Kinesiologia Slovenica, 28, 2, 130-146 (2022), ISSN 1318-2269 Original article 130 ABSTRACT Depressive symptoms among older adults are the second leading cause of disability and functional decline. Physical activity has gained considerable attention for its benefits in preventing and treating depressive symptoms. The majority of existing studies are quantitative in nature, but qualitative research into how people with depressive symptoms view physical activity in relation to their mental health is insufficient. We recruited 23 female participants from a recreational center in Ljubljana to participate in semi-structured interviews. Our aim was to identify how physical activity influences everyday life and its perceived effect on mental health among our participants. We used mixed methods, with an accent on qualitative methods. Conventional content analysis was used to explore the data from the interviews. We identified that increased satisfaction, well-being, and improved physical health are key factors through which participants find physical activity useful in stress and depression management. We can conclude that intentional physical activity in the form of walking, running, cycling, or group or individual workouts has a positive impact on physical and psychological wellbeing and has a positive impact on a person’s life. Our findings can be used in future studies to assess any successful non-pharmacological treatments for depression symptoms, such as different exercise programs, support groups, or different social activities. Keywords: Older adults, physical activity, mental health, depressive symptoms, public health 1Centre of active Fužine, Retirenment home Fužine, Ljubljana, Slovenia 2Faculty of sport, University of Ljubljana, Ljubljana, Slovenia IZVLEČEK Depresivni simptomi so drugi najpogostejši vzrok nezmožnosti in funkcionalnega upada pri starejših. Telesna dejavnost je v zadnjih letih pridobila več veljave pri preventivi in zdravljenju depresije. Dosedanje raziskave so večinoma kvantitativne, primanjkuje pa kvalitativnih raziskav, kjer bi pridobili globlji vpogled v subjektivno zaznavanje vpliva telesne dejavnosti na duševno zdravje pri posameznikih. V naši raziskavi je sodelovalo 23 udeležencev iz Centra aktivnih Fužine. Naš cilj je bil predstaviti, kako udeleženci subjektivno zaznavajo vpliv telesne dejavnosti na vsakodnevno življenje in duševno zdravje. Za analizo smo uporabili mešane metode s poudarkom na kvalitativnih metodah. Za analizo podatkov iz intervjujev smo uporabili konvencionalno metodo. Ugotovili smo, da so povečanje zadovoljstva, blagostanje in povečano telesno zdravje ključni dejavniki, zaradi katerih naši udeleženci menijo, da je telesna dejavnosti koristna pri stresu in depresiji. Sklepamo lahko, da namerna telesna dejavnost, kot je hoja, tek, kolesarjenje, individualne in skupinske vadbe, pozitivno vplivajo na telesno in duševno blagostanje. Izsledki naše raziskave lahko uporabimo kot osnovo za nadaljnje delo na področju razvoja učinkovitih ne- farmakoloških oblik zdravljenja, kot različni programi telesne vadbe, podporne skupine in interesne dejavnosti za zmanjšanje simptomov depresije s telesno dejavnostjo. Ključne besede: Starejši odrasli, telesna dejavnosti, duševno zdravje, simptomi depresije, javno zdravje Corresponding author*: Lucija Vinkšel, Centre of active Fužine, Retirenment home Fužine, Nove Fužine 40, 1000 Ljubljana, Slovenia E-mail: lucija.vinksel@gmail.com Lucija Vinkšel 1,* Saša Cecić Erpič 2 SUBJECTIVE PERCEPTION OF THE IMPACT OF PHYSICAL ACTIVITY ON THE MENTAL HEALTH OF OLDER WOMEN WITH SEVERE MENTAL DISTRESS SUBJEKTIVNA ZAZNAVA VPLIVA REDNE TELESNE DEJAVNOSTI NA DUŠEVNO ZDRAVJE STAREJŠIH ŽENSK Z IZKUŠNJO HUDE DUŠEVNE STISKE Kinesiologia Slovenica, 28, 2, 130-146 (2022), ISSN 1318-2269 Physical Activity and Mental Health Among Women 131 INTRODUCTION Depression is a highly prevalent mental disorder, affecting around 340 million people worldwide and critically impacting the world’s public health (Dinas et al., 2011; Pickett et al., 2017). The World Health Organization (WHO) lists depression as the second leading cause of disability and functional decline in later adulthood (Lopez et al., 2006). According to data from the international EURODEP study, depressive symptoms occur in 14.5% of older women patients (Copeland et al., 2004), with women being 2-to-3 times more likely than men to be affected (Kessler, 2003). Depression is a mood disorder categorized by the presence of various signs and symptoms such as negative thinking, loss of interest and energy, feelings of hopelessness and helplessness, sleep disturbances, appetite changes, and reckless behaviour (American Psychiatric Association, 2000). This disorder is commonly treated with medication (antidepressants) and/or psychotherapy (Mead et al, 2008). Negative side effects of antidepressants are a common cause of unsuccessful treatment, causing 50% of patients to discontinue treatment (Cassano & Fava, 2002). Furthermore, the majority of elderly depressed people do not receive adequate treatment (Heinzel et al, 2015), likely