Qualitative analysis of the Meals, Mindfulness, & Moving Forward (M3) lifestyle programme: Cultivating a ‘safe space’ to start on a ‘new path’ for youth with early episode psychosis

Abstract

Aim:

The Meals, Mindfulness, & Moving Forward (M3 ) programme included nutrition education, hands-on cooking classes, mindfulness meditation practice, physical activities and facilitated group sharing. M3 was designed as a supplement to standard care for youths (age 15–25 years) with first-episode psychosis (FEP) who were clients of coordinated specialty care teams. M3 ‘s primary aim was feasibility by demonstrating high programme attendance; secondary aims included cardiometabolic measures. Data collection included quantitative and qualitative outcomes. The aim of the qualitative study was to understand participants’ and study partners’ experiences during the programme and to understand programme elements that were helpful for young people to sustain healthy lifestyle choices 6 weeks post-programme.

Methods:

During the last programme session, we conducted two focus groups, one with participants (n = 13) and one with their study partners (n = 11); 6 weeks post-intervention, individual semi-structured interviews were conducted with 11 participants. All interviews were audio recorded and transcribed; grounded theory methods guided thematic analysis.

Results:

Main themes from the focus groups included appreciation for a ‘non-stigmatizing’ environment providing participants and study partners with a sense of ‘dignity’ that enabled a ‘new path’. Six weeks post-intervention, participants reported continued use of mindfulness practice to stay grounded and assist with making healthful lifestyle changes. However, many were unsure of how to sustain these changes long-term.

Conclusion:

The results suggest that young people with FEP value a non-stigmatizing space that allows for social engagement and facilitates healthy behaviours. Short-term, M3 participants reported behaviour change but wanted on-going support to sustain healthy behaviours.

1. INTRODUCTION

Young people with psychosis contend with stigma, misunderstanding and strains on their ability to successfully negotiate school, jobs and relationships. They face tough choices about medications that are effective but also fraught with side-effects, including weight gain, glucose dysregulation and increased lipids (Brown, Kim, Mitchell, & Inskip, 2010; Thornicroft, 2011). In addition, first episode psychosis (FEP) is associated with poor medical outcomes that include cardiovascular disease and increased mortality, whether or not a person is on medication (Brown et al., 2010; Thornicroft, 2011). FEP often occurs at a vulnerable time, as few teens and young adults are prepared to make healthy choices regarding substance use, diet and exercise.

Holistic lifestyle training programmes have earned attention as a possible framework to address cardiometabolic risk factors associated with a diagnosis that are compounded by the use of antipsychotic medication (Curtis et al., 2016; Firth et al., 2016; Holt et al., 2019; Lovell et al., 2014; Usher et al., 2019). Controlled studies evaluating diet education, and physical activity in early psychosis report benefit in attenuated weight gain, weight loss, improved dietary choices and improved psychotic symptoms (Bonfioli, Berti, Goss, Muraro, & Burti, 2012; Bruins et al., 2014; Curtis et al., 2016; Firth, Carney, Elliott, et al., 2016; Firth, Carney, Elliot, et al., 2018; Holt et al., 2019; Lovell et al., 2014; Teasdale et al., 2016). A pilot study conducted by Curtis et al. (2016) showed that a 12-week individualized early nutritional and physical activity intervention can attenuate weight gain associated with psychotropic medication use in youth (age 14–25 years) with FEP. Several studies by Firth, Carney, Elliott, et al. (2016); Firth et al. (2018) evaluating aerobic exercise in young men with FEP have demonstrated that exercise can decrease the severity of negative symptoms and improve cognition.

