilitator was perceived support from family and friends (67,71,72). Barriers: Individuals with SMI cited barriers if they did not feel comfortable with other peers or the peer group (81,83,86), if they did not receive support within their private social network (67,72,76,92), or if professionals or the atmosphere of the intervention location were perceived as impersonal (76,78,83,89). “The atmosphere was truly like in an assembly line. It wasn’t a place of compassion, and the empathy of personal touch wasn’t there with the care” (78). Social Opportunities Summary: Social opportunities played a crucial role in facilitating engagement in health-promoting interventions. Support from both professionals and peers was highly valued, especially when it was consistent, empathetic, and respectful. A strong sense of accountability and motivation arose from having a dedicated professional and the opportunity to share experiences in a group setting. Peer support fostered a trusting and enjoyable environment where individuals with SMI could make friends, network, and support each other. Conversely, barriers arose when individuals felt uncomfortable with peers, lacked support from their private social networks, or found the intervention environment impersonal or unfriendly. These insights highlight the importance of creating socially supportive, empathetic, and consistent intervention settings. 3.4.3 Motivation Reflective Motivation Facilitators: Individuals with SMI saw the assumed health benefits as a motivation to participate in a health-promoting intervention (71–73,75,76,78,82,83,85,88,90,92). "I do not want to catch diabetes; so, this is part of the reason why I'm trying to lose weight" (72). As individuals with SMI in one study cited the first step toward participating in the intervention could be motivated by the recommendation of a healthcare professional (78). Regular participation was motivated by the support of professionals (35,66,71,72,76,77,83,85,87,89,91), peers or peer groups (66,68,69,72,83,87,91,92), friends and family (67,71,72,91,92). "I have this friend, she has this attitude, if I say that I’m not going somewhere she’s like, 'You are so going. Get dressed.' Then, I have to go." (72) . It was also reported that taking health measurements in a group-based setting was motivating because of the opportunity to show success to others (75,83). It was seen as motivating when professionals called to remind individuals of an appointment or ask why a person had not attended (79). Barriers: Individuals with SMI reported that their motivation was negatively affected when they received no social support from their social environment (67,72,76,92). No perceived physical health improvements were seen as demotivating (78,90). “My weight hasn’t changed, and it’s truly demotivating” (78). For example, when intervention participation was interrupted due to active illness (85). Too demanding cognitive aspects of the intervention were also considered a barrier to motivation (78). Reflexive Motivation Summary: Reflective motivation was a significant driver of participation in health-promoting interventions. Health concerns, such as preventing diabetes, often motivated individuals with SMI to engage in behavior change. Regular participation was further supported by the encouragement and accountability provided by professionals, peers, and family members. Additionally, the opportunity to track progress through health measurements in a group setting and reminders from professionals helped maintain motivation. However, barriers included a lack of social support, absence of perceived physical improvements, and interruptions due to illness, which led to demotivation. These findings underscore the importance of maintaining social support and ensuring that interventions are not overly demanding in terms of cognitive load. Automatic motivation Facilitators: Automatic motivation was reported if participation was associated with positive feelings, such as having fun or looking forward to meet up with professionals or group (35,68,69,72,73,82,87–89). High motivation was expressed by feelings of belonging and friendship with other peers (68,69,79,82,83,87,88). "You know exercise can be a fun thing. [...]...you’re in a group, you know, and you're and you're having fun. It’s a different class. It’s a different program where I can be myself, you know. I’m being myself, having fun with a group of individuals, and exercising, which makes it all worthwhile" (87) . Barriers: Individuals with SMI especially cited symptoms of mental illness or side effects of medication coming with a lack of motivation (71,74,76,78,81). “I was so weak from all the medication I was on. I just wanted to sleep” (81) . At the beginning of the intervention, feelings of discomfort in social situations or concerns about stigma were reported (69,76). Automatic Motivation Summary : Automatic motivation was often facilitated by positive emotional experiences, such as having fun, feeling a sense of belonging, and enjoying the company of peers in a group setting. Many individuals with SMI reported that the enjoyment of socializing and exercising together significantly contributed to their motivation. However, barriers to automatic motivation included the negative impact of mental illness symptoms or medication side effects, which led to fatigue and a lack of motivation. Initial discomfort in social situations and concerns about stigma also hindered engagement at the start of the intervention. These findings emphasize the importance of creating enjoyable, socially supportive environments and considering the potential effects of mental health symptoms and medication on motivation. 4 Discussion This systematic review of qualitative evidence identified barriers to and facilitators of health behavior change, based on the perspective of individuals with SMI participating in a health-promoting intervention. A total of 27 studies involving 547 individuals met the inclusion criteria. While many participants reflected on or evaluated the interventions, a small number were also involved in their design or development (i.e., codesign). The identified factors were mapped to the six subcomponents of the COM-B model to support a structured and theory-informed synthesis. Strengths and limitations To the best of the authors' knowledge, this is the first systematic review of qualitative evidence focused exclusively on barriers and facilitators for health behavior change reported by the individuals with SMI who participated in or have finished a health-promoting intervention. A key strength of this qualitative review lies in the emphasis on incorporating the lived experiences and perspectives of individuals with SMI as captured in the primary studies. The use of the COM-B model (64) as a deductive analysis framework provided a structured yet flexible basis for categorizing behavioral influences. However this systematic review of qualitative evidence has several limitations. First, the boundaries between the COM-B categories were not always clearly distinguishable, leading to instances of double coding (e.g., where capability and opportunity interacted). While analytically challenging, these overlaps may better reflect the complexity of real-world behavior. Second, due to resource constraints—particularly as this review was conducted in the context of a doctoral thesis—not all review steps were conducted independently by two reviewers. The second author double-checked 20% of the quality appraisal, and COM-B coding. We acknowledge that full independent assessments across all steps would have enhanced the validity and reliability of the findings, and we recognize this as a methodological limitation. To ensure rigor where most critical, both authors independently screened and assessed all full texts for inclusion, with discrepancies resolved through discussion. Although systemic factors such as healthcare policy and funding were beyond the scope of this review, it is important to acknowledge their influence. The generalizability of the findings may be limited due to differences in the healthcare systems of the included studies, and the results may not apply to countries not represented in the included studies. Future research should explore how such systemic factors influence the implementation and outcomes of health-promoting interventions. There seems also a need for longitudinal studies on how health behavior change in SMI populations is maintained over time. By addressing these gaps, future research can help build more equitable, effective, and person-centered approaches to health promotion for individuals with SMI. Facilitators In line with findings from the general population (95–97), individuals with SMI cite the desire for improved physical health as their primary motivation for participating in a health-promoting intervention. If individuals with SMI do not perceive improvements in their health, their motivation to continue the intervention decline. This aligns with the work of Wood and Neal (2016), who emphasize for general population that successful health behavior interventions often rely on establishing new habits through consistent repetition in stable contexts, thereby reducing the reliance on conscious motivation and willpower (98). Similarly, Clear (2018) advocates for the power of "atomic habits," suggesting that focusing on tiny, consistent improvements can lead to significant long-term behavior change. These perspectives underscore the necessity of designing interventions that support gradual habit formation and provide mechanisms for sustaining these behaviors over time (99). Vancampfort et al. assume that this is particularly important for individuals with a SMI (100). This indicates that the quick enabling of small changes in health behavior must be highly considered to maintain motivation. A perceived impersonal atmosphere or attitude on the part of professionals is a hindrance. Satisfaction is expressed as the opportunity to maintain social contacts as part of the intervention, which is extremely helpful for the desired change in health behavior. Group settings are greatly beneficial because social interaction enables the desire for belonging, exchange, and friendship. These findings are related to the enabling hypothesis, which states that social support increases self-efficacy as a prerequisite for behavioral change (101). These findings are particularly meaningful because individuals with a SMI are more likely to suffer from loneliness and have smaller social networks (102). Loneliness, in turn, has an unfavorable effect on cardiovascular risk