because of specific challenges associated with treating depression later in life, such as a higher prevalence of other comorbid disorders (Birrer & Vemuri, 2004) and a lower awareness and social unacceptance of mental disorders (Heinzel et al, 2015). Furthermore, when compared to younger people, older people do not respond as effectively to standard treatment (Cuijpers et al, 2006). While depression is less common among older adults, the prevalence is higher if accompanied by a cognitive, functional, or physical decline (Bruce, 2001). Older adults face specific challenges that can affect the onset of depression, such as physical illness (cardiovascular diseases, genetic predisposition, virus infection, etc.) or life changes (retirement, loss of social interaction, loss of important others, decreasing health and lack of social support) that are specific to late adulthood (Alonso and Hernandez, 2009). In recent years, physical activity (PA) has gained considerable attention for treating depressive symptoms. Regular PA is not only good at preventing depression but it can also be used as a treatment, by itself or in combination with standard treatments (Josefsson et al, 2014; Nyström et al, 2015). Moreover, similar results are observed in older adults. Blumenthal and colleagues (1999) conducted one of the first randomized control trials with a sample of older adults diagnosed with depression and favoured exercise compared to standard treatment. Longitudinal Kinesiologia Slovenica, 28, 2, 130-146 (2022), ISSN 1318-2269 Physical Activity and Mental Health Among Women 132 studies with non-depressed and depressed older adults show a correlation between regular PA and depression, with individuals who have regular PA throughout life being less likely to suffer from depression. Indeed, PA can improve the quality of life and protect against other mental illnesses (Gudmundsson et al., 2015; Ku et al., 2012). This present qualitative study addresses the personal experiences of physical activity among older people suffering with depression at any point in their lifetime through semi-structured interviews, perceived PA, and the effects on their health, mood, and everyday life. METHODS Ethnical approval Upon our written request, as it is regulated at the Faculty of Sport, University of Ljubljana, Slovenia, the Ethics Committee of the Faculty granted us written consent and approval to conduct the study. Participants provided written informed consent for the use of interview evidence where their anonymity was guaranteed. Methodological approach We employed a mixed methods approach with an emphasis on qualitative methodology. Quantitative data provides significant insight into the phenomena, but it lacks understanding and patients' view of the problem. If we want to treat depression with alternative methods such as exercise, we should consider the patients' perception of this approach. It may offer a new insight that we can otherwise dismiss due to our own beliefs as researchers. Therefore, it is an important contribution to the existing quantitative data for a better understanding of the phenomena (Hsieh & Shannon, 2005). Within qualitative methods, we used content analysis as it has been widely applied in health research (Danielsson et al, 2016; Elo & Kyngäs, 2008; Hsieh & Shannon, 2005; Sweeney et al, 2019). Content analysis focuses on the characteristics of language as communication with attention to the content or contextual meaning (Madill et al, 2000). Content analysis was used as the aim of the study was to provide an overall view, new insights, knowledge and practical guidance on the data. The method allows the researcher to be flexible in terms of research design (Elo & Kyngäs, 2008). We used conventional content analysis because there was no conceptualization beforehand, as the method uses an open and flexible approach, discovering similarities and differences in the data that arise during data analysis (Hsieh and Shannon, 2005). In addition, it is recommended to use this type of method Kinesiologia Slovenica, 28, 2, 130-146 (2022), ISSN 1318-2269 Physical Activity and Mental Health Among Women 133 for sensitive topics such as mental health problems, ((Danielsson et al, 2016; Elo & Kyngäs, 2008). The aim of our study was to answer the following questions: a.) which aspects of physical activity are important to them; b.) how participants perceive PA and its impact on mental health; c.) what motivates them to be physically active; and d.) how PA affects their lives. Sampling and participant recruitment Participants were recruited from the local centre for recreation in Ljubljana (Center aktivnih Fužine) based on purposive sampling. The head of the centre selected potential participants, and contact details were provided to the researchers. After an initial phone call, sharing the details of the research and eligibility with participants, each participant was scheduled for a private face-to-face interview. The ethics of research were reviewed, and all participants signed a written consent allowing the use of their data. The