In the past two decades, a number of studies have evaluated mindfulness-based practices in psychosis. Mindfulness practice involves concerted attention combined with introspective awareness, allowing an individual to gain insight into their adaptive and maladaptive thoughts and feelings (Bishop et al., 2004; Chadwick et al., 2008; Khoury, Lecomte, Comtois, & Nicole, 2015; Rapgay & Bystrisky, 2009). Reported benefits include improvements in positive and negative symptoms and shortened duration of hospital re-admissions (Aust & Bradshaw, 2016; Khoury et al., 2015). The Lancet Psychiatry Commission recently highlighted the importance of addressing physical and behavioural comorbidities of mental illness; they identify multi-modal lifestyle programmes that address physical inactivity, diet risk behaviours and stress as promising areas for research (Firth et al., 2019).

This paper reports the qualitative outcomes from the Meals, Mindfulness, & Moving Forward (M3) programme. The programme consisted of six weekly sessions with training in diet/nutrition, physical activity, mindfulness and social engagement for participants with early psychosis (defined as a first-episode within the past 4 years) who were clients of the community-based Early Assessment Support Alliance (EASA) (Usher et al., 2019). M3 quantitative outcomes are published (Usher et al., 2019); briefly, the primary outcome of feasibility was achieved with 88% (15/17) completing at least 4 out of 6 sessions. Compared to a usual care group, M3 participants had significantly less positive psychotic symptoms and a trend in BMI attenuation 6 weeks post-programme (Usher et al., 2019). The aim of the qualitative study was to understand participant and study partner experiences and to understand programme elements that were helpful for maintaining healthy lifestyle choices 6 weeks post-programme.

2. METHODS

2.1. Design and participants

The M3 study was a community stake-holder-informed pilot clinical trial using a non-randomized control group design (Usher et al., 2019). Participants included clients from EASA at three county sites in the Portland, Oregon metropolitan area. EASA serves individuals ages 15–25 with early psychotic symptoms. At the time of the study, EASA’s inclusion criteria included having a first-episode of psychosis within 2 years of entering EASA and clients could remain in the programme for 2 years. EASA teams provide coordinated specialty care, including family assertive community treatment with a primary therapist/service coordinator, nursing/psychiatric support, occupational therapy and access to housing, employment and academic support specialists (EASA, 2016; Melton et al., 2013). For both M3 and control groups, EASA clients received information on the study from posters and brochures available at the clinics. In addition, interested clients were given study contact information or consented to be contacted by the study team through direct promotion from EASA team leaders during regular outpatient visits.

M3 intervention group participants enrolled in the 6-week programme for one of two programme dates, Cohort 1: April 12, 2015-May 23, 2015; and Cohort 2:July 11, 2015-August 15, 2015. Enrolment was limited to a maximum of 10 participants with 10 study partners for each cohort. The control group included EASA clients who enrolled without receiving the M3 programme from April 12, 2016-May 27, 2016. Outcomes were assessed at baseline, 6 weeks and 12 weeks.

M3 inclusion criteria were an episode of psychosis within 4 years of study enrolment; being an EASA client or EASA graduate; age 15–25 years; having a study partner available (for participants in M3 intervention); having a primary care or mental health provider; being able to read and write in English. Exclusion criteria were active suicidal or homicidal thoughts within 1 month of baseline, or high risk for disruptiveness to group process or being dangerous to self or others (evaluated during baseline interview with a psychiatrist).

The study protocol was approved by the Oregon Health & Science University’s (OHSU) Institutional Review Board and registered at ClinicalTrials.gov (NCT00122954). Written informed consent was obtained from each study participant and their study partner prior to participation in the study.

2.2. Intervention

M3 was based on holistic behaviour intervention models to improve wellness in daily life. Mindfulness meditation; cooking classes; field trips to a supermarket and a low cost fast-food restaurant; nutrition education; exercise (walking, home-exercises, taiko drumming, yoga and jiu jitsu); and moderated group discussion were utilized to facilitate healthier living. Study partners participated in all activities alongside participants with the intent that partners would be a support outside of the programme to bolster maintenance of healthy behaviours. Mindfulness practice components were designed using a trauma-informed care approach and comprised the first 30 min of each programme session; programme details have been published (Usher et al., 2019).