factors (103) and increased symptoms of mental illnesses (104,105). For this reason, the opportunity for successful social interactions should be explicitly promoted and supported in health-promoting interventions targeting individuals with SMI. Learning content is facilitated when it is clear and comprehensible, and regular breaks and repetitions enable the absorption of new knowledge. A change in health behavior is always accompanied by acquiring knowledge based on which decisions can be made (106,107). This is particularly true for individuals with SMI, whose ability to absorb information may be limited due to cognitive conditions (108,109). In the group setting, the study participants also found it particularly helpful to talk to each other and explain topics and when the topics to be worked on could be chosen independently. The individuals with SMI implicitly indicated typical behavior change techniques (110), such as self-monitoring or positive reinforcement in most of the included studies. These findings should be considered when developing and implementing interventions. Barriers Constrained financial circumstances and reduced access to economic opportunities were shown to be a barrier. Individuals with SMI are disproportionately affected by income inequality (111). As a result, factors such as transportation to intervention sites, access to fitness facilities, and the availability of appropriate equipment should be carefully considered when designing health-promoting interventions for this population. In addition, nutritional recommendations and related purchasing decisions should be adapted or supported to reflect financial constraints. Periods of increased psychological symptoms represent meaningful barriers to health behavior change, such as the intervention not being attended regularly or new routines not being maintained. This is of great importance, as there are consistently observed associations between attendance rate and successful behavioral change, even in the general population (112,113). This suggests that when developing and implementing health-promoting interventions addressing individuals with SMI, care must also be taken to ensure the possibility of returning to the intervention after an acute phase of illness. Furthermore, it seems crucial to specifically address psychological symptoms and their interaction with physical health and behavioral changes in a health-promoting intervention to discuss coping strategies. In one study, individuals with SMI reflected on their experiences nine months after the intervention ended, highlighting the considerable challenges of maintaining health behavior over time(76). This also applies to the general population (95,114) but is particularly true for individuals with SMI (114). Therefore, offering programs focused on maintaining behavioral changes following temporary interventions might be helpful. Such as the Diabetes Prevention Program (DPP) which includes a structured maintenance phase aimed at supporting long-term behavior change, with evidence showing sustained lifestyle improvements over time (115). Integration across COM-B Components and Recommendations This review suggests that barriers and facilitators often intersect across COM-B domains. For example, psychological capability (e.g., health knowledge) is supported by social opportunity (e.g., group discussions), while automatic motivation (e.g., enjoyment) is reinforced by structured physical opportunity (e.g., accessible, well-designed settings). Recognizing these interactions can help practitioners design more holistic and integrated interventions. Practitioners working with individuals with SMI should aim to: Design interventions that emphasize early, achievable goals to foster initial success and sustained engagement. Create socially supportive environments that promote trust, inclusion, and a sense of belonging. Use clear, engaging, and repetitive educational strategies tailored to the cognitive and learning needs of the population. Incorporate evidence-based behavior change techniques , such as self-monitoring, reinforcement, and action planning. Address logistical and financial barriers through low-threshold, practical supports (e.g., transportation, affordable food options). Ensure continuity by planning for long-term maintenance , including relapse support and opportunities for re-engagement after periods of illness. 5 Conclusions This systematic review synthesizes the perspectives of individuals with SMI on facilitators and barriers to health behavior change in health-promoting interventions. While some factors, such as motivational challenges and knowledge gaps, are shared with the general population, this review highlights key issues particularly relevant to individuals with SMI—including the impact of mental health symptoms, the central role of social support, and significant financial and structural barriers. A key insight emerging from this review is that health behavior change among individuals with SMI often depends less on individual willpower and more on external opportunities—such as supportive environments, accessible services, and inclusive program structures. These findings point to the need for low-threshold, context-sensitive interventions that prioritize structural accessibility, continuity, and tailored support. In line with our initial aim, this review contributes to the development of conceptual frameworks that highlight the interaction of COM-B components—demonstrating how capability, opportunity, and motivation are deeply intertwined in the lived experience of health behavior change. Future research should build on this integrated perspective, exploring how environmental and systemic conditions can be optimized to enable sustained change for individuals with SMI. List of Abbreviations BCW: behavior change wheel; CASP: Critical Appraisal Skills Program; COM-B: capability, opportunity and motivation for behavior change; PRISMA: Preferred Reporting Items for Systematic reviews and Meta-Analysis; INDIVIDUALS WITH SMI: Individuals with serious mental illness; JBI: Johanna Briggs Institute; OSF: Open Science Framework. Declarations Ethics Approval and Consent to participate Not applicable. Consent for Publication Not applicable. Availability of Data and Materials The datasets used and/ or analyzed are available from the corresponding author on reasonable request. Competing Interests The authors declare that they have no competing interests. Fundings This article is part of the first author's doctorate in the doctoral college Health Services Research: Health Equity . This article is part of the first author’s doctoral work within the Doctoral College Health Services Research: Health Equity . The Doctoral College is conducted in collaboration between the University of Education Freiburg, the Catholic University of Applied Sciences Freiburg, and the Protestant University of Applied Sciences Freiburg.This is supported by the federal state of Baden-Württemberg, Germany, through state graduate funding. Open-access publishing facilitated by the University of Education Freiburg. 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Available from: http://www.nejm.org/doi/abs/10.1056/NEJMoa012512 Table 2 Table 2 is available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Additionalfile1PRISMA2020checklist.docx Additional file 1: PRISMA checklist Additionalfile2Searchstrategyforallmajordatabases.docx Additional file 2: Search strategy for all major databases Table2Criticalappraisalandcharacteristicsoftheincludedstudiesandinterventions.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 18 Dec, 2025 Reviewers agreed at journal 08 Dec, 2025 Reviewers invited by journal 03 Dec, 2025 Submission checks completed at journal 22 May, 2025 First submitted to journal 17 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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databases\u003c/p\u003e","description":"","filename":"Additionalfile2Searchstrategyforallmajordatabases.docx","url":"https://assets-eu.researchsquare.com/files/rs-4793963/v1/e2b7fb579749ec9ad71e4eab.docx"},{"id":101366047,"identity":"e9018226-5440-4293-87e9-1bda6e4d546b","added_by":"auto","created_at":"2026-01-29 00:59:48","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":22989,"visible":true,"origin":"","legend":"","description":"","filename":"Table2Criticalappraisalandcharacteristicsoftheincludedstudiesandinterventions.docx","url":"https://assets-eu.researchsquare.com/files/rs-4793963/v1/e0437266a5f73e72b986df0e.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Barriers and Facilitators to Health Behavior Change: Perspectives of Individuals with Serious Mental Illness in Health-Promoting Interventions – A Systematic Review of Qualitative Evidence","fulltext":[{"header":"1\tBackground","content":"\u003cp\u003eSerious mental illness (SMI) \u0026ndash; including schizophrenia, bipolar disorder, and major depression \u0026ndash; is defined as a mental, behavioral, or emotional disorder that results in substantial functional impairment and limits one or more major life activities\u0026nbsp;(1). Individuals with SMI face a life expectancy up to 25 years shorter than the general population (2\u0026ndash;5), largely due to a higher incidence of cardiovascular diseases (3,6,7), which are often driven by modifiable lifestyle factors (8). Obesity is significantly more common in this population\u0026nbsp;(9,10), partly because of metabolic side effects of antipsychotic medications\u0026nbsp;(11\u0026ndash;13). Additionally, individuals with SMI often have poor dietary patterns \u0026ndash; low in fruits, vegetables, and fiber, and high in processed foods and sugars\u0026nbsp;(14\u0026ndash;17)\u0026nbsp;\u0026ndash; and are less physically active, frequently leading sedentary lifestyles\u0026nbsp;(8,18,19). Smoking rates remain disproportionately high among individuals with SMI, with nicotine often used as a coping strategy, despite its contribution to cardiovascular and respiratory disease risk\u0026nbsp;(20,21). Also fragmented healthcare systems in which physical symptoms are often misattributed to psychiatric conditions, lead to delayed recognition and treatment of physical illnesses\u0026nbsp;(6,22\u0026ndash;25).\u0026nbsp;In response to these disparities, international calls have been made to develop interventions that specifically address the physical health of individuals with SMI\u0026nbsp;(26\u0026ndash;30). Health-promoting interventions \u0026ndash; structured programs aimed at improving physical and mental well-being through healthier behaviors\u0026nbsp;(31)\u0026nbsp;\u0026ndash; are a promising approach to reducing risk factors and improving long-term outcomes in this population.