The ontological and epistemological assumptions underpinning the methodology were constructivist and interpretivist. The analysis was approached from the perspective of understanding participants’ subjective experience, and aligned with constructivism which acknowledges human reality is constructed through individuals’ interactions and interpretations of the world and others [18]. Meanings therefore emerge from constructions (or reconstructions) of individuals’ experiences of an empirical reality [19]. The resultant knowledge from the qualitative data is constructed by the interviewee and interviewer [20]. In interpretivism, social reality is interpreted by the meanings participants produce and reproduce [21], and interpretive research attempts to understand phenomena through accessing the meanings participants assign to them [22]. The methodology employed placed the onus on the participant’s view of the situation [23].

Semi structured interviews were conducted with 15 participants. Interview questions were informed by the research literature and with input of a person with lived experience of psychosis. Semi-structured interviews enabled the participants to share their experiences. All the data were analysed together.

Ethical approval was gained from United Kingdom’s (UK) Health Research Authority (HRA); Research Ethics Committee (REC) reference: 21/EM/0047. All participants provided informed consent.

Participants were recruited from an NHS early intervention psychosis service. Forty participants were recruited as part of a mixed methodological project, 31 undertook the intervention. Fifteen participants from the full sample were recruited for interview. For inclusion in the study, participants needed to be within the age of 18 to 65, a patient of the early psychosis service, based in the community and able to understand written and oral English. Any participants who for a medical reason could not wear a watch like device on their wrist, or who did not have the capacity to consent were excluded.

Sampling was non-probabilistic, accessible, and purposive to achieve a representative sample of 15 adults in terms of age, gender and ethnicity. The characteristics of the 15 participants are presented in Table 1.

The eight-week intervention incorporated: a free to keep Fitbit (including instructions and set up), exercise and sleep hygiene advice sheets, as well as three patient engagement sessions with EIP clinical staff. Each engagement session offered support and encouragement; and facilitated a discussion regarding the use of the Fitbit, the application of exercise and sleep hygiene advice, as well as relevant feedback.

Informed written consent was obtained from all the participants. Two researchers working separately carried out one-to-one semi-structured interviews over the phone. A series of closed questions were initially asked regarding the functionality and usability of the Fitbit (e.g., did you have any problems wearing the Fitbit?); these responses were subjected to content analysis. The remainder of the interview was semi-structured, with questions relating to sleep, exercise, and well-being—as well as to participants’ experiences of using the Fitbit. One participant (P12) spoke limited English and a translator was used to relay answers to the interviewer. All interviews were recorded, the length of the interviews ranged from 19.57 - 56.03 minutes (M = 37.24, SD = 9.42); interviews were transcribed verbatim.

Reflexive thematic analysis (TA) was used to analyse the data [24] [25]. Reflexive TA is a systematic process of developing, analysing and interpreting patterns within a qualitative data set to establish a set of themes [24]. Thematic network analysis (TNA), a type of reflexive TA was utilised to develop basic, organising, and global themes [26]. The analytical process undertaken was aligned to six steps: 1) dataset familiarisation; 2) data coding; 3) initial theme generation; 4) theme development and review; 5) theme refining, defining and naming; and 6) writing up [25]. NVivo software v.12 was used to assist analysis. Initial codes were generated by two researchers (one recruited as an advisor with lived experience of psychosis) working independently. Themes were further categorised into subthemes by three researchers who collaborated to refine and relabel the finalised themes. To further strengthen the interpretation of the analysis, the research team discussed and reviewed the findings. To ensure trustworthiness of the data, guidance was followed to promote credibility, transferability, dependability, and confirmability [27]. Group analysis was undertaken, i.e. not split on gender.

Content analysis of responses regarding usability of the Fitbit, as well as sleep and exercise habits prior to using the Fitbit was undertaken. The numerical results and an illustrative quote are presented in Table 2.

Figure 1 presents a theme map of the use of the wearable physical activity and sleep tracker (Fitbit) and the interlink between exercise, sleep and wellbeing.

This organising theme collates the different ways in which the Fitbit was used in relation to participants’ sleep and physical exercise. It is comprised of five sub-themes:

1) To monitor physical health, body metrics, sleep and steps

The Fitbit was used to check and monitor a range of health, body, and exercise metrics data. More specifically the following physical metrics were monitored:

Weight

P3: Like it, it’s really good because, you can work out, what your calorie intake should be and then obviously, work out what you want it to be to lose a little bit of weight and then you can keep track of it;

Diet

P5: I also tried to eat healthier, like having fruit daily and stuff. It just made me a lot more aware and I could see what I had done and it also gives out reminders and stuff;

Steps

P10: You can use it to check your steps and see and monitor how much exercise you’ve done;

Heartrate

P7: It was just nice to be able to have constant check up on my heartrate… it was interesting to find out like… to see how fast it was beating and whether it was like good or not;

Water intake

P11: You update it, so every time I drink water I put it into like a log. So, I log it in to the Fitbit app and it says, “okay you’ve drunk this much water”.