2.3. Qualitative methods

During the last programme session, participants (n = 13) and study partners (n = 11) participated in separate focus groups. Each focus group was facilitated by two study team members who were not involved with intervention delivery (Senders, Seibel). A focus group discussion guide consisted of a pre-defined series of questions with aims to better understand the participants experience in the programme.

At 12 weeks, individual semi-structured interviews were conducted to better understand M3 programme elements that may have contributed to healthy behaviour changes post-programme; barriers to change were also assessed (n = 11). An a priori discussion guide was used for each interview to explore whether the intervention continued to have an impact on the participants’ lives, that is, change in resilience, self-efficacy and lifestyle behaviours.

All qualitative data were recorded and transcribed verbatim. Transcripts were uploaded to a web-based qualitative data analysis programme (Dedoose Version 8.0.35, 2018) and were reviewed in triplicate by authors (Usher, Thompson and Borgatti) to gain an overall sense of the data (Braun & Clarke, 2006). Two authors conducted initial coding and created a codebook for subsequent coding. The codebook defined each code, explained when the code should be used, and provided an example of proper application with quotes from the transcript. Transcripts were then open coded (Thompson, Borgatti and Bodden). Grounded theory methods (Charmaz, 2006) guided iterative coding, and any discrepancies in code application were discussed amongst the study team and resolved by consensus. Established codes were compared between different collection time points within the same individual’s data, and across respondents. Related codes were aggregated into themes and subthemes until thematic saturation was reached and a theoretical framework could be developed to account for the findings of the analysis (Glaser, 2001). The analyses of focus group and individual participant interview data were discussed with the study team and programme staff to ensure interpretations accurately reflected the data.

3. RESULTS

Baseline characteristics of the participants are displayed in Table 1. Characteristics of those who participated in the focus group (n = 13) and interviews (n = 11) represent those from the full cohort (n = 17). From the focus groups, two main themes and several underlying concepts were identified as key experiences reported by participants in the M3 programme: (a) Building dignity by reducing stigma within the programme environment, which provided a flexible and ‘safe space’ for participants to engage with others through collaborative activities leading to an empowered sense of self; (b) Building resilience through exposure to self-care activities around mindfulness, nutrition and physical activity created a framework for participants to challenge themselves, cultivate relationships and fostered hopefulness for improving health and wellbeing, a ‘new path’. In support of these themes, a common experience expressed by study partners was family solidarity in the process of learning how to improve wellbeing (Table 2).

TABLE 1.

Baseline characteristics

	M3 focus group	M3 participants individual interviewees	M3 participants total sample
	(n = 13)	(n = 11)	(n = 17)
	Mean (SD) or %	Mean (SD) or %	Mean (SD) or %
Age (years)	19.5 (3.7)	19.7 (3.6)	19.5 (3.8)
Gender (male)	3/13 (23.1%)	4/11(36.4%)	5/17 (29.4%)
Race (white)	5/13 (38.4%)	4/11 (36.4%)	7/17 (41.20%)
Medication use*	10/13 (76.9%)	7/11 (63.6%)	11/17 (64.7%)
BMI	30.7 (6.7)	29.4 (4.9)	30.5 (6.8)
QSANS**	39.9 (22.6)	35.7 (21.7)	41.9 (21.3)
QSAPS**	21.8 (16.3)	17.4 (15.9)	(15.3)

^*Neuroleptic medication (Atypical antipsychotics: aripiprazole, carbamazepine, clonzapine, divalproex sodium, lamotrigine, lurasidone, olanzapine, quetiapine, risperidone, ziprasidone; Miscellaneous antipsychotic agents: lithium, loxapine; Phenothiazine antipsychotics: fluphenazine).

^**Quick Scale for the Assessment of Negative Symptoms (QSANS), Positive Symptoms (QSAPS).