\u0026nbsp;Studies have demonstrated the effectiveness of smoking cessation\u0026nbsp;(32), nutrition\u0026nbsp;(33), and physical activity\u0026nbsp;(34\u0026ndash;37). However, most of these studies were conducted in highly controlled settings, and high dropout rates up to 50% among participants were observed\u0026nbsp;(38\u0026ndash;45). A meta analysis indicates key factors influencing dropout rates included the qualification of the professional delivering the intervention, continuous supervision and motivational components\u0026nbsp;(46). Studies have shown that individuals with serious mental illness (SMI) are interested in improving their physical health\u0026nbsp;(25,47\u0026ndash;54), which indicates that their needs are not yet being adequately addressed. To develop interventions that are truly responsive, it is essential to understand how individuals with SMI perceive the barriers to and facilitators of health behavior change. Qualitative research is particularly well-suited to exploring complex social phenomena, subjective experiences, and the contextual factors that shape health behaviors\u0026nbsp;(55). As such, qualitative studies are ideal for gaining deeper insight into the lived experiences of individuals with SMI as they attempt to change their health behaviors through participation in health-promoting interventions. \u0026nbsp;Although several qualitative studies have explored these experiences of individuals with SMI in health-promoting interventions, their perspectives have not yet been systematically reviewed or synthesized. A synthesis of this existing qualitative evidence provides an opportunity to learn from their lived experiences and to identify common patterns and context-specific insights. This review aims to fill that gap by conducting a systematic review and thematic synthesis of qualitative studies with the goal of identifying perceived barriers to and facilitators of health behavior change among individuals with SMI. The findings are intend to support the development of more accessible, effective, and person-centered health-promoting interventions for this population. To guide this aim, the study addresses the following research question: \u003cem\u003eWhat barriers and facilitators to health behavior change do individuals with serious mental illness report when participating in health promotion interventions?\u003c/em\u003e\u003c/p\u003e"},{"header":"2\tMethods","content":"\u003cp\u003eA systematic review and thematic synthesis of qualitative studies were conducted following the recommendations for systematic reviews of qualitative evidence by the Johanna Briggs Institute (JBI) (56) and the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) (see Additional file 1) (57). These frameworks provide guidelines for developing and synthesizing qualitative research and ensuring the quality and rigor of reviews. The objectives, inclusion criteria, and methods were specified and documented in a protocol published in the Open Science Framework (OSF) (58).\u003c/p\u003e\n\u003ch2\u003e2.1\u0026nbsp; \u0026nbsp;\u0026nbsp;Inclusion Criteria\u003c/h2\u003e\n\u003cp\u003eThe inclusion and exclusion criteria for which studies are considered should be clear and unambiguous concerning the population and phenomena of interest, the context, and the types of studies (56). The criteria were determined a priori. The \u003cstrong\u003epopulation\u003c/strong\u003e of interest included\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eadult individuals with severe mental illnesses. In this study, SMI is understood as a diagnosable mental, behavioral, or emotional disorder that results in serious functional impairment and substantially interferes with or limits one or more major life activities, such as schizophrenia, bipolar disorder or major depression (1). Individuals with neurological disorders, such as dementia; nonchronic mental illnesses, including perinatal depression; or physical illness in the foreground, such as cancer, were excluded. The \u003cstrong\u003ephenomenon of interest\u0026nbsp;\u003c/strong\u003ewas how the individuals with SMI evaluates health-promoting interventions they were participating in or had completed. Health-promoting interventions (59) were defined as those that included at least two aspects of physical health (such as diet and physical activity). The \u003cstrong\u003eaim\u003c/strong\u003e was to identify barriers and facilitators that made health behavior changes easier or more difficult. In this context, \"barriers\" were defined as any physiological, psychological, or socioecological condition negatively affecting a person’s health behavior\u0026nbsp;change in a health-promoting intervention\u0026nbsp;(54).\u0026nbsp;Therefore, \"facilitators\" were defined as any physiological, psychological, or socioecological condition that positively affects a person’s health behavior change in a health-promoting intervention\u0026nbsp;(54).\u0026nbsp;Concerning the \u003cstrong\u003econtext\u003c/strong\u003e, studies were included regardless of the setting where the interventions took place, such as community-based, supportive housing, inpatient or outpatient clinics. Interventions were included if they addressed at least two physical health factors: (e.g. physical activity and nutrition). Single interventions, such as smoking cessation only, were excluded. Interventions delivered exclusively via telephone or internet were excluded if they did not involve structured, interactive components supporting self-management, as the focus was on interventions with more comprehensive formats aimed at facilitating behavior change through engagement and support. Only qualitative studies were included to understand the complex social phenomena, subjective meanings, and the contextual factors that shape health behaviors, and in-depth insights that quantitative studies cannot offer\u0026nbsp;(55).\u0026nbsp;Studies were included when they involved the perspectives of the individuals with SMI who were participating or had completed a health-promoting intervention and reported barriers or facilitators concerning health behavior change. Mixed method studies were included if their qualitative data were congruent with the research question. If a study included other groups of individuals, including professionals, the results referring to these groups were not included.\u003c/p\u003e\n\u003ch2\u003e2.2\u0026nbsp; \u0026nbsp;\u0026nbsp;Search Strategy\u003c/h2\u003e\n\u003cp\u003eAn initial limited search in PsycINFO was undertaken to identify studies on the topic. The text words in the titles and abstracts of relevant articles, including the index terms used to describe the articles, were used to develop an entire search strategy for PsycINFO. The reference lists of identified studies were hand-screened for further relevant data. The search strategy, including all identified keywords and index terms, was then adapted for each database (see Additional file 2). To ensure comprehensive and interdisciplinary coverage of the topic, we purposefully selected databases representing key relevant disciplines. \u003cstrong\u003eMedline\u003c/strong\u003e (via PubMed) was included for its extensive focus on medical and clinical literature, \u003cstrong\u003ePsycINFO\u003c/strong\u003e for psychological research, \u003cstrong\u003eCINAHL\u003c/strong\u003e for nursing and allied health studies, and the \u003cstrong\u003eSocial Sciences Citation Index (SSCI)\u003c/strong\u003e for research in sociology, education, and related social sciences. This strategy allowed to capture diverse perspectives relevant to health behavior interventions. While databases such as Web of Science were considered, SSCI – also part of the Web of Science Core Collection – was chosen specifically for its focused indexing of the social science literature most pertinent to our research objectives. The databases were searched between August 29, 2023, and June 1, 2024. No time limit or language was set for inclusion An example of the search strategy used is displayed in Table 1.\u003c/p\u003e\n\u003cp\u003eTable 1: Example search string PsychInfo\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePsycINFO\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDE \"Serious Mental Illness\" OR MM \"Mental Disorders\" OR DE \"Schizophrenia\" OR DE \"Anxiety Disorders\" OR DE \"Major Depression\" OR DE \"Bipolar Disorder\" OR DE \"Borderline Personality Disorder\"\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAND\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDE \"Physical Activity\" OR DE \"Physical Fitness\" OR DE \"Activity Level\" OR DE \"Actigraphy\" OR DE \"Active Living\" OR DE \"Exercise\" OR DE \"Aerobic Exercise\" OR DE \"Dietary Treatment\" OR DE \"Diets\" OR DE \"Healthy Eating\" OR DE \"Obesity\" OR \"\"Dietary Intervention*\" OR \"Physical Health\" OR exercis*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAND\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDE \"Treatment Refusal\" OR DE \"Treatment Barriers\" OR DE \"Treatment Compliance\" OR DE \"Client Participation\" OR DE \"Client Attitudes\" OR barriers OR facilitators\" OR enabl* OR promot*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch2\u003e2.3\u0026nbsp; \u0026nbsp;\u0026nbsp;Study Screening\u003c/h2\u003e\n\u003cp\u003eThe identified records were imported into the systematic review tool Covidence (60). Duplications were removed, and the first author screened the titles and abstracts to exclude records irrelevant to the research question. All remaining full texts were then assessed for eligibility by the first and second author independently. Discrepancies occurred in a small number of cases and were resolved through discussion to reach consensus. For example, there were occasional disagreements about whether studies focusing solely on one behavioral domain (e.g., diet or physical activity) met the criteria for inclusion. Reasons for exclusion were documented for all full-text articles at this stage.\u003c/p\u003e\n\u003ch2\u003e2.4\u0026nbsp; \u0026nbsp;\u0026nbsp;Data Extraction\u003c/h2\u003e\n\u003cp\u003eThe studies included were extracted by the first author. A data extraction table was used, which included the author, year, country, study objectives, study participants, data collection, data analysis, and health-promoting intervention components. The first author completed the data extraction. The second author independently checked 20% of the data for consistency. Any discrepancies were discussed.