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Journal of Public Health Advance Access originally published online on October 5, 2005
Journal of Public Health 2005 27(4):326-330; doi:10.1093/pubmed/fdi048
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© The Author 2005, Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved.

Access to exercise referral schemes – a population based analysis



R. A. Harrison
R. A. Harrison, Senior Research Fellow (Honorary), Evidence for Population Health Unit, University of Manchester, Oxford Road, Manchester M13 9PT; Senior Research Fellow (Honorary), Bolton Primary Care Trust, St Peter’s House, Bolton BLI 1PP


F. McNair

L. Dugdill
F. McNair, PhD Student, L. Dugdill, Reader in Exercise and Health, School of Community, Health Sciences and Social Care, Salford University, Greater Manchester, M5 4WT

Address correspondence to Dr Roger A Harrison. E-mail: roger.harrison{at}manchester.ac.uk

Background Sedentary behaviour is a public health priority in many countries. Hundreds of community-based exercise referral schemes have been established in Europe and USA, to increase physical activity. Experimental evidence questions the effectiveness of these schemes. No previous evaluations have considered a population approach nor provide detailed information on the types of people accessing these schemes. This is of concern given increasing health inequalities in other areas of care. Our register-based study quantified the numbers and characteristics of patients referred and accessing a district-wide exercise referral scheme. The analysis considers the effectiveness of these schemes to a geographically defined population.

Methods Data were collected prospectively from a patient register for referrals made to a district-wide exercise referral scheme in north-west England. Analysis examined referral rates and the influence of practitioner and patient characteristics on access to the scheme.

Results Over 5 years, 6610 adults were referred from 125 general practices, with 60.8 per cent female and a mean age of 51.3 years (SD 12.6). This represents 4 per cent of the adult sedentary population in that district. The most common reason for referral was musculoskeletal or cardiovascular risk. Overall, 79 per cent attended at least the first appointment, with statistically significant predictors by age and reason for referral. Those referred for ‘fitness’ or ‘mental health’ were most likely to attend. Patients in the youngest and oldest age groups were least likely to attend. Patient’s sex and deprivation and the number of patients referred by each general practice did not influence attendance.

Conclusions Primary-care patients seem to view the concept of exercise referral schemes positively but practitioners remain reluctant to refer many of their sedentary patients. There is doubt that exercise referral schemes like this will influence population levels of sedentary behaviour, when considered alongside their impact on physical activity in the longer term.

Keywords: exercise referall, exercise on prescription, physical activity, health promotion


   Introduction
TOP
 Introduction
Methods
 Results
 Discussion
 References
 
Government policy in England continues to support exercise referral schemes, or ‘exercise on prescription’, to increase uptake of healthy lifestyle behaviours in the general population.1 These schemes aim to encourage and support people to engage in regular physical activity often working in partnership between primary care and local leisure services.2–4 The majority of people in England, and many other countries are sedentary,5–8 giving priority to increasing population levels of physical activity. Sedentary behaviour has a major negative impact on health, which can be reversed through physical activity.9–13 Factors associated with the transition from sedentary behaviour to habitual participation in physical activity are complex.14–17 Exercise officers working through exercise referral schemes were seen to have advantages to deal with this complexity, compared with busy clinicians, including expert knowledge, skills and dedicated time.18–21 There has been a rapid expansion in exercise referral schemes across the UK and other countries22,23 now operating to a quality assurance framework in England.24

Despite the popularity of exercise referral schemes, at least amongst providers,2–4 experimental studies raise doubt about their effectiveness.2,21,25,26 It is also necessary to consider their wider effect on a population – that is, their population impact.27 This considers the effectiveness of the intervention as well as the proportion of the total sedentary population referred and the proportion who go on to access the service.

We used a register-based approach to determine the likely impact of these interventions at a population level. We also sought to examine factors associated with uptake of the service. This information provides a wider perspective on the effectiveness of these interventions, at a population level, to be incorporated with experimental evidence from randomized controlled trials.


   Methods
TOP
 Introduction
 Methods
Results
 Discussion
 References
 
The analysis used a patient register for all referrals made to a district-wide exercise referral scheme. The catchment area for the service was a local government district (local authority area) in the north-west of England. One hundred and twenty-five general practitioners and their staff were able to refer sedentary patients to the exercise scheme. Patients were eligible for referral if they were participating in no or only a little physical activity a week and had no clinical contraindications to physical activity, as determined by the clinician. Health professionals referred eligible patients by completing a referral form, to record patient details (age, sex, address, medical history of note) and the main reason for referral (in addition to being sedentary). Appointments were then arranged with the patient to attend an initial consultation with the exercise officer at a local leisure centre. The exercise referral scheme was similar to other schemes operating in that area, previously described.2 In brief, during the consultation, the exercise officer worked with the patient to identify a suitable physical activity programme in and outside of the leisure centre, over 12 weeks. This included subsidized use of local authority leisure facilities and supervised exercise sessions at the leisure centre. At the end of the 12 weeks, the patient was reassessed by the exercise officer and a programme of continued physical activity defined.

