Background
Methods
Results
First Author & year | Design & Quality | Intervention | Venue | Duration (weeks) | Population |
---|---|---|---|---|---|
Beaufort Research 2013 [49] | CSSc
| Welsh National ERS | LC | 16 | Wales; N = 1000; Age ≥18 |
Beers 2006 [21] | Qualitativeb
| Free access to advice and facilities – ELC participants | LC | 12 | Wirral; N = 181; Age 16–79 |
Carroll 2002 [19] | Qualitativea
| GP referred - activities including gym, swimming and aerobics | LC | Varied | Mid and North England; N = 35; South Asian Muslim women; plus 10 GP referrers, 13 scheme providers |
Clarke 1996 [43] | CSSb
| GP referred ERS with personalised counselling and tailored exercise prescription | LC | 12 | Birmingham; N = 500; mean age ca 46 [SD ca 14.0]; 69 % F; 40 % social class IV/V |
Cock 2006 [35] | Qualitativec
| GP referred ERS (5 schemes); activities included gym-, water- and hall-based exercises | LC | 10–13 | South & North England; N = 1024 |
Crone 2002 [22] | Qualitativeb
| GP referred ERS (3 schemes) | Varied | Ca 12 | North & South West England; N = 18; mean age 55.5 years; F13 M5 |
Crone 2005 [54] | |||||
Cummings 2010 [44] | CSSb
| Exercise for Health programme; walking, gym, swim, cycle and class-based exercises | Not stated | Not stated | Northern Ireland; N = 210; mean age 54.8 ± 15.7; F106 M104 |
Day 2001 [50] | CSSc
| Exercise for Health programme; consultation & follow up | Varied | 8 | Scottish borders; N = 324 |
Graham 2006 [23] | Qualitativeb
| GP referred ERS - Consultation, exercise, review. | LC/G | 14 | North West England; N = 985 |
Qualitativeb
| ERS - Gym-and class-based activities | LC | 10 | East Sussex; N = 8; Age 43–77 years; all female | |
Joyce 2010 [36] | Qualitativec
| ERS (some GP referred) - Gym membership on prescription for patients with obesity related conditions | G | 12 | County Durham; N = 25 in community; GP ERS N = 5; F3 M2; 4/5 were >50 years old |
Khanam 2008 [45] | CSSb
| GP referred ERS- 3 gym sessions per week (overweight women) | LC | Not stated | East London; N = 25; Age 30–60 mean age 47.3 (SD 9.1); all F; Bangladeshi; Muslim |
Lord 1995 [37] | Qualitativec
| GP referred ERS −3 sessions per week | LC | 10 | Stockport; N = 252; Ag 30–55; F198 53 M53 1 Unknown; Socially deprived area; plus 6 referrers, 7 scheme providers |
Markland 2010 [46] | CSSb
| GP referred ERS [no further description] | Not stated | 10 | UK (location not stated); N = 136; mean age 54.5; (SD 12.9); range 23–80; all F. |
Martin 1999 [25] | Qualitativeb
| GP referred ERS | LC/G | 10 | Margate Kent; N = 77; mean age 53 years; F39 M28 |
Qualitativeb
| Primary care referred ERS including gym-based sessions and swimming | LC | 26 | Inner London; N = 17; mean age 54.7 (SD 12.4); range 31–68); F13 M4; plus 7 referrers, 4 scheme providers | |
Morton 2008 [47] | CSSb
| ERS (no detail) - Two sessions per week | LC | Ca 10–12 | UK (location not stated); N = 30; mean age 51.9 years; F22 M8 |
Murphy 2010 [27] | Qualitativeb
| GP referred ERS with discounted sessions in six centres | LC | 16 | Wales; N = 32 participants; CHD risk factors |
Moore 2013 [58] | |||||
Myron 2009 [38] | Qualitativec
| GP referred ERS - 2 centres | Varied | Not stated | UK (location not stated); N not stated. Mean age 42, range 20–72; 71 % F. |
Rahman 2011 [48] | CSSb
| GP referred ERS; free of charge – 2 sessions per week | LC | 12 | UK (location not stated); N = 653; 18–83 years; F = 68.6 %. M = 31.4 % |
Schmidt 2008 [28] | Qualitativeb
| GP or health professional referred ERS -Specialist advice and low cost access to facilities | Not stated | 20 | Amsterdam, Netherlands; N = 523; Low SES and ethnic minority women aged 24–55 |
Sharma 2012 [29] | Qualitativeb
| Health professional referred ERS - 2 supervised gym sessions per week | LC | South London; N = 9; 37–61 year; F4 M5; stroke survivors | |
Shaw 2012 [30] | Qualitativeb
| GP referred for pre-exercise screening, health coaching (3 sessions) and community based exercise | Varied | 52 | Paisley, Scotland; N = 174; mean age 69.9 years; 43 M41; patients with stable coronary heart disease |
Singh 1997 [39] | Qualitativec
| GP referred supervised ERS – 20 sessions free, 20 half price | LC | Not stated | South East London; N = 13; age range 30–61; F11 M2 |
Stathi 2004 [31] | Qualitativeb
| Supervised ERS – gym and class based activities | LC | Not stated | South West England; N = 13; age range 63–79; F5 M8 |
Tai 1999 [51] | Longitudinala
| GP referred ERS -Tailored programme of 20 sessions | LC | 10 | Inner London; N = 152; age range 16–75; F108 M44 |
Taket 2006 [32] | Qualitativeb
| GP referred pilot ERS – three exercise consultations plus phone calls – walking, gardening, classes | Not stated | 52 | Inner London; N = 225; Age 44–65; F 22 M15; Type II diabetics; plus 14 non participants, 32 health professionals |
Gauvin 2007 [59] | |||||
Taylor 1996 [40] | Qualitativec[within RCT] | GP referred ERS with 20 sessions at half cost – included rowing, cycling, step machine and treadmill sessions. | LC | 10 | Hailsham, East Sussex; N = 142; age range 40–70 years; patients with CHD risk factors |
Taylor 1998 [60] | |||||
Walsh 2012 [41] | Qualitativec
| Local authority subsidised exercise programme | Not stated | 12 | UK (location not stated); N = 2101, ≥age 45; chronic joint pain/osteo-arthritis; plus 88 scheme providers |
Ward 2007 [42] | Qualitativec
| GP referred Welsh Heartlinks programme - ERS, Tai Chi, SlimSwim; motivational interviews | Varied | 52 | Merthyr Tydfil, Wales; N = 317; 24–88 years; F212 M105; plus 3 referrers |
Wiles 2