\u003c/p\u003e\n\u003ch2\u003e2.5\u0026nbsp; \u0026nbsp;\u0026nbsp;Quality Appraisal\u003c/h2\u003e\n\u003cp\u003eThe quality of the studies was appraised using the Qualitative Checklist for Qualitative Studies (CASP) (61). Therefore, the CASP provides criteria concerning the validity of results, methodology, research design, recruitment, data collection, analysis, and ethical issues taken into consideration. The first author appraised all studies against quality. The second author independently appraised 20% of those studies. Any discrepancies were discussed.\u003c/p\u003e\n\u003ch2\u003e2.6\u0026nbsp; \u0026nbsp;\u0026nbsp;Analysis and Synthesis\u003c/h2\u003e\n\u003cp\u003eThe data were extracted to MAXQDA (62) a qualitative data software tool, and the study results were analyzed using a framework analysis (63) informed by the COM-B model (64). As part of the behavioral change wheel (BCW), the COM-B model conceptualizes behavior as the result of an interaction between three core components: \u003cstrong\u003eCapability\u003c/strong\u003e (both physical and psychological), \u003cstrong\u003eOpportunity\u003c/strong\u003e (both physical and social), and \u003cstrong\u003eMotivation\u003c/strong\u003e (both reflective and automatic)\u0026nbsp;(64). We used the COM-B model to guide our findings by mapping factors associated with health behavior change to these subcomponents using a coding guide developed by Michie et al. (64,65). For example, participants’ knowledge and mental skills were coded under \u003cem\u003epsychological capability\u003c/em\u003e, while access to supportive environments or resources was coded under \u003cem\u003ephysical opportunity\u003c/em\u003e. Distinct from the concept of automaticity in cognitive science \u003cem\u003eautomatic motivation\u003c/em\u003e refers to emotional responses, impulses, and habits that influence behavior\u003cem\u003e.\u003c/em\u003e The COM-B model approach allowes to systematically identify barriers and facilitators to health behavior change and to generate practice-oriented intervention points. The first author coded all studies. The second author independently coded 20% of the studies to ensure consistency. Any discrepancies were discussed. Themes were continuously compared and contrasted during the data synthesis process to promote the accuracy and validity of translation and interpretation. The factors assigned to the six subcomponents of the model are discussed separately below. The included studies were summarized.\u003c/p\u003e"},{"header":"3\tResults","content":"\u003ch2\u003e3.1\u0026nbsp; \u0026nbsp;\u0026nbsp;Results of the research\u003c/h2\u003e\n\u003cp\u003eThe literature search occurred between August 29, 2023, and June 1, 2024. A total of 4242 studies were found, of which 850 were identified as duplicates and removed. A total of 3392 studies were screened with titles and abstracts. For full-text review, a total of 47 studies were selected. A total of 27 studies (66\u0026ndash;92) were eligible for the systematic review of qualitative evidence (see Figure 1).\u003c/p\u003e\n\u003cp\u003eFigure 1: Flowchart\u003c/p\u003e\n\u003ch2\u003e3.2\u0026nbsp; \u0026nbsp;\u0026nbsp;Characteristics of the included studies\u003c/h2\u003e\n\u003cp\u003eThe following summary describes the characteristics of the included studies and interventions in which the individuals with SMI participated (see Table 2).\u003c/p\u003e\n\u003cp\u003eA total of 13 studies were conducted in the USA (66\u0026ndash;68,72\u0026ndash;74,76,80,81,84,85,87,92), four in the UK (69,71,77,83) and three in the Netherlands (70,88,89), two in Sweden (90,91) and Australia (79,82), and one in Denmark (75), Canada (78), and Israel (86). Studies were published between 2008 and 2022. Data collection was carried out using semistructured interviews (68,70\u0026ndash;76,78\u0026ndash;82,84\u0026ndash;91,93), but qualitative interviews (84,92) or focus groups (66,67,69,77,80) were not further described. Thematic analysis was predominantly used for data analysis (66\u0026ndash;68,70,72\u0026ndash;74,76,77,81\u0026ndash;83,85,87\u0026ndash;89,92), some with a predominantly existing framework (78,79,91). Other studies used content analysis (80,90), one grounded theory methodology (86), a pragmatic approach (69), and a secondary inductive approach (71). The samples varied in size between two (84) and 84 (86) individuals with SMI. In total, 547 indivduals with SMI provided their perspectives on barriers to and facilitators of health behavior change in the context of health-promoting interventions. Jimenez et al. (72\u0026ndash;74), Walburg et al. (88,89), and W\u0026auml;rdig et al. (90,91) published different studies with the same sample. The interventions mainly took place in community mental health services (66\u0026ndash;69,72\u0026ndash;74,76,79,81\u0026ndash;85,88,89,92), two in supportive housing or community residentials (80,86), one in a long-term inpatient facility (70), a primary care setting (71) and two in a psychiatric outpatient setting (75,87), one of which had additional substance use (75).\u003c/p\u003e\n\u003cp\u003eConcerning the intervention components, 12 interventions were group-based (66,68,69,79,80,82\u0026ndash;84,86,90\u0026ndash;92). Furthermore, nine studies were conducted in a one-on-one setting (67,71\u0026ndash;74,76\u0026ndash;78,85), and six were conducted partly in a one-on-one setting and partly group-based (70,75,81,87\u0026ndash;89). Guidance was predominantly provided by a trained specialist (66\u0026ndash;77,80\u0026ndash;82,84\u0026ndash;86,88\u0026ndash;92), such as a health professional, mental health professional, physical therapist, nutritionist, or fitness trainer. Trained peers were involved in the implementation of three interventions (66,80,81). The total duration of the interventions ranged from 12 weeks (82) to 24 months (92), with the majority of interventions lasting 12 months (67,69,72\u0026ndash;74,76,80,85,88,89). All interventions involved theoretical input related to healthy eating and physical activity. The physical activity started at a beginner level and gradually increased in intensity and duration over time, including exercises to music, walking, and other activities (66\u0026ndash;68,73,85,86,90,91). The diet component emphasized a balanced diet rich in vegetables, fruits, whole grains, and low-fat dairy, with a focus on calorie and fat reduction. Participants were taught strategies for healthy eating, meal planning, and overcoming barriers, often using self-monitoring tools like food logs (66,73,86,87,92).\u003c/p\u003e\n\u003cp\u003eIn 21 interventions, behavioral change techniques(66\u0026ndash;70,72\u0026ndash;76,80\u0026ndash;82,84,85,87\u0026ndash;92), such as motivational interviewing or goal setting, were shown. In 12 interventions, practical interventions such as physical activities or cooking classes were applied (67,70,72,72,74,76,77,82,83,85,87\u0026ndash;92), and two optional fitness sessions were offered (66,68). The frequency of intervention units was monthly in one intervention (78), daily in two interventions (70,77), and weekly in seven interventions (80\u0026ndash;82,84,87,90,91). In 12 interventions, the frequency differed through intervention time, with reduced meetings at the end (66\u0026ndash;69,72\u0026ndash;74,85,86,88,89,92). The duration of an intervention session was up to 60 minutes in seven interventions (67,72\u0026ndash;74,76,80,82) and up to 120 minutes in three interventions (69,90,91). Six studies referred to the SHAPE intervention (67,72\u0026ndash;74,76,85).\u0026nbsp;This motivational health-promoting intervention aimed to improve physical fitness through dietary changes and increased physical activity. Each participant with SMI received a one-year membership to a local fitness facility and ongoing support from a health mentor.\u0026nbsp;Six interventions were adopted from diabetes programs\u0026nbsp;(66,68,69,80,84,86), and one was an obesity and diabetes treatment intervention in a primary physical health service\u0026nbsp;(78).\u003c/p\u003e\n\u003ch2\u003e3.3\u0026nbsp; \u0026nbsp;\u0026nbsp;Qualitative assessment\u003c/h2\u003e\n\u003cp\u003eThe overall quality of the included studies against the CASP Qualitative Checklist (61) was variable. Although all studies were included regardless of CASP score, the quality ratings were taken into account during synthesis, with lower-quality studies interpreted more cautiously. Five studies met all 10 of the evaluation criteria (68,75,83,87,92). A total of 11 studies met nine criteria (66,67,71\u0026ndash;74,76,78,79,82,85) because the relationship between participants and researchers, recruitment strategy, or data analysis was not clear. Three studies met eight evaluation criteria (70,80,86) because the relationships between participants and researchers, data analysis, findings statements, or ethical considerations were not clear. Two studies met seven (69,81), one study six (84), and one study five (77) evaluation criteria, with unclear research design, data collection, the relationship between participants and researchers, ethical issues, or data analysis (see Table 2).\u003c/p\u003e\n\u003cp\u003eTable 2: Critical appraisal and characteristics of the included studies and interventions\u003c/p\u003e\n\u003ch2\u003e3.4\u0026nbsp; \u0026nbsp;\u0026nbsp;Data Synthesis with the COM-B Model\u003c/h2\u003e\n\u003cp\u003eThe results of the studies were mapped into the COM-B model of behavior change with its six subcategories. Categories, definitions of the categories and subcategories, and example quotes are presented in Table 3. A total of 63 facilitators and 36 barriers to health behavior change were identified in this systematic review (Figure 2).\u003c/p\u003e\n\u003cp\u003eTable 3: COM-B model: categories, definitions, and example quotes\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"973\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCOM-B model\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDefinition\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSubcategories\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 605px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExample quote\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 973px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCapability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eIndividual\u0026apos;s psychological and physical capacity to engage in the activity concerned. It includes having the necessary knowledge and skills.