Before analysis, the register was checked for consistency and errors. A code was assigned to each general practitioner that the patient was registered with, through which the referral was made. The patients’ postcodes were electronically matched to local authority ward codes and then matched to nationally derived scores of index of multiple deprivation (IMD).28 IMD scores were grouped into quintiles, (1=least deprived; 5=most deprived). The primary reason for referral (other than sedentary behaviour) was re-coded into eight key clinical categories.

Descriptive statistics presented information on the numbers and characteristics of patients referred to the exercise scheme. Logistic regression identified predictors for attending the first consultation, adjusting for age, sex and IMD, with 95 per cent confidence intervals. Analyses were carried out using SPSS for Windows (release 11.01). Approval for this research was granted by the local research ethics committee and the research governance committee.


   Results
TOP
 Introduction
 Methods
 Results
Discussion
 References
 
Over the 5 years from January 1998 to December 2002, 6610 referrals were made to the exercise referral scheme. The number of referrals made by health professionals attached to the 125 general practitioners in the locality ranged from one to 450. Almost half of the 125 general practitioners and their support staff referred between one and 10 patients (42.1 per cent, 53/125), a third (28.8 per cent 36/125) between 11 and 50 patients, and 12 per cent (15/125) referred between 51 and 100 patients. Staff at a small number of practices (16.8 per cent, 21/125) referred between 100 and 450 patients over 5 years.

Women accounted for 60.8 per cent of referrals (4016/6610) and of all patients the mean age was 51.3 years (SD 12.6, range 18–89 years). There was no important difference in the age of women compared with men (women 50.4 years, SD 12.78, range 18–89 years; men 52.8 years, SD 12.2, range 18–84 years). In terms of age, the largest proportion of patients referred to the exercise officer was in the 10-year age group 55–64 years. The distribution of men and women was similar across all ages (Table 1).


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  		Table 1 Age and sex distribution of referred patients

 

The two most common reasons for the referral, in addition to sedentary behaviour, were musculoskeletal conditions and cardiovascular risk factors (Table 2). There was a positive relationship between older age and referrals associated with CVD or musculoskeletal problems, accounting for 45.0 per cent of those aged 18–44 years increasing to 70.5 per cent aged 45 years and above. There were substantial differences in the proportion of women compared with men who were referred for CVD or musculoskeletal conditions. In women, 23.8 per cent (955/4016) and 37.1 per cent (1490/4016) were referred for these two categories, respectively, compared with 39.4 per cent (1021/2594) and 26.3 per cent (681/2594) of men. In the CVD category, the three main reasons for referral were elevated blood pressure (36.8 per cent, 728/1976), angina (24.0 per cent, 474/1976) and previous heart attack (12.8 per cent, 254/1976). In the musculoskeletal group the three main reasons for referral were arthritis (50.1 per cent, 1087/2171), back pain (47.1 per cent, 1022/2171) and osteoporosis (1.3 per cent, 28/2171).


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  		Table 2 Reason for referral (main category) by age groups

 

Attendance at first appointment
Of the 6610 patients referred to the exercise officer, 79.0 per cent (5225/6610) attended at least the first consultation. Attendance rates did not differ amongst men and women (79.2 per cent women, 78.9 per cent men; ORadj age 0.91, p=0.64). Attendance rates were highest in the age groups spanning 25–74 years, with 77.0–80.3 per cent in those age groups attending compared with 74.0 per cent aged 18–24 years and 72.1 per cent aged at least 75 years.

Patients referred for a specific reason were more likely to attend the first appointment compared with a referral with ‘no reason’ (other than sedentary behaviour) (79.7 per cent 4683/5875, versus 73.7 per cent 542/735, ORadj age sex 1.37, 95 per cent CI 1.15–1.64, p=0.001). The categories of ‘mental health’ (82.6 per cent, 280/339), ‘other’ (82.6 per cent, 38/46) and ‘CVD’ (81.8 per cent, 1616/1976) had the highest attendance rates. However, in the logistic regression model, only ‘fitness’ and ‘mental health’, when compared with ‘no-reason’, remained significant predictors of attendance (Table 3).