inclusion criteria are as follows: a.) women aged 65 or older, b.) being physically active for at least 6 months prior to the study, and c.) having previously experienced depression or low mood. Instruments In our study, we designed a semi-structured interview. The scheme was divided into five different topics: a.) general demographic characteristics (7 questions), b.) experience with physical activity (6 questions), c.) experience with PA and its effect on mood (10 questions), d.) motivation and PA (4 questions), and e.) influence of PA on everyday life (8 questions). In addition, we also assessed the presence of depressive symptoms during the study. Participants themselves filled out the questionnaire before the interview. The results of the questionnaires were analysed after the interview. We used Zung’s self-rating depression scale (Zung, 1965), which consists of 20 items that rate the four common characteristics of depression: the persuasive effect, the physiological equivalents, other disturbances, and psychomotor activities. There are ten positively and ten negatively phrased questions. Each item was scored on a scale of 1-4 (from a little of the time to most of the time). The sum of the scores can vary from 25 to 100, with 25 to 49 indicating the absence of depression and higher scores indicating more severe depression. Kinesiologia Slovenica, 28, 2, 130-146 (2022), ISSN 1318-2269 Physical Activity and Mental Health Among Women 134 Procedure and data analysis All face-to-face semi-structured interviews were conducted in a private room. All interviews were audio recorded for downstream analysis. Participants were informed that there were no right or wrong answers. The answers were reflective, and participants were encouraged to talk freely about their experience. The semi-structured interview allowed the researcher to ask questions to reconfirm and evaluate the participant’s narrative. The duration of the interviews was not set. Content analysis started after transcription of the recorded data. Each transcription was systematically read, and words and statements that were deemed to be relevant were highlighted. Using MSWord, we used different colours to highlight the relevant and related themes and then break them down into sub-categories. We read the interview questions multiple times to link similarities and differences among the emerging themes. The main categories were highlighted with bold colours, and sub-categories with the same shade in lighter colours. The codes were organized based on our questionnaire. The questionnaire (attached in the appendix) was then divided into four categories (physical activity, mental health, motivation, and daily living), which served as our main codes. The other codes were determined from the participants' narrative. We organized them based on the hypernym and hyponym. For example, our second order code was psychological factors, which is a hypernym for the specific psychological states participants described (better mood, feeling of satisfaction, etc.). In some cases, further distinction was needed, and we formed fourth order codes. We used inductive and deductive reasoning and a method of constant comparison between and within the participant samples to look for valuable similarities and differences (Hsieh & Shannon, 2005). We wanted to distinguish and recognize all possible aspects of each main category and see if there were any differences and similarities as well as overall common themes that emerged. Memo PA effects many aspects of a person's life. We wanted to identify how older women perceived PA and its effect on their lives. Interviews were performed individually in a quiet setting. The interviews lasted from 30 minutes to an hour. It was observed that some participants were more open to discussion, and others were answering with more caution and needed more encouragement to talk about their experiences. Reflecting on the past provoked stronger emotions in some participants, such as sadness and grief. Others reacted in a positive way and showed acceptance of past events. We noticed some clear patterns that emerged in almost every Kinesiologia Slovenica, 28, 2, 130-146 (2022), ISSN 1318-2269 Physical Activity and Mental Health Among Women 135 interview. Our questions were organized by the general themes we thought were relevant to our research questions, such as general characteristics of PA, motivation, effect on mental health, and effect on everyday life. Those were our 4 pre-disposed first order codes to guide the interviews. General characteristics were organized by general experience and characteristics of PA (2nd order), then each to more specific themes such as why and why not being active (3rd order) and types of PA (3rd order), and the 4th order codes were specific things the participants mentioned. In our study, motivation was organized by psychological, physical, and psychosocial (2nd order); specific aspects were our 3rd order codes; and in some cases, further grouping was needed for 4th order codes. Effects on mental health were broken down into short- term