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003ePhysical capability\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 605px;\"\u003e\n \u003cp\u003eFacilitator: \u003cem\u003eBefore I started the sugar was all high and now when they test it`s down in the normal range.\u0026nbsp;\u003c/em\u003e\u003cem\u003e(\u003c/em\u003eVazin et. al. 2016, p.14)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 605px;\"\u003e\n \u003cp\u003eBarrier: \u003cem\u003eThe trainer was a big encouragement. It\u0026acute;s like I need more than a year. I wasn`t ready for my year to end.\u0026nbsp;\u003c/em\u003e(Lesley \u0026amp; Livingood 2015, p. 6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003ePsychological capability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 605px;\"\u003e\n \u003cp\u003eFacilitator: \u003cem\u003e\u0026ldquo;I was like \u0026Igrave;\u0026rsquo;ll never be able to get into a group of people\u0026rsquo; [...] and it showed that I could actually put on a real conversation with somebody outside the family [...] I wasn\u0026rsquo;t afraid, which was cool\u003c/em\u003e\u0026rdquo; (Shiner et al 2008, p.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 605px;\"\u003e\n \u003cp\u003eBarrier: \u003cem\u003e\u0026apos;\u0026apos; \u0026apos;One plate isn\u0026rsquo;t going to hurt you,\u0026apos; but the plate is like this [gestures] big, and it\u0026rsquo;s all mounded, it\u0026rsquo;s huge, and then everyone had to have a drink, and I\u0026rsquo;m like, \u0026apos;I don\u0026rsquo;t drink anymore\u0026apos; \u0026quot; (Aschbrenner et al. 2013)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 973px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOpportunity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eAll factors that lie outside the individual and make the behavior possible or prompt it.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003ePhysical opportunity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 605px;\"\u003e\n \u003cp\u003eFacilitator: \u003cem\u003eI think the greatest help has just been the repetition and just kind of instilling that in my mind. (\u003c/em\u003eYarborough et al. 2016, p. 8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 605px;\"\u003e\n \u003cp\u003eBarrier: I didn`t go because I ended \u003cem\u003eup feeling very overwhelmed with other appointments in general.\u0026nbsp;\u003c/em\u003e(Melamed et al. 2019, p. 6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eSocial opportunity\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 605px;\"\u003e\n \u003cp\u003eFacilitator: \u003cem\u003eBecause they are in the same boat, they know exactly what you mean and how you feel.\u0026nbsp;\u003c/em\u003e(Aschbrenner et al. 2016, p.14)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 605px;\"\u003e\n \u003cp\u003eBarrier: \u003cem\u003eThe atmosphere was really like an assembly line. It wasn`t a place of compassion and the empathy or personal touch wasn\u0026acute;t there with the care\u0026nbsp;\u003c/em\u003e(Melamed et al. 2019, p.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 973px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMotivation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eBrain processes that energize and direct behavior, not just goals and conscious decision-making. It includes habitual processes, emotional responding, as well as analytical decision-making.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eReflexive motivation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 605px;\"\u003e\n \u003cp\u003eFacilitator: They`ll tell me, `\u003cem\u003eYou need to go to the gym. Think how good you\u0026acute;ll feel afterwards\u003c/em\u003e\u003cem\u003e\u0026acute;\u003c/em\u003e. (Aschbrenner et al. 2013, p. 3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 605px;\"\u003e\n \u003cp\u003eBarrier: \u003cem\u003eThe atmosphere was really like an assembly line. It wasn`t a place of compassion and the empathy or personal touch wasn\u0026acute;t there with the\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eAutomatic motivation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 605px;\"\u003e\n \u003cp\u003eFacilitator: I\u0026acute;m having fun with a group of people and I\u0026acute;m exercising and it makes it all worthwhile. (Vazin et al. 2016, p. 6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 605px;\"\u003e\n \u003cp\u003eBarriers: \u003cem\u003eI was so weak from all medication I was on, I just wanted to sleep, just daydream all day long.\u0026nbsp;\u003c/em\u003e(Olmos-Ochoa et al. 2019, p. 17)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 3 COM-B model: categories, definitions and example quotes\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFigure 2: COM-B model: identified facilitators of and barriers to health behavior change\u003c/p\u003e\n\u003ch3\u003e3.4.1\u0026nbsp; \u0026nbsp;Capability\u003c/h3\u003e\n\u003cp\u003e\u003cstrong\u003ePhysical Capability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFacilitators:\u003c/strong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003eIndividuals with SMI felt that they could change their health behavior because of the intervention. This was attributed to new health knowledge, such as managing issues with fresh produce or specific ingredients (66,71,74,76,80,82,83,85,87,88,91,92), including newly acquired health skills, such as reading food labels, preparing simple healthy meals (67,76,82,84,85,87,88,91,92). The individuals with SMI reported perceived, primarily minor, improvements in physical health (71,73,85,87,88,90). \u003cem\u003e\u0026quot;Although I was skinny... I could not breathe very well when I was going up and down the stairs. This improved. My clothes were not smelly anymore [...]\u0026quot;\u0026nbsp;\u003c/em\u003e(71).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBarriers:\u0026nbsp;\u003c/strong\u003eHealth-related behavioral changes were described as impossible if the individuals with SMI reported severe side effects of the medication (74,79,80,86) or, especially at the beginning of the intervention, preexisting physical impairments (76,80,81,85,86). In particular, this was observed when exercises were perceived as too strenuous (66,78,80,81,84,86,88,90). Individuals with SMI reported that the maintenance of health-related behavioral changes after the end of the program or after switching to less close monitoring was particularly challenging (76,77,80,84,88,90,92). \u003cem\u003e\u0026quot;I was not ready for my year to end\u0026quot;\u0026nbsp;\u003c/em\u003e(76)\u003cem\u003e.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePhysical Capabilities Summary:\u003c/strong\u003e Physical capability influenced participants\u0026rsquo; ability to engage in and sustain health-related behavior change. Facilitators included newly acquired health knowledge and skills gained through the intervention, as well as perceived physical health improvements. However, barriers were reported in relation to medication side effects, preexisting physical limitations, and the intensity of certain exercises. Sustaining changes proved particularly difficult once structured support ended. These findings suggest that interventions should accommodate varying physical abilities and include strategies for long-term support.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePsychological Capabilities\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFacilitators:\u0026nbsp;\u003c/strong\u003eIndividuals with SMI stated that they felt ready for a behavior change before participating in the intervention (69,71,74,78,85,89\u0026ndash;91). It was seen as helpful that the intervention enabled them to reflect on their own health-related behavior (72,75,85,88,91,92). Constant contact persons and a group setting were perceived as pleasant (66,68,69,79,82\u0026ndash;84,87,88,91,92). Reported improvements in mental health were observed in connection with the intervention (73,75,76,83,85,87,88,90\u0026ndash;92). \u0026ldquo;\u003cem\u003eI was like I`ll never be able to get into a group of people\u0026rsquo; [...] and it showed that I could actually put on a real conversation with somebody outside the family [...] I wasn\u0026rsquo;t afraid, which was cool\u0026rdquo;\u003c/em\u003e (94).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBarriers:\u0026nbsp;\u003c/strong\u003eIndividuals with SMI cited symptoms during worse episodes of severe mental illness as a barrier to behavioral change (68,68,70,71,74\u0026ndash;76,78,79,81,83,86,88,90,92). Assumptions were expressed that behavior change would be beyond one\u0026apos;s capability (71,78,80,90,91) or -in a small number of studies- perceived unnecessary (70,75). Moreover, the individuals with SMI has expressed cultural norms and habits as obstacles to behavioral change (67,72,80,92). \u003cem\u003e\u0026apos;\u0026apos; \u0026apos;One plate isn\u0026rsquo;t going to hurt you,\u0026apos; but the plate is like this [gestures] big, and it\u0026rsquo;s all mounded, it\u0026rsquo;s huge, and then everyone had to have a drink, and I\u0026rsquo;m like, \u0026apos;I don\u0026rsquo;t drink anymore\u0026apos; \u0026quot;\u003c/em\u003e\u003cem\u003e(67)\u003c/em\u003e\u003cem\u003e.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePsychological Capabilities Summary:\u003c/strong\u003e Psychological capabilities played a central role in enabling or hindering behavior change among individuals with SMI. Key facilitators included participants\u0026rsquo; initial readiness to change, the opportunity for self-reflection within the intervention, and improved mental health outcomes that reinforced motivation. Conversely, barriers stemmed from the symptoms of SMI itself, low self-efficacy, perceptions that change was unnecessary, and cultural habits that conflicted with healthier behaviors. These findings underscore the importance of designing interventions that account for fluctuating mental health status, support self-belief, and address culturally ingrained behaviors.