TABLE 2.

Illustrative quotes from study partners (focus group interview)

Theme	Quotes*
1. Building dignity by reducing stigma	‘Having people the same age group really, it helps because then you see that, you know, like, they’re, they’re my peers, they’re part of my specific age group, and they’re doing the same things that I’m doing. They’re having some of the same problems that I’m doing and, it just really makes, I know as a study partner it made me feel like, wow, um, like maybe I’m not alone in how I’m feeling right now because all these other people in the study group, they’re having some of the same types of feelings, same types of communication problems. And it just made me feel less isolated.’
	‘…I loved that also about you guys - that was very compassion (sic) and very, um, accepting. She needs more spaces like that, where people just let her do her thing, right? By the time we went - even if she didn’t do much during the class time, by the time we went home she’d be a lot calmer. Like today she was really barking this morning, right now she’s like with a smile on her face, so thank you.’
2. Building resilience through self-care activities	‘Yes. I wanted to be able to do something in community with my daughter. It’s one of the reasons why I brought my whole family to come to do this. You know, it’s about wellness right, better living for people. And just, I think it’s really important to integrate your whole family and the people that are mostly around them to - to learn to do things with them.’
	‘What we learned from, like, the first session that I went to was with the whole yoga and the learning how to be mindful and just taking a step back to really just be in that moment, really helps because a lot of the time my partner would - there’s just so much going on in her - in our lives and everything and she’s constantly worried about a whole bunch of other stuff and so to just learn how to be able to take a step back and just be in one singular moment for just, even if it’s only for five minutes, it really reduced the stress levels at home a lot, because then we were, alright well we can just sit back and enjoy this movie for a little bit. And we don’t have to watch the whole thing right away, you can pause it and, you know, do other stuff and then come back when our minds were clearer, come back to it. And before we just didn’t know how to do that and she, I don’t know, she felt really overwhelmed with like, a lot of the stuff that’s going on in our lives and, yeah, so the learning how to be mindful of being in that moment really, really helped a lot.’

^*Quotes were lightly edited for readability.

3.1. Theme 1: Building dignity by reducing stigma

The core concept within the theme of building dignity is the creation of a ‘safe space’ through reducing the experience of stigma within the programme’s boundaries. Subthemes that contributed to the concept of ‘safe space’ were (a) caring staff and flexible expectations within a non-clinical environment; (b) enjoyable activities that involved collaborative participation with study staff and study partners. The integrated nature of the experience fostered (c) respectful interactions and developed peer support. Combined, these factors helped the participant to (d) cultivate an identity separate from diagnosis. The net effect was to foster a sense of dignity, defined as a sense of pride and respect for one’s self and others.

1. Caring staff, flexible expectations, non-clinical environment

   ‘It wasn’t just the doctors it was also the volunteers. They were really easy to talk to and really friendly. It was like, they were people, they are people, we are all human beings. And like we all treated each other like human beings. Not like, all ‘this person’ people start to label you, but not here. It’s different.’

2. Participation in collaborative and enjoyable activities

   ‘I found that the programme was pretty fun and entertaining. We like laughed every-time, every day. I have done yoga in the past but it was nice to refresh myself with it, or meditation, or the mindfulness activities. And it was fun when we went to Chipotle and when we went to the Safeway and did a little scavenger hunt. I did enjoy the Taiko drumming the most, and the jiu jitsu. All the stuff was pretty fun. And I did learn a few things about myself and how I look at or perceive things. I also learned some cool stuff like cooking some simple meals and stuff like the mac and cheese with lots of veggies and some stir fry. It was awesome to participate in a collaborative environment and enjoyable activities.’

3. Foster respectful interactions and peer support

   ‘I think the M3 study overall helped me with my perception of people’s characteristics. I think it slowed that down and made me less judgmental of people. I have my mom to do that but then I have to learn that myself to, you know? I really catch myself sometimes, you know, like, “Oh I shouldn’t think that, that’s stupid.” I’m sure we all do that but it’s really…changed my perception and focus on things. I really enjoy that.’