and long-term effects, which were further described as specific effects that participants explained in the interviews. Everyday life was divided into 3 main 2nd order codes (everyday chores and life; interpersonal relationships and social life; and non-activity due to illness or other obstacles) that we formed from participants' specific narrations (3rd order codes). Some needed further grouping to form 4th order codes (non-activity, for example, was described as a sense of faulty and declining health, which were recognized as psychological and physical factors, so we made a 4th order code). RESULTS A total of 23 women were included in the study. During the study, only one of the participants had an acute depressive episode. On average, they scored 37 points (SD=13,6) on Zung’s self- rating depression scale (in appendix), indicating the absence of depressive symptoms. The participants' age varied between 60 and 76 years (mean±SD, 66,8 ± 4, 63 years) and all were retired (11,6 ± 5,5 years). The majority of the sample had a V. level of education and were married or in long-term relationships (N=12), nine were widowed and two were single. With the exception of one, all had children. They attended regular PA in the centre between three and ten years (6,8 ± 2,2 years). The participants had depressive episodes after retirement (ranging between 22 and four years ago), but we did not ask for a specific time period. In Tables 1-4, we presented codes in the order derived from the content analysis. We organized them by 4 aspects of PA (General PA, motivation, mental health, and everyday life). Kinesiologia Slovenica, 28, 2, 130-146 (2022), ISSN 1318-2269 Physical Activity and Mental Health Among Women 136 Table 1. Codes derived from the interview and number of answers for physical activity. First order code Second order code Third order code Forth order code N Physical activity (PA) PA experience Regular PA Awareness of the importance of PA 10 Need to move 12 Habit from childhood 3 Reasons for non- activity Lack of time 13 Family obligations 11 Unawareness of the importance of PA 3 PA characteristics Type of PA Various types of PA 23 Feeling fatigued 12 Environment not important 20 A friendly relationship with a personal trainer 23 Table 1 represents the general characteristics and experience of PA. Referring to the past and present experiences, it was observed that participants were regularly active because they were aware of the benefits, felt they needed to move, and were used to being active since childhood. One participant described: »I have to move, for my health and to feel better. That is why I come here almost every day. In many cases, family obligations and work were the main factors in the past for not being active. Participant said: »There has been a lot of work; I had to take care of my ill mom, family obligations, children, always something.« Kinesiologia Slovenica, 28, 2, 130-146 (2022), ISSN 1318-2269 Physical Activity and Mental Health Among Women 137 Table 2. Codes derived from the interview and number of answers for motivation for physical activity. First order code Second order code Third order code Forth order code N Motivation for PA Psychological factors Feeling of satisfaction 15 Improved mood 16 Need to move 12 Satisfying own interests 23 Physical factors Maintaining physical health 23 Improving health 10 Maintaining/improving physical abilities 12 Managing other illnesses 8 Psychosocial factors Independence 21 Autonomy 21 Socialising New friendships 8 Inclusions in a social group 10 Overcoming low motivation Schedule 13 Awareness of the positive effect of PA 12 Feeling guilty 10 Table 2 represents the motivation for PA. The main psychological factors were feelings of satisfaction and satisfying their interests. They enjoyed exercising, so the activity itself is a motivation. participant's quote: »Because I like to be active, I like to dance. I feel satisfied that I did something for myself.« Physical factors were related to general physical health, which were recognized as very important. Participant stated: »Mainly I want to take care of my health. I want to stay in good shape at this stage of life. To be able to take care of me.« The latter is correlated to the psychosocial aspect because they mentioned how important it is to stay independent from others and stay autonomous. Overcoming low motivation evoked negative feelings. A feeling of guilt was the most prominent. Strategies to overcome it were Kinesiologia Slovenica, 28, 2, 130-146 (2022), ISSN 1318-2269 Physical Activity and Mental Health Among Women 138 awareness of positive effects and a schedule. They felt obligated to be there. A participant explained: »I feel very bad when I do not go, I feel disappointed. So that is why I usually go. I know it is on my schedule and I try not to second think to go or not. « Table 3. Codes derived from the interview and number of answers for effect of physical activity on mental health. First order code Second order code Third order code Forth order code N Effects of PA on mental health Short-term changes