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  		Table 3 Odds of attending the first appointment by referral reason (adjusted for age and sex and for age, sex and IMD)

 

Of all referrals, 83.7 per cent (5534/6610) were successfully matched using the patient’s postcode to information on IMD. Across all patients, IMD had no effect on influencing the likelihood of attending for the first appointment (ORadj age sex 1.02, 95 per cent CI 0.97–1.06). Within each referral category, a significant effect of IMD was found for patients referred for respiratory problems, with patients in the most deprived quintile more likely to attend the first appointment compared with the least deprived (Table 4). The likelihood of patients attending the consultation with the exercise officer did not appear to be influenced by factors associated with the referring health profession. We found no relationship between the number of patients referred to the scheme by general practitioners and their staff (ORadj 1.00, 95 per cent CI 0.99–1.00) nor when comparing those referring at least 200 patients, compared with less than this (ORadj 1.01, 95 per cent CI 0.98–1.03) (adjusting for age, sex, referral reason and IMD).


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  		Table 4 Effect of index of material deprivation (bottom vs. top quintile) for attendance, within each referral category (age/sex adjusted)

 


   Discussion
TOP
 Introduction
 Methods
 Results
 Discussion
References
 
Main findings
Analysis of referrals over 5 years to a district-wide exercise referral scheme found that few patients were referred relative to the 70 per cent of sedentary adults residing in this area.29 Using this data, we estimate that only 4 per cent of the ‘at risk’ population were referred to the exercise referral scheme over the 5 years. Adults were referred from all ages but over half were aged 45–64 years old. The most common reason for referral was for musculoskeletal or coronary disease. The majority of patients referred to the exercise referral scheme attended at least the first consultation. Patients in the top and bottom age groups were least likely to attend but there was no difference among men and women. The reason for referral had some impact on the likelihood of attending the first appointment, which was greatest amongst people referred for mental health or fitness.

What is already known on this topic?
Previous evaluations of exercise referral schemes have concentrated on measuring their ability to increase sustained levels of physical activity amongst people consenting to take part in randomized controlled trials of these interventions. The small number of randomized controlled trials found these interventions have a modest impact on increasing physical activity within months of starting the intervention.2,25,26 However, this gain is not sustained for a period of at least 12 months.2 Attendance rates to at least the first consultation following referral to these types of schemes has been found to vary from 35 per cent to 85 per cent.2,26,30 Factors associated with referral and attendance rates have not been examined in the past. Nor has consideration previously been given to referral rates as a proportion of sedentary people in the local population.

What this study adds
This is the first evaluation of an exercise referral scheme to consider their potential to reduce sedentary behaviour within a geographically defined population. Our study highlights that over 5 years, few sedentary people were referred to a district-wide exercise referral scheme. We highlighted that the majority of patients were referred by a small number of general practices, despite many practitioners trying out the intervention by referring at least one patient over the 5 years examined. Data presented here questions the extent that these schemes can meet the needs of all sedentary adults, particularly the youngest and oldest adults. This is further highlighted by the wide range of conditions for which patients were referred.

Limitations of this study
Our study lacks information on levels of physical activity amongst those attending and not attending the exercise referral scheme. It was intended to examine factors associated with ‘access’ to these schemes, rather than their effectiveness in increasing physical activity amongst those who did attend. The former is an important component of the population impact of an intervention, and the latter has been examined previously in randomized controlled trials.2,25,26 Patients not attending the initial consultation may have found other ways to increase their physical activity after referral from primary care and one should not assume that they remained sedentary. Many factors are likely to influence why patients choose to accept a referral to an exercise referral scheme and this is currently being examined from the perspective of ‘socialisation’ (McNair, PhD thesis). Data for our study come from the referrals database, which relies on having received the referral form from the practitioner. These could be faxed or posted to the exercise referral office. Some may have been lost in transit although the numbers are likely to be low and would not markedly alter our conclusions.

The main strengths of our study include the population perspective that has previously been overlooked. Our analysis of the 6610 referrals spanned 5 years, allowing seasonal or annual fluctuations to be accounted for. It also ensured that our results were not influenced by initial enthusiasm for a new service and at the same time, provided ample time for a new service to become established and known.

Conclusion
Exercise referral schemes are unlikely to contribute to population levels of physical activity. Further attention needs to be given to the potential effectiveness of neighbourhood or ‘area-based’ interventions as these can increase physical activity amongst larger numbers of people.31–33 Primary care must continue its important role in this21 and consider the appropriateness of referral pathways and available activity programmes. This needs to be from the perspective of the general sedentary population and, at the same time, needs to consider the requirements for specific patient or client groups. Traditional exercise referral schemes may be best reserved for those who are most in need of strictly supervised exercise activity, within a controlled environment, including recent survivors of stroke or myocardial infarction.34,35 We must ensure that new and established services and interventions are shown to be effective, before making recommendations. This was certainly not the approach with respect to exercise referral schemes.


   References
TOP
 Introduction
 Methods
 Results
 Discussion
 References
 

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