4. 4. Empower identity separate from diagnosis

   ‘I wasn’t really worrying about… Well, I was worrying, I was worrying a lot. I had to take a lot of walks a I was here but when I talked to other people here, like him and her and stuff. Like, I didn’t worry as much and I was making friends like, “Yeah, I’m socializing” and, “Yeah, I’m doing stuff on my own without like, clinging to my mom” and I am doing better. And these people aren’t judging me about my mental illness too, so that’s a bonus!’

   Elements of a ‘safe space’ during the M3 programme included a caring staff, a casual non-clinical environment and facilitation of peer and family support. These elements served to reduce stigma and empowered participants to cultivate a sense of well-being.

3.2. Theme 2: Building resilience through exposure to self-care activities

‘I’d have to say that my favourite part of the study was either the exercise or that hands-on cooking lesson because what we made was really delicious. I just thought that it was neat to do something like super hands on, like you were actually doing it. Like it felt fun, that’s what made part of this fun is not just like having to listen to someone while they cook, but actually cooking yourself.’

Participants valued hands-on learning that helped to foster connections to healthy food choices, fun exercise options that could be incorporated into their daily lives, and practical mindfulness techniques that were centring and grounding. These useful self-care skills provided tangible resilience-building opportunities that could be applied outside of the treatment environment.

3.3. Individual interviews 6 weeks post-programme

During the follow-up interviews, individual behaviour change post-programme was assessed and five themes emerged. Three themes illuminated aspects of the programme that participants found most useful post-intervention as well as the magnitude in which the programme had impacted their lifestyle behaviours, including: (a) increased self-efficacy from gaining skills for making healthier choices around food and experiencing ways of being more active; (b) support components from study partners, peer shared experience, and programme resource binder; and (c) building resilience through mindfulness training. The fourth theme informed on barriers to maintain healthy behaviour change that included cost of gym membership or cooking classes, and not liking vegetables. The fifth theme informed on suggestions for future programmes that included continuing M3 weekly or M3 reunion meetings/booster sessions, fostering peer-support for healthy behaviours (Tables 3 and 4).

TABLE 3.

Development of codes and themes from individual interviews

Themes	Codes	F (n)a	Indicators
1. Increased self-efficacy	Skills for making healthier choices around food	15 (11)	• Looking for shorter ingredient lists • Understanding different types of fats listed on label • Understanding the difference in caloric contents (eg, sugar vs fat) • Eating ‘large variety’ of foods • Strategies to reduce fast food consumption • Eating different coloured foods • Being able to identify healthy options when eating out • Understanding appropriate portions • Reducing amount of carbs consumed • Preparing supplies and ingredients before cooking • Learning tips directly from chefs • Hands-on experience was motivational to cook more
•	Ways of becoming more active	8 (6)	• Going to the gym • Joining weight lifting training • Jogging • Taking the dog on walks for exercise • Walking to get a ‘tea’ to not be sedentary • Served as a reminder of the importance of exercise • Enjoyment of physical activity through martial arts • Trying new activities like Taiko • Exposure to new types of exercise
2. Support components	Use of programme resources	8 (7)	• Helpful to refresh on learned concepts • Go through resources quite often • Good resource • Used to stay on track toward personal nutrition goals • Excited about walks in resource section • Resource to use when ready to start cooking • Great tool for saving money • Reminder of healthy eating strategies
•	Role of social support	6 (5)	• Going to farmer’s market and discussing healthy eating with peer from programme • Learning with study partner and sharing in strategies to improve wellbeing • Having someone to share in the experience and hold you accountable • Mutual support and not feeling alone • Sharing meditation techniques with family members at home • Whole family welcome at programme and engaged together to improve wellbeing
3. Building resilience	Utilization of mindfulness concepts and practices	7 (6)	• Traffic on highway or studying for exams • Being grounded without judgement • Calm yourself and having control of your mind and aided falling asleep • Using the body scan to stay in the moment and ease stress • Acknowledge stressful things and let them go • Radical acceptance to help with conflict resolution • Being grounded when dealing with stressful conversations with others • Increased awareness of surroundings
4. Behaviour change barriers	Barriers to making and maintaining change	10 (7)	• Slipped disc preventing physical activity • Taste preference (ie, dislike of vegetables) • Returned to disordered eating patterns • Cost of eating healthy and gym memberships • Interested in cooking classes but cannot afford • Not the primary shopper of cook and does not want to be • Places to practice martial arts are not located near home • Not the primary food maker and kitchen is small • Difficulty in committing to regular activities but will take a walk-in class • Lack of continued support made it difficult to maintain new behaviours as time went on
5. Suggestions for future programmes	Desire for continued support	7 (7)	• Weekend retreats as reminder and for accountability • Weekly sessions all year long • Once a week required to remember material, monthly is not enough • Regular review of the material required to keep the positive flow going • Peer support to see what changes people were able to make • Reunion meetings to see what people continued to do