Increased energy 19 Psychological relaxation 15 Physical relaxation 7 Positive mood Distraction from negative thoughts 23 Postponing the problem 10 Long term changes Satisfaction 15 Improvement in mood 23 Positive thinking 18 Psychological resilience 21 Better stress management Constructive problem solving 9 Positive thinking 18 Acceptance of unpleasant events 10 Forming new interpersonal relationships and socializing Interpersonal support 11 Acceptance in a social group 8 Personal development Reaching goals Satisfying interests Better self-esteem 20 23 23 Sens of usefulness 18 Kinesiologia Slovenica, 28, 2, 130-146 (2022), ISSN 1318-2269 Physical Activity and Mental Health Among Women 139 Table 3 represents the effect of PA on mental health. Short-term effects are increased energy, relaxation, and positive mood. In addition, a positive mood right after the workout was described as a distraction from negative thoughts and postponing the problem. To quote a participant: »It helps me if I am in a low mood. I come here and I see my friends. I forget about problems at home. For the time I focus on myself and that helps me to relax. « Long-term changes were described as increased satisfaction, improved mood, better stress management, and improved social life and personal development. Overall, it had a positive effect on their mental health. One participant concluded: "Coming to the center helped me not to fall back into depression. It gives me positive energy, and I am happier throughout the day. That is the key. You have to accept certain things in life and move on. My activities maintain my happiness, mood, and overall well-being. And later added, "Otherwise I would just sit at home and think about negative events that happened to me." Table 4. Codes derived from the interview and the d number of answers for the effect of physical activity on everyday life. First order code Second order code Third order code Forth order code N Effect of PA in everyday life Everyday chores and life More active life 23 Better organization 20 Sense of meaning 20 Doing housework with ease 23 Interpersonal relationships and social life Improvising interpersonal relationships Improving marital relations 14 Socializing as motivation for PA 15 Sense of belonging 10 Forming closer relationships Help 11 Sharing life experiences 8 Decreasing loneliness 7 Non-activity due to physical illness or other obstacles Psychologically factors Feeling of usefulness 20 Sense of faulty 20 Dissatisfaction 13 Kinesiologia Slovenica, 28, 2, 130-146 (2022), ISSN 1318-2269 Physical Activity and Mental Health Among Women 140 Loneliness 10 Decreased mood 12 Physical factors Declining health 12 Decline in physical abilities 15 Less efficacy in everyday chores 9 Everyday life was affected in different ways, such as better organization and a feeling of meaning in a day. It also affected interpersonal relations with important others as well as better social networking. The result was decreased loneliness, support, and help from newfound friendships. As the participant described: »It gives me structure. I know what I will do each day, what is coming, and what activities I have. Otherwise, I would sit at home alone and watch TV. I think that would not be good. Family obligations or physical illnesses were the main obstacles to missing a workout. Negative feelings emerged, such as a sense of failure, loneliness, and decreased mood. Participant concluded: »There was a short time when I was injured and I could not go. I felt bad and I quickly noticed my physical performance went down fast. That made me unhappy.« DISCUSSION Our study is one of the first in Slovenia to examine how older people perceive physical activity and its relationship to mental stress or depressive symptoms, with promising results for future research. Overall, we can conclude that PA is one of the preferable activities for older women. The majority of people believe it is a viable strategy for dealing with mental stress while also improving physical health. The most prevalent factors were increased satisfaction, increased well-being, and improved physical health. Our findings were consistent with other studies on the type of PA in many ways. We found that participants did not prefer a specific type of PA but rather participated in activities they found interesting. We recognized a slight trend toward aerobic exercise, which we also found in many other meta-analysis (Josefsson et al, 2014; Nyström et al, 2015; Strohle, 2009), but that is likely due to the nature of the available activities rather than their personal choice. (Callaghan et al, 2011) found that the preferred type of PA had better results than the prescribed type in Kinesiologia Slovenica, 28, 2, 130-146 (2022), ISSN 1318-2269 Physical Activity and Mental Health Among Women 141 decreasing depressive symptoms. Indeed, the subjective experience of PA has more influence on depressive symptoms than its specific characteristics. We noticed similar patterns among our participants regarding the effects of PA on mental health. Changes were described as being