\u003c/p\u003e\n\u003ch3\u003e3.4.2\u0026nbsp; \u0026nbsp;Opportunity\u003c/h3\u003e\n\u003cp\u003e\u003cstrong\u003ePhysical opportunities\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFacilitators:\u0026nbsp;\u003c/strong\u003eFacilitators were seen as helpful if activities were offered, particularly various theoretical and practical aspects of health, nutrition, and physical activity (70,83,84,89). In one study, participants with SMI expressed a preference for small group settings of no more than ten individuals, which they found more comfortable (69). Within group environments, repetition of learning content was seen as beneficial, along with the use of worksheets and the opportunity for health measurements (75,83,91,92). In relation to nutrition, some participants reported that tasting sessions (69,83,85), food diaries (82,92), and structured nutrition plans (91) supported their behavior change. Additional supportive elements, such as cooking classes (92) or grocery shopping activities (82) were mentioned in a limited number of studies. Concerning physical activity, individuals with SMI appreciated structured guidelines for exercise units (66,91), especially if they were not too strenuous or could be as in one study mentioned carried out with music (72). \u003cem\u003e\u0026quot;Doing exercises with music is almost like dancing except that you are working muscles; that\u0026rsquo;s what I like\u0026quot;\u0026nbsp;\u003c/em\u003e(72)\u003cem\u003e.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIt was considered beneficial if the intervention location was perceived as pleasant (69,83). Concerning the duration of a program unit, the individuals with SMI reported that it should not last longer than two hours and should not occur too early in the day due to the typical symptoms of mental illness with a lack of motivation, especially in the morning (69,83). The provision of light refreshments was reported to be pleasant (69,83). Transportation to the intervention location was essential to enable participation (67,69,79). Having access to professional health workers was reported to be beneficial (82,90).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBarriers\u003c/strong\u003e: Financial aspects were named as barriers to a health behavior change (72,78,80,81,83,86,90); for example, travel costs, implementation of dietary recommendations, or sporting activities with additional expenses. In an inpatient setting, the individuals with SMI were unable to leave the facility unaccompanied, which led to nonparticipation (77).\u003c/p\u003e\n\u003cp\u003eIt was also reported that obligations such as caring for family members or a job prevented regular participation (75,78,79,81,83). Intervention locations that were too far away or difficult to reach were cited as barriers (78,79,85). Similarly, the intervention location was perceived as unsafe (80,85) or unpleasant (78). Poor weather conditions, such as rain or cold, were rated in one study as obstacles (92). Within clinical programs, organizational processes are perceived as too complex (78). \u003cem\u003e\u0026quot;There\u0026rsquo;s been a lot of back and forth with the clinic [...] so it\u0026rsquo;s kind of hard to manage\u0026quot;\u0026nbsp;\u003c/em\u003e(78). It was also felt to be a hindrance if too much advice was given in general or there was no opportunity to actively apply what had been learned (66,80). A sole focus on calories instead of a healthy diet was perceived as unhelpful (66). In one study it was perceived as a barrier if the lessons did not address mental health or the side effects of psychotropic medication (66).\u003c/p\u003e\n\u003cp\u003eA barrier was mentioned when the technologies provided did not work or did not work sufficiently, such as pedometers falling off (66,81). Exercises that were too strenuous were rated as undesirable (72).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePhysical Opportunities Summary:\u0026nbsp;\u003c/strong\u003ePhysical opportunities strongly shaped participation and engagement in health-promoting interventions. Key facilitators included structured and accessible program formats, and guided physical exercises adapted to participants\u0026rsquo; capabilities. A pleasant environment, suitable timing, transport support, and access to professionals were also valued. In contrast, barriers included financial constraints, restrictive institutional settings, logistical challenges (e.g., distant or unsafe locations), and external obligations like caregiving or employment. Participants also noted issues with overly rigid content, poor integration of mental health considerations, and malfunctioning technologies. These insights emphasize the importance of designing low-threshold, flexible, and context-sensitive interventions for individuals with SMI.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSocial Opportunities\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFacilitators:\u0026nbsp;\u003c/strong\u003eSocial opportunities were seen in the support provided by professionals (72,76\u0026ndash;79,82,83,85,89,89,91,92) and trained peers with whom they described a working alliance (76,84). In several studies, individuals with SMI reported being supported by professionals who demonstrated an open-minded (83,91), humorous (83), interested (79), empathetic (79),or respectful (76,83) attitude. In one study, professionals were also perceived as helpful when serving as role models (66). Trained professionals were valued (83,89), especially when the same professional was available throughout the intervention (69,72). \u003cem\u003e\u0026ldquo;I had a trainer who I met each week, which was probably one of the reasons I was able to do things because when you meet with someone, it\u0026rsquo;s easier to hold yourself accountable [...]\u0026rdquo;\u0026nbsp;\u003c/em\u003e(72)\u003cem\u003e.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ePeer support was also reported to be beneficial (66,68,69,72,79,82,83,88,89,91), as individuals with SMI started seeing in a group the possibility of sharing successes and challenges (68,72,82,83,88,89,91). Doing exercise in the peer group was also seen as helpful and enjoyable (82\u0026ndash;84,92). A trusting atmosphere within the group was considered a prerequisite (82\u0026ndash;84,92). Therefore, changes in group members were unwanted for this reason (69). Individuals with SMI experience a group as an opportunity for social networking (82,83,88) or for making friends (68,82,83). \u003cem\u003e\u0026ldquo;You share things with each other, you learn and grow as a person. Making friendships, having bonds, solving problems with each other, and working as a team. That was a lot of fun\u0026quot;\u0026nbsp;\u003c/em\u003e(68). Another facilitator was perceived support from family and friends (67,71,72).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBarriers:\u0026nbsp;\u003c/strong\u003eIndividuals with SMI cited barriers if they did not feel comfortable with other peers or the peer group (81,83,86), if they did not receive support within their private social network (67,72,76,92), or if professionals or the atmosphere of the intervention location were perceived as impersonal (76,78,83,89). \u003cem\u003e\u0026ldquo;The atmosphere was truly like in an assembly line. It wasn\u0026rsquo;t a place of compassion, and the empathy of personal touch wasn\u0026rsquo;t there with the care\u0026rdquo;\u003c/em\u003e (78).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSocial Opportunities Summary:\u003c/strong\u003e Social opportunities played a crucial role in facilitating engagement in health-promoting interventions. Support from both professionals and peers was highly valued, especially when it was consistent, empathetic, and respectful. A strong sense of accountability and motivation arose from having a dedicated professional and the opportunity to share experiences in a group setting. Peer support fostered a trusting and enjoyable environment where individuals with SMI could make friends, network, and support each other. Conversely, barriers arose when individuals felt uncomfortable with peers, lacked support from their private social networks, or found the intervention environment impersonal or unfriendly. These insights highlight the importance of creating socially supportive, empathetic, and consistent intervention settings.\u003c/p\u003e\n\u003ch3\u003e3.4.3\u0026nbsp; \u0026nbsp;Motivation\u003c/h3\u003e\n\u003cp\u003e\u003cstrong\u003eReflective Motivation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFacilitators:\u0026nbsp;\u003c/strong\u003eIndividuals with SMI saw the assumed health benefits as a motivation to participate in a health-promoting intervention\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e(71\u0026ndash;73,75,76,78,82,83,85,88,90,92). \u003cem\u003e\u0026quot;I do not want to catch diabetes; so, this is part of the reason why I\u0026apos;m trying to lose weight\u0026quot;\u0026nbsp;\u003c/em\u003e(72). As individuals with SMI in one study cited the first step toward participating in the intervention could be motivated by the recommendation of a healthcare professional (78).\u003c/p\u003e\n\u003cp\u003eRegular participation was motivated by the support of professionals (35,66,71,72,76,77,83,85,87,89,91), peers or peer groups (66,68,69,72,83,87,91,92), friends and family (67,71,72,91,92). \u003cem\u003e\u0026quot;I have this friend, she has this attitude, if I say that I\u0026rsquo;m not going somewhere she\u0026rsquo;s like, \u0026apos;You are so going. Get dressed.\u0026apos; Then, I have to go.\u0026quot;\u0026nbsp;\u003c/em\u003e(72)\u003cem\u003e.\u0026nbsp;\u003c/em\u003eIt was also reported that taking health measurements in a group-based setting was motivating because of the opportunity to show success to others\u0026nbsp;(75,83). It was seen as motivating when professionals called to remind individuals of an appointment or ask why a person had not attended\u0026nbsp;(79).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBarriers:\u003c/strong\u003e Individuals with SMI reported that their motivation was negatively affected when they received no social support from their social environment (67,72,76,92). No perceived physical health improvements were seen as demotivating (78,90). \u003cem\u003e\u0026ldquo;My weight hasn\u0026rsquo;t changed, and it\u0026rsquo;s truly demotivating\u0026rdquo;\u0026nbsp;\u003c/em\u003e(78). For example, when intervention participation was interrupted due to active illness (85). Too demanding cognitive aspects of the intervention were also considered a barrier to motivation (78).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eReflexive Motivation Summary:\u003c/strong\u003e Reflective motivation was a significant driver of participation in health-promoting interventions. Health concerns, such as preventing diabetes, often motivated individuals with SMI to engage in behavior change. Regular participation was further supported by the encouragement and accountability provided by professionals, peers, and family members. Additionally, the opportunity to track progress through health measurements in a group setting and reminders from professionals helped maintain motivation. However, barriers included a lack of social support, absence of perceived physical improvements, and interruptions due to illness, which led to demotivation. These findings underscore the importance of maintaining social support and ensuring that interventions are not overly demanding in terms of cognitive load.