^aF is the overall frequency at which indicators were identified for each code, n is number of unique participants who contributed indicators for each code.

TABLE 4.

Illustrative quotes for themes derived from individual interviews

Themes	Codes	Illustrative Quotesa
1. Increased self-efficacy	Skills for making healthier choices around food	‘…Doing the practicing in the grocery store and the ordering at Chipotle I think was helpful, knowing what to order, what not to order, and stuff like that. Healthy choices.’
		‘There’s just like little things that I learned that I – I still try to keep in mind, like when I’m doing grocery shopping and whatnot. Sometimes I’ll look at the nutrition label, for example will get like how many ingredients were in it. If there’s like a really long list I know that it’s harder for my body to process things like that when there’s a lot of ingredients.’
	Ways of becoming more active	‘[I’m] trying to be more active than before… So going on walks with my dog.’
		‘[I’m currently doing] some cardio, but mostly weights. Like, I train my legs, and my arms, and my core… And, uh, I decided at school that I’m going to join the weight lifting club.’
2. Support components	Use of programme resources	‘Just like having that cookbook… I’m excited to get it because, like, it’ll be a good tool to keep using and to remember to eat healthier and stuff.’
	Role of social support	‘…It was a benefit to have a study partner then it wouldn’t be just you trying to make the changes, you would have someone else trying to make these changes with you, so you wouldn’t feel all alone.’
3. Building resilience	Continued of skills/mindfulness	‘I think the thing that helped me out the most was the mindfulness part, more about the… meditation therapy, and you know, you can look in your environment more, and stuff. I think that’s really helped me to sort of be able to cope [in] more situations that I found stressful before. Like especially a lot of traffic on the highway, or lots of stress studying for exams and stuff.’
		‘I use the mindfulness sometimes. It helps me when I go shopping. Like, when I get overwhelmed I just – I, I use it to help me get back in the moment and… not freak out and wig out and stuff.’
4. Behaviour change barriers	Barriers to making and maintaining change	‘I don’t know, I can’t, half of your plate is supposed to be vegetables, it’s just not going to happen.’
		‘The problem mostly is money issues. It was very expensive to buy foods that are healthy a lot of the time. And also getting memberships is pretty expensive. Yeah, the expense is a challenge.’
5. Suggestions for future programmes	Desire for continued support	‘Maybe at some point if they want to get the first group back together or something…’
		‘Yeah, but if you guys do weekend retreats I would totally go… Yeah I would like that a lot. I’m always – I’m always down to do something like that, so… if you guys get together just let me know, I’ll – I’ll show up.’

^aQuotes were lightly edited for readability.