short-term and long-term. Participants noticed increased energy, physical and mental relaxation, positive thinking, and pleasure. Indeed, participants can notice increased self-esteem, pleasure, energy, and positive thinking following PA (Glenister, 1996). Diversion from negative thoughts seems to be the most distinctive short-term effect. Participants described how they forget about their worries and negative thoughts during PA, which provides them with a short relief from depressive symptoms. This has been suggested in some other studies researching possible mechanisms (Buckworth et al, 2013). Our findings are in line with other similar research (Cooney et al, 2013), suggesting that physical activity influences self-esteem and self-imagine, and that there is a positive relationship between self- esteem and decreased depressive symptoms (Ossip-Klein et al, 1989). Moreover, feelings of confidence or competence in one part of life (PA) can translate to others and affect overall mental health (Strohle, 2009). One of the main symptoms of depression is a lack of motivation. In our study, all participants showed very strong intrinsic motivation (enjoying activity), which was not the case in similar studies (Pickett et al, 2017). This is likely because our participants did not have depression during our interview and the crisis had already been resolved. Motivation in the early stages of depression is mainly extrinsic and, through time, participants become intrinsically motivated (Pickett et al., 2017). The effects of social interaction during exercise seem to be complex and intertwined with affecting mood and motivation. In the motivational domain, we found social interaction to be an important motivational factor, but due to the nature of our study, we cannot determine its impact on depressive symptoms. Some research suggests that social interaction is more important at the early stages of an exercise program, especially as a motivator (North et al, 1990). Other qualitative research (Kratz et al, 2014) reveals that the main motivation for those suffering from depression is to participate in activities that they find enjoyable and comfortable with (Miller et al, 2019). In the mental health domain, we recognized decreased feelings of loneliness, feelings of acceptance, and increased social support. Indeed, group-based interventions outperformed Kinesiologia Slovenica, 28, 2, 130-146 (2022), ISSN 1318-2269 Physical Activity and Mental Health Among Women 142 home-based interventions (Nyström et al., 2015), owing to improved motivation and external control (Burke et al, 2005). While many studies focus on the role that social interaction plays in symptom reduction, there can be a variety of outcomes. For example, there is a positive link between social interaction and a reduction in depression (Ernst et al, 1998), but social interaction does not impact depressive symptoms (Glenister, 1996). Physical activity may have a positive impact on the overall improvement in quality of life. Indeed, our participants recognized positive outcomes from PA, especially staying independent and having a structured and meaningful day. This is critical for promoting PA and motivating people to participate in regular exercise, especially among older adults, where PA can help them stay independent longer (Schuch et al, 2016). As research shows, PA is one of the best and most accessible ways to improve the quality of life in older adults (Rejeski & Mihalko, 2001; Schuch et al, 2016). Lastly, we examined obstacles to not being active. While lack of motivation, low mood, and fatigue are commonly reported reasons for non-compliance in exercise programs (Srensen, 2006), we found that our participants were highly motivated and valued PA. Again, this is likely because our participants were not showing depressive symptoms during our interviews. We managed to answer all the main questions we presented prior to the study. During the analysis, we found some additional insights that we were not expecting. One of the most interesting was the complex influence that social interaction has on different aspects, such as motivation and mental health. Limitations The current study has several limitations. Since we only sampled a small number of participants from one recreational centre, all individuals were women who had had a positive experience with physical activity, and they may not accurately represent the larger sample. We did not separate between clinically and non-clinically depressed patients, making our results difficult to relate to other more standard treatment options. In addition, since our participants self- evaluated their experiences as stressful, the stressful life events could have been long resolved with little or no association to the current situation. We cannot estimate the impact that PA has on depressive symptoms. Kinesiologia Slovenica, 28, 2, 130-146 (2022), ISSN 1318-2269 Physical Activity and Mental Health Among Women 143 Future directions Since our study suggests a subjective perception that PA does indeed help with mental health, it would