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAutomatic motivation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFacilitators:\u0026nbsp;\u003c/strong\u003eAutomatic motivation was reported if participation was associated with positive feelings, such as having fun or looking forward to meet up with professionals or group (35,68,69,72,73,82,87\u0026ndash;89). High motivation was expressed by feelings of belonging and friendship with other peers (68,69,79,82,83,87,88). \u003cem\u003e\u0026quot;You know exercise can be a fun thing. [...]...you\u0026rsquo;re in a group, you know, and you\u0026apos;re and you\u0026apos;re having fun. It\u0026rsquo;s a different class. It\u0026rsquo;s a different program where I can be myself, you know. I\u0026rsquo;m being myself, having fun with a group of individuals, and exercising, which makes it all worthwhile\u0026quot;\u0026nbsp;\u003c/em\u003e(87)\u003cem\u003e.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBarriers:\u0026nbsp;\u003c/strong\u003eIndividuals with SMI especially cited symptoms of mental illness or side effects of medication coming with a lack of motivation (71,74,76,78,81). \u003cem\u003e\u0026ldquo;I was so weak from all the medication I was on. I just wanted to sleep\u0026rdquo;\u0026nbsp;\u003c/em\u003e(81)\u003cem\u003e.\u003c/em\u003e At the beginning of the intervention, feelings of discomfort in social situations or concerns about stigma were reported\u0026nbsp;(69,76).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAutomatic Motivation Summary\u003c/strong\u003e: Automatic motivation was often facilitated by positive emotional experiences, such as having fun, feeling a sense of belonging, and enjoying the company of peers in a group setting. Many individuals with SMI reported that the enjoyment of socializing and exercising together significantly contributed to their motivation. However, barriers to automatic motivation included the negative impact of mental illness symptoms or medication side effects, which led to fatigue and a lack of motivation. Initial discomfort in social situations and concerns about stigma also hindered engagement at the start of the intervention. These findings emphasize the importance of creating enjoyable, socially supportive environments and considering the potential effects of mental health symptoms and medication on motivation.\u003c/p\u003e"},{"header":"4\tDiscussion","content":"\u003cp\u003eThis systematic review of qualitative evidence identified barriers to and facilitators of health behavior change, based on the perspective of individuals with SMI participating in a health-promoting intervention. A total of 27 studies involving 547 individuals met the inclusion criteria. While many participants reflected on or evaluated the interventions, a small number were also involved in their design or development (i.e., codesign). The identified factors were mapped to the six subcomponents of the COM-B model to support a structured and theory-informed synthesis.\u003c/p\u003e\n\u003ch2\u003eStrengths and limitations\u003c/h2\u003e\n\u003cp\u003eTo the best of the authors\u0026apos; knowledge, this is the first systematic review of qualitative evidence focused exclusively on barriers and facilitators for health behavior change reported by the individuals with SMI who participated in or have finished a health-promoting intervention. A key strength of this qualitative review lies in the emphasis on incorporating the lived experiences and perspectives of individuals with SMI as captured in the primary studies. The use of the COM-B model (64) as a deductive analysis framework provided a structured yet flexible basis for categorizing behavioral influences.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHowever this systematic review of qualitative evidence has several limitations. First, the boundaries between the COM-B categories were not always clearly distinguishable, leading to instances of double coding (e.g., where capability and opportunity interacted). While analytically challenging, these overlaps may better reflect the complexity of real-world behavior. Second, due to resource constraints\u0026mdash;particularly as this review was conducted in the context of a doctoral thesis\u0026mdash;not all review steps were conducted independently by two reviewers. The second author double-checked 20% of the quality appraisal, and COM-B coding. We acknowledge that full independent assessments across all steps would have enhanced the validity and reliability of the findings, and we recognize this as a methodological limitation. To ensure rigor where most critical, both authors independently screened and assessed all full texts for inclusion, with discrepancies resolved through discussion.\u003c/p\u003e\n\u003cp\u003eAlthough systemic factors such as healthcare policy and funding were beyond the scope of this review, it is important to acknowledge their influence. The generalizability of the findings may be limited due to differences in the healthcare systems of the included studies, and the results\u0026nbsp;may not apply to countries not represented in the included studies. Future research should explore how such systemic factors influence the implementation and outcomes of health-promoting interventions. There seems also a need for longitudinal studies on how health behavior change in SMI populations is maintained over time. By addressing these gaps, future research can help build more equitable, effective, and person-centered approaches to health promotion for individuals with SMI.\u003c/p\u003e\n\u003ch2\u003eFacilitators\u003c/h2\u003e\n\u003cp\u003eIn line with findings from the general population (95\u0026ndash;97), individuals with SMI cite the desire for improved physical health as their primary motivation for participating in a health-promoting intervention. If individuals with SMI do not perceive improvements in their health, their motivation to continue the intervention decline. This aligns with the work of Wood and Neal (2016), who emphasize for general population that successful health behavior interventions often rely on establishing new habits through consistent repetition in stable contexts, thereby reducing the reliance on conscious motivation and willpower (98). Similarly, Clear (2018) advocates for the power of \u0026quot;atomic habits,\u0026quot; suggesting that focusing on tiny, consistent improvements can lead to significant long-term behavior change. These perspectives underscore the necessity of designing interventions that support gradual habit formation and provide mechanisms for sustaining these behaviors over time (99). Vancampfort et al. assume that this is particularly important for individuals with a SMI (100). This indicates that the quick enabling of small changes in health behavior must be highly considered to maintain motivation.\u003c/p\u003e\n\u003cp\u003eA perceived impersonal atmosphere or attitude on the part of professionals is a hindrance. Satisfaction is expressed as the opportunity to maintain social contacts as part of the intervention, which is extremely helpful for the desired change in health behavior. Group settings are greatly beneficial because social interaction enables the desire for belonging, exchange, and friendship. These findings are related to the enabling hypothesis, which states that social support increases self-efficacy as a prerequisite for behavioral change (101). These findings are particularly meaningful because individuals with a SMI are more likely to suffer from loneliness and have smaller social networks (102). Loneliness, in turn, has an unfavorable effect on cardiovascular risk factors (103) and increased symptoms of mental illnesses (104,105). For this reason, the opportunity for successful social interactions should be explicitly promoted and supported in health-promoting interventions targeting individuals with SMI.\u003c/p\u003e\n\u003cp\u003eLearning content is facilitated when it is\u0026nbsp;clear and comprehensible, and regular breaks and repetitions enable the absorption of new knowledge. A change in health behavior is always accompanied by acquiring knowledge based on which decisions can be made (106,107). This is particularly true for individuals with SMI, whose ability to absorb information may be limited due to cognitive conditions (108,109). In the group setting, the study participants also found it particularly helpful to talk to each other and explain topics and when the topics to be worked on could be chosen independently. The individuals with SMI implicitly indicated typical behavior change techniques (110), such as self-monitoring or positive reinforcement in most of the included studies. These findings should be considered when developing and implementing interventions.\u003c/p\u003e\n\u003ch2\u003eBarriers\u003c/h2\u003e\n\u003cp\u003eConstrained financial circumstances and reduced access to economic opportunities\u0026nbsp;were shown to be a barrier. Individuals with SMI are disproportionately affected by income inequality (111). As a result, factors such as transportation to intervention sites, access to fitness facilities, and the availability of appropriate equipment should be carefully considered when designing health-promoting interventions for this population. In addition, nutritional recommendations and related purchasing decisions should be adapted or supported to reflect financial constraints.\u003c/p\u003e\n\u003cp\u003ePeriods of increased psychological symptoms represent meaningful barriers to health behavior change, such as the intervention not being attended regularly or new routines not being maintained. This is of great importance, as there are consistently observed associations between attendance rate and successful behavioral change, even in the general population (112,113). This suggests that when developing and implementing health-promoting interventions addressing individuals with SMI, care must also be taken to ensure the possibility of returning to the intervention after an acute phase of illness. Furthermore, it seems crucial to specifically address psychological symptoms and their interaction with physical health and behavioral changes in a health-promoting intervention to discuss coping strategies.