Sleep

P8: I found the display useful being able to track your sleep.

2) To motivate and encourage to exercise

Using the Fitbit motivated and encouraged participants to engage in, do more, and/or sustain exercise.

P3: I think it kind of makes you more motivated…It spurs you on to do that… keep on walking or keep on swimming.It encouraged and motivated me to make physical activity, more regular. It’s just made me more motivated.

The Fitbit gave a reminder to be physically active, and this encouraged physical activity.

P12: He was just checking how many steps he did. And of course, when he did some kind of steps, he was always motivated a little bit to make more and all of that. And also, even when he didn’t get enough steps, the watch just made him alert to do another 200 step you know.

The Fitbit modified behaviour in relation to exercise, acting as a motivating factor on occasions when participants felt like they did not want to exercise.

P9: It changes my behaviour to think it encourages me to do more. I think it does, definitely it does. I just keep on looking at me watch and keep walking. I try and then hit the steps target. The Fitbit can sometimes motivate me when I don’t want to [Exercise].

Part of the motivation and encouragement came from how participants used the Fitbit to set goals.

P7: I think it helped me to keep, because one of my goals was to lose a bit of weight, and to maintain that weight loss. So, it helped me main, it helped me to, to keep track of the 10,000 steps, helped me to on that trajectory, really. So, it encouraged me in some ways to do more and achieve those goals.

Fitbit feedback and monitoring provided a sense of achievement; further motivating individuals to set and accomplish goals.

P4: I’ve got this achievement in the App and, that I think that can sort of boost your mental health a little bit, that you know, you are doing stuff, you are being active. It helps my mental health because it’s about the achievement and what I’m doing.

P10: I guess it’s just kind of, it’s interesting to be able to look at your stats and judge on that base and try and reach goals based on that. I would say it motivates me. I am trying to achieve something.

3) Cognisant of physical activity

Participants used the Fitbit to gain awareness and insight of physical activity levels as well as keep a track record of accomplishments.

P2: I was more conscious of my activity, my physical activity. More aware of it, more aware, the how much, doing, like so much physical activity.

P6: When you do the steps and you get, and then this, for some reason, sends a message to the app. And it says you achieve your goals. And you know, you’ve done this, you’ve done that. And it’s quite, it’s quite good to know that.

P5: But the steps, I didn’t really—like it made me aware of how many steps I take and want to take more. I was more aware of it and wanting to do it because it would remind me.

Another positive outcome of being cognisant of physical activity was that it provided participants with a deeper comprehension of their physical health, the positive impact of physical activity, and fostered confidence for self-management and control.

P7: The amount of information shared a lot of the information about your activity levels means that you’re constantly aware of your health. I am much more concerned about my health. Where I am health wise… it’s made me feel more in control of my health as well.

4) Cognisant of sleep and sleep patterns

This theme acknowledges the reassurance and awareness provided via Fitbit’s sleep data insights.

P8: I do see it as useful being able to track your sleep as well. I find it intriguing more than anything… and monitoring my sleep out of curiosity.

P10: It was just sheer curiosity and awareness about my sleep.

P1: It’s been really good to have the Fitbit recording the sleep because you just get to know a little bit more about your patterns and stuff like that… it’s not something that you’d normally be able to easily get data on.

P7: I think it’s helped in terms of tracking how many hours of sleep I’m getting because when I look at the app, it tells me how many hours and it tells me what the, what the divided is, what the split is between REM, light sleep. Yeah, so REM, light sleep and deep sleep.

P14: There is the element of understanding how you have slept or being able to see how you’ve slept. Again, it’s reassurance. I’m less agitated so is it this reassurance that helps me not be so agitated. it tells your mind that you had a good sleep so you’re gonna have a good day as well.

5) Reminder, cue and prompt in order to get enough sleep

The Fitbit was a tool for the participants to achieve better sleep habits and to endeavour to get enough sleep each night. One Fitbit function used to achieve this was to set a reminder or prompt to go to bed at a reasonable time, thus facilitating an effective number of sleep hours.

P7: There’s a prompt at 9.07. It tells me I need to get ready for bed. At 9.07 on the dot. So that’s when it tells me to go to bed. Most of the time I follow the instruction.

P14: It acts as a reminder and happens and can mean that I go to bed earlier and try and get more sleep.

P15: It does give me notifications at 10, to go to sleep, which I do, I do follow sometimes.

Several participants used the Fitbit to assess quantity of sleep, and thenadapted sleep behavior accordingly to ensure sufficient sleep was achieved the following night.

P3: When I can track and see how long I’ve actually slept, sometimes if I, if I have not had enough sleep that I know I need to go to bed a bit earlier the next day.

Both the ability to monitor sleep habits and enhanced awareness resulted in participants endeavouring to go to sleep at a reasonable time and get enough sleep.

P5: It was more awareness and like because I knew it was monitoring my sleep so my sleep schedule I would try to go to sleep at reasonable times and stuff like that and get a good fair amount of sleep.