be appropriate to expand the topic further. There is a need for more controlled studies with proper diagnosis of mood disorders. A comparison of different free time activities with PA or an examination of obstacles and motivations for participation in PA would help us create a standard guideline. Longitudinal studies would elucidate long-term changes in mental health when people are physically active. CONCLUSION Our study presents promising results regarding physical activity and depressive symptoms, suggesting that PA has a positive impact on a person’s mood if they are motivated to participate in physical activity. This is critical when applying guidelines for people suffering from mental illness. Regular PA has been shown to improve mental and physical functioning as well as other aspects of life, such as stress management, improved quality of life, and increased independence and autonomy, all of which are crucial later in life. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Kinesiologia Slovenica, 28, 2, 130-146 (2022), ISSN 1318-2269 Physical Activity and Mental Health Among Women 144 REFERENCES Alonso, S., & Hernandez, P. (2009). Women and Depression. Nova Science Publishers. American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th edition). American Psychiatric Publishing, Inc. Buckworth, J., Dishman, R. K., O'Connor, P. J., & Tomporowski, P. D. (2013). Exercise psychology, 2nd ed. Human Kinetics. Birrer, R. B., & Vemuri, S. P. (2004). Depression in later life: a diagnostic and therapeutic challenge. American Family Physician, 69(10), 2375-2382. https://www.aafp.org/afp/2004/0515/p2375.html Bruce, M. L. (2001). Depression and disability in late life: directions for future research. American Journal of Geriatric Psychiatry, 9(2), 102-112. https://doi.org/10.1176/appi.ajgp.9.2.102 Burke, S., Carron, A., Eys, M., Ntoumanis, N., & Estabrooks, P. (2005). Group versus Individual Approach? A Meta-Analysis of the Effectiveness of Interventions to promote physical activity. Sport and Exercise Psychology Review, 2. Callaghan, P., Khalil, E., Morres, I., & Carter, T. (2011). Pragmatic randomised controlled trial of preferred intensity exercise in women living with depression. BMC public health, 11, 465-465. https://doi.org/10.1186/1471- 2458-11-465 Cassano, P., & Fava, M. (2002). Depression and public health: an overview. Journal of psychosomatic research, 53(4), 849-857. https://doi.org/10.1016/S0022-3999(02)00304-5 Cooney, G. M., Dwan, K., Greig, C. A., Lawlor, D. A., Rimer, J., Waugh, F. R., McMurdo, M., & Mead, G. E. (2013). Exercise for depression. Cochrane database of systematic reviews, 9. https://doi.org/10.1002/14651858.CD004366.pub6 Copeland, J. R., Beekman, A. T., Braam, A. W., Dewey, M. E., Delespaul, P., Fuhrer, R., Hooijer, C., Lawlor, B. A., Kivela, S. L., Lobo, A., Magnusson, H., Mann, A. H., Meller, I., Prince, M. J., Reischies, F., Roelands, M., Skoog, I., Turrina, C., deVries, M. W., & Wilson, K. C. (2004). Depression among older people in Europe: the EURODEP studies. World Psychiatry, 3(1), 45-49. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1414664/ Cuijpers, P., van Straten, A., & Smit, F. (2006). Psychological treatment of late-life depression: a meta-analysis of randomized controlled trials. International Journal of Geriatric Psychiatry, 21(12), 1139-1149. 171(4), 453- 462. https://doi.org/10.1176/appi.ajp.2013.13030325 Danielsson, L., Kihlbom, B., & Rosberg, S. (2016). "Crawling Out of the Cocoon": Patients' Experiences of a Physical Therapy Exercise Intervention in the Treatment of Major Depression. Physical Therapy, 96(8), 1241- 1250. https://doi.org/10.2522/ptj.20150076 Dinas, P. C., Koutedakis, Y., & Flouris, A. D. (2011). Effects of exercise and physical activity on depression. Irish Journal of Medical Science, 180(2), 319-325. https://doi.org/10.1007/s11845-010-0633-9 Elo, S., ̨ & Kyngäs, H. (2008). The qualitative content analysis process. Journal of Advanced Nursing, 62(1), 107- 115. https://doi.org/10.1111/j.1365-2648.2007.04569 Ernst, E., Rand, J. I., & Stevinson, C. (1998). Complementary therapies for depression: an overview. Archives of General Psychiatry, 55(11), 1026-1032. https://doi.org/10.1001/archpsyc.55.11.1026 Fiske, A., Wetherell, J. L., & Gatz, M. (2009). Depression in older adults. Annual review of clinical psychology, 5, 363-389. https://doi.org/10.1146/annurev.clinpsy.032408.153621 Glenister, D. (1996). Exercise and mental health: a review. Journal of the Royal Society of Health, 116(1), 7-13. https://doi.org/10.1177/146642409611600102 Kinesiologia Slovenica, 28, 2, 130-146 (2022), ISSN 1318-2269 Physical Activity and Mental Health Among Women 145 Gudmundsson, P., Lindwall, M., Gustafson, D. R., Östling, S., Hällström, T., Waern, M., & Skoog, I. (2015). Longitudinal associations between physical activity and depression scores in Swedish women followed 32 years. Acta Psychiatrica Scandinavica, 132(6), 451-458. https://doi.org/10.1111/acps.12419 Heinzel, S., Lawrence, J., Kallies, G., Rapp, M., & Heissel, A. (2015). Using exercise to fight depression in older adults. The Journal of Gerontopsychology and Geriatric Psychiatry, 28, 149-162. https://doi.org/10.1024/1662- 9647/a000133 Hsieh, H.