The themes revealed that while M3 had an overall positive impact on individual’s belief in their ability to change, the changes in place 6 weeks post-programme were incremental and not large. Additionally, the majority of participants requested continued support through sustained programming and further peer group interaction (Tables 3 and 4).

4. DISCUSSION

Participants reported that the programme provided a safe space and decreased stigma associated with psychosis, allowing them to build a sense of dignity and empowerment. Every interaction between two or more people offers the opportunity for dignity to be promoted or violated (Jacobson, 2009). Encounters are more likely to promote dignity when the relationship is grounded in solidarity (eg, rapport, empathy, trust) and the setting offers accessibility, transparency and friendliness (Jacobson, 2009). M3 promoted dignity with peers, study partners and the study team in an accessible and transparent forum where solidarity of the “whole” group was formed while engaging in lifestyle wellness activities (Table 2). In FEP, perceptions of stigma and feeling “different” are factors that contribute to delay in help-seeking and reluctance to recognize symptoms (Gronholm, Thornicroft, Laurens, & Evans-Lacko, 2017). Personal feelings of stigma, often reinforced by environmental stigma, are barriers to recovery from psychosis (Gronholm et al., 2017). Subjective recovery is the process of overcoming symptoms to move toward health and wellness; inherent is a person’s feelings of hope and empowerment to overcome their symptoms, with social support and social engagement as key factors in the recovery process (Frost et al., 2017; Temesgen, Chien, & Bressington, 2018). Recovery-oriented services in psychosis are patient-centred and aim to strengthen and acknowledge a person’s capacity to achieve a meaningful life that includes well-being (Temesgen et al., 2018). The design and intention of M3 was to enhance EASA services with an active lifestyle programme that included mindfulness training. M3’s mission was to maximize efforts in building resilience and hope in young people with FEP and their families and to foster well-being.

Participant interviews aimed to understand specific programme elements that were useful in maintaining health behaviours, as well as barriers to sustaining healthy behaviours 6 weeks post-programme. Three of the five themes supported M3’s goal of building resilience and self-efficacy for healthy lifestyle behaviour change (Tables 3 and 4, Themes 1–3). M3 is one of the few lifestyle programmes in FEP that includes mindfulness training along with diet, exercise and social engagement. Mindfulness was added as a “grounding” skill to decrease anxiety and enhance learning and engagement around diet, exercise and social engagement. The qualitative data from both focus groups and individuals highlight mindfulness training as a key element in staying grounded and building resilience. The qualitative data also supports the study’s quantitative findings, 6-weeks post-programme the M3 groups showed a significant improvement in positive psychotic symptoms (Quick Scale for the Assessment of Positive Symptoms – QSAPS) and a trend in BMI attenuation compared to the usual care group (Usher et al., 2019).

4.1. Limitations

The limitations of the study included a small sample size. Not all of the 17 participants in the M3 group participated in the qualitative data collection, although baseline characteristics of the qualitative group are representative of the whole group (Table 1). There is potential bias as members of the study team were involved in the study activities; we minimized bias by having investigators who were not involved in M3 activities conduct focus groups and interviews.

4.2. Future directions

Future directions for evaluation and implementation of M3 were informed by a post-programme stake-holder meeting. Key feedback included: continuing M3 as an active lifestyle programme with outreach to rural areas; developing an M3 app for smart phones to connect M3 programme completers to a platform focused on healthy behaviours to support sustainability; development of a certification programme to leverage EASA graduates into paid roles within the M3 programme as social engagement facilitators.

5. CONCLUSIONS

The M3 programme was an activity-based diet, exercise, mindfulness training that fostered social engagement in youth with FEP. The qualitative findings support the programme’s ability to reduce stigma, foster resilience and self-efficacy short-term. Barriers included cost of continuing diet and exercise training outside of M3 and participants expressed a desire for continued support of an active-lifestyle training programme through M3 booster sessions, reunion meetings, or peer support meetings focused on healthy lifestyle.

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.