\u003c/p\u003e\n\u003cp\u003eIn one study, individuals with SMI reflected on their experiences nine months after the intervention ended, highlighting the considerable challenges of maintaining health behavior over time(76). This also applies to the general population (95,114) but is particularly true for individuals with SMI (114). Therefore, offering programs focused on maintaining behavioral changes following temporary interventions might be helpful. Such as the Diabetes Prevention Program (DPP) which includes a structured maintenance phase aimed at supporting long-term behavior change, with evidence showing sustained lifestyle improvements over time (115).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIntegration across COM-B Components and Recommendations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis review suggests that barriers and facilitators often intersect across COM-B domains. For example, psychological capability (e.g., health knowledge) is supported by social opportunity (e.g., group discussions), while automatic motivation (e.g., enjoyment) is reinforced by structured physical opportunity (e.g., accessible, well-designed settings). Recognizing these interactions can help practitioners design more holistic and integrated interventions.\u003c/p\u003e\n\u003cp\u003ePractitioners working with individuals with SMI should aim to:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eDesign interventions that emphasize \u003cstrong\u003eearly, achievable goals\u003c/strong\u003e to foster initial success and sustained engagement.\u003c/li\u003e\n \u003cli\u003eCreate \u003cstrong\u003esocially supportive environments\u003c/strong\u003e that promote trust, inclusion, and a sense of belonging.\u003c/li\u003e\n \u003cli\u003eUse \u003cstrong\u003eclear, engaging, and repetitive educational strategies\u003c/strong\u003e tailored to the cognitive and learning needs of the population.\u003c/li\u003e\n \u003cli\u003eIncorporate \u003cstrong\u003eevidence-based behavior change techniques\u003c/strong\u003e, such as self-monitoring, reinforcement, and action planning.\u003c/li\u003e\n \u003cli\u003eAddress \u003cstrong\u003elogistical and financial barriers\u003c/strong\u003e through low-threshold, practical supports (e.g., transportation, affordable food options).\u003c/li\u003e\n \u003cli\u003eEnsure continuity by \u003cstrong\u003eplanning for long-term maintenance\u003c/strong\u003e, including relapse support and opportunities for re-engagement after periods of illness.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"5\tConclusions","content":"\u003cp\u003eThis systematic review synthesizes the perspectives of individuals with SMI on facilitators and barriers to health behavior change in health-promoting interventions. While some factors, such as motivational challenges and knowledge gaps, are shared with the general population, this review highlights key issues particularly relevant to individuals with SMI\u0026mdash;including the impact of mental health symptoms, the central role of social support, and significant financial and structural barriers.\u003c/p\u003e\n\u003cp\u003eA key insight emerging from this review is that health behavior change among individuals with SMI often depends less on individual willpower and more on external opportunities\u0026mdash;such as supportive environments, accessible services, and inclusive program structures. These findings point to the need for low-threshold, context-sensitive interventions that prioritize structural accessibility, continuity, and tailored support.\u003c/p\u003e\n\u003cp\u003eIn line with our initial aim, this review contributes to the development of conceptual frameworks that highlight the interaction of COM-B components\u0026mdash;demonstrating how capability, opportunity, and motivation are deeply intertwined in the lived experience of health behavior change. Future research should build on this integrated perspective, exploring how environmental and systemic conditions can be optimized to enable sustained change for individuals with SMI.\u003c/p\u003e"},{"header":"List of Abbreviations","content":"\u003cp\u003eBCW: behavior change wheel; CASP: Critical Appraisal Skills Program; COM-B: capability, opportunity and motivation for behavior change; PRISMA: Preferred Reporting Items for Systematic reviews and Meta-Analysis; INDIVIDUALS WITH SMI: Individuals with serious mental illness; JBI: Johanna Briggs Institute; OSF: Open Science Framework.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/ or analyzed are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFundings\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis article is part of the first author\u0026apos;s doctorate in the doctoral college \u003cem\u003eHealth Services Research: Health Equity\u003c/em\u003e. This article is part of the first author\u0026rsquo;s doctoral work within the Doctoral College \u003cem\u003eHealth Services Research: Health Equity\u003c/em\u003e. The Doctoral College is conducted in collaboration between the University of Education Freiburg, the Catholic University of Applied Sciences Freiburg, and the Protestant University of Applied Sciences Freiburg.This is supported by the federal state of Baden-W\u0026uuml;rttemberg, Germany, through state graduate funding. Open-access publishing facilitated by the University of Education Freiburg.\u003c/p\u003e\n\u003cp\u003eAuthors Contributions\u003c/p\u003e\n\u003cp\u003eGP: conceptualization, data curation, formal analysis, investigation, methodology, project administration, visualization, writing - original draft. \u003cstrong\u003eFF\u003c/strong\u003e: conceptualization, methodology, supervision, validation, writing - review and editing. Both authors read and approved the final version of the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWHO Mental Disorder. Mental disorders [Internet]. [cited 2023 May 6]. Available from: https://www.who.int/news-room/fact-sheets/detail/mental-disorders\u003c/li\u003e\n\u003cli\u003eChan JKN, Tong CHY, Wong CSM, Chen EYH, Chang WC. Life expectancy and years of potential life lost in bipolar disorder: systematic review and meta-analysis. Br J Psychiatry [Internet]. 2022 Sep [cited 2022 Dec 28];221(3):567\u0026ndash;76. Available from: https://www.cambridge.org/core/product/identifier/S0007125022000198/type/journal_article\u003c/li\u003e\n\u003cli\u003eDruss BG, Zhao L, Von Esenwein S, Morrato EH, Marcus SC. 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Available from: http://www.nejm.org/doi/abs/10.1056/NEJMoa012512\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Table 2","content":"\u003cp\u003eTable 2 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"serious mental illness, physical health, health promotion, qualitative evidence synthesis, COM-B model, barriers, facilitators","lastPublishedDoi":"10.21203/rs.3.rs-4793963/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4793963/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003ePhysical health-promoting interventions for individuals with serious mental illness (SMI) have been shown to be clinically effective in improving health outcomes, yet often fall short in meeting participants’ needs, as reflected in high dropout rates.However, studies indicate that individuals with SMI want to improve their physical health. To address this need, a detailed understanding of the barriers to and facilitators of health behavior change for individuals with SMI participating in health-promoting interventions is crucial.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eTo identify barriers to and facilitators of health behavior change for individuals with SMI in health promoting interventions, a systematic review of qualitative evidence was conducted. Medline, PsycINFO, CINHAL, and SSCI databases were searched for qualitative studies reporting perspectives on health behavior changes among individuals with SMI (18 +) who participated in health-promoting interventions. Health-promoting interventions were defined as those that included at least two aspects of physical health (such as diet and physical activity). The Critical Appraisal Skills Programme (CASP) tool was utilized to assess the quality of the studies. Data were extracted, thematically analyzed, and mapped to the capability, opportunity and motivation for behavior change (COM-B) model.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eA total of 4242 references were identified and 27 studies, including 547 individuals with SMI, met the eligibility criteria. Informed by the COM-B model, individuals with SMI reported physical and psychological capabilities that led to improvements in physical and mental health as a result of participating in a health-promoting intervention. Physical and social opportunities, such as clear and coherent intervention content or support from trained professionals, were identified as facilitator of behavior change. Additionaly motivation played a crucial role in sustaining health behavior changes among individuals with SMI.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eThis review identifies key factors shaping health behavior change among individuals with SMI, emphasizing that change often depends more on external opportunities than on individual motivation alone. These findings highlight the importance of accessible, inclusive, and socially supportive interventions, and contribute to the development of integrated, person-centered frameworks for research and practice.\u003c/p\u003e","manuscriptTitle":"Barriers and Facilitators to Health Behavior Change: Perspectives of Individuals with Serious Mental Illness in Health-Promoting Interventions – A Systematic Review of Qualitative Evidence","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-29 00:59:37","doi":"10.21203/rs.3.rs-4793963/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-12-18T06:32:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"81236864464288300489835148011179530778","date":"2025-12-08T21:24:26+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-03T09:44:22+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-22T09:07:11+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-05-17T08:17:06+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"07bba938-13c9-4cca-8240-96750ab93f98","owner":[],"postedDate":"January 29th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-29T00:59:37+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-29 00:59:37","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4793963","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4793963","identity":"rs-4793963","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}