-F., & Shannon, S. (2005). Three Approaches to Qualitative Content Analysis. Qualitative health research, 15, 1277-1288. https://doi.org/10.1177/1049732305276687 Josefsson, T., Lindwall, M., & Archer, T. (2014). Physical exercise intervention in depressive disorders: meta- analysis and systematic review. Scandinavian Journal of Medicine and Science in Sports, 24(2), 259-272. https://doi.org/10.1111/sms.12050 Kessler, R. C. (2003). Epidemiology of women and depression. Journal of Affective Disorders, 74(1), 5-13. https://doi.org/10.1016/S0165-0327(02)00426-3 Kratz, A. L., Ehde, D. M., & Bombardier, C. H. (2014). Affective mediators of a physical activity intervention for depression in multiple sclerosis. Rehabilitation Psychology, 59(1), 57-67. https://doi.org/10.1037/a0035287 Ku, P.-W., Fox, K. R., Chen, L.-J., & Chou, P. (2012). Physical activity and depressive symptoms in older adults: 11-Year Follow-Up. American Journal of Preventive Medicine, 42(4), 355-362. https://doi.org/10.1016/j.amepre.2011.11.010 Lopez, A. D., Mathers, C. D., Ezzati, M., Jamison, D. T., & Murray, C. J. L. (2006). Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data. The Lancet, 367(9524), 1747-1757. https://doi.org/10.1016/S0140-6736(06)68770-9 Madill, A., Jordan, A., & Shirley, C. (2000). Objectivity and reliability in qualitative analysis: realist, contextualist and radical constructionist epistemologies. British journal of psychology, 91, 1-20. https://doi.org/10.1348/000712600161646 Mead, G. E., Morley, W., Campbell, P., Greig, C. A., McMurdo, M., & Lawlor, D. A. (2008). Exercise for depression. Cochrane database of systematic reviews, (4). https://doi.org/10.1002/14651858.CD004366.pub3 Miller, K. J., Mesagno, C., McLaren, S., Grace, F., Yates, M., & Gomez, R. (2019). Exercise, mood, self-efficacy, and social support as predictors of depressive symptoms in older adults: direct and interaction effects. Frontiers in Psychology, 10, 2145-2145. https://doi.org/10.3389/fpsyg.2019.02145 North, T. C., McCullagh, P., & Tran, Z. V. (1990). Effect of exercise on depression. Exercise and Sport Science Review, 18, 379-415. http://dx.doi.org/10.1249/00003677-199001000-00016 Nyström, M. B. T., Neely, G., Hassmén, P., &Carlbring, P. (2015). Treating major depression with physical activity: a systematic overview with recommendations. Cognitive Behaviour Therapy, 44(4), 341-352. https://doi.org/10.1016/j.pneurobio.2012.05.009 Ossip-Klein, D.J., Doyne, E.J., Bowman, E.D., Osborn, K.M., McDougall-Wilson, I. B., & Neimeyer, R. A. (1989). Effects of running or weight lifting on self-concept in clinically depressed women. Journal of consulting and clinical psychology, 57, 158-161.https://doi.org/10.1037/0022-006X.57.1.158 Pickett, K., Kendrick, T., & Yardley, L. (2017). “A forward movement into life”: A qualitative study of how, why and when physical activity may benefit depression. Mental Health and Physical Activity, 12, 100-109. https://doi.org/10.1016/j.mhpa.2017.03.004 Rejeski, W. J., & Mihalko, S. L. (2001). Physical Activity and Quality of Life in Older Adults. The Journals of Gerontology: Series A, 56(suppl_2), 23-35. https://doi.org/10.1093/gerona/56.suppl_2.23 Schuch, F. B., Vancampfort, D., Rosenbaum, S., Richards, J., Ward, P. B., & Stubbs, B. (2016). Exercise improves physical and psychological quality of life in people with depression: A meta-analysis including the evaluation of control group response. Psychiatry Research, 241, 47-54. https://doi.org/10.1016/j.psychres.2016.04.054 Kinesiologia Slovenica, 28, 2, 130-146 (2022), ISSN 1318-2269 Physical Activity and Mental Health Among Women 146 Sørensen, M. (2006). Motivation for physical activity of psychiatric patients when physical activity was offered as part of treatment. Scandinavian Journal of Medicine and Science in Sports, 16(6), 391-398. https://doi.org/10.1111/j.1600-0838.2005.00514.x Strohle, A. (2009). Physical activity, exercise, depression and anxiety disorders. Journal of Neural Transmission, 116(6), 777-784. https://doi.org/10.1007/s00702-008-0092-x Stubbs, B., Vancampfort, D., Hallgren, M., Firth, J., Veronese, N., Solmi, M., Brand, S., Cordes, J., Malchow, B., Gerber, M., Schmitt, A., Correll, C. U., De Hert, M., Gaughran, F., Schneider, F., Kinnafick, F., Falkai, P., Moller, H. J., & Kahl, K. G. (2018). EPA guidance on physical activity as a treatment for severe mental illness: a meta- review of the evidence and Position Statement from the European Psychiatric Association (EPA), supported by the International Organization of Physical Therapists in Mental Health (IOPTMH). European Psychiatry, 54, 124- 144. https://doi.org/10.1016/j.eurpsy.2018.07.004 Sweeney, A. M., Wilson, D. K., 6 Brown, A. (2019). A qualitative study to examine how differences in motivation can inform the development of targeted physical activity interventions for African American women. Evaluation and Program Planning, 77. https://doi.org/10.1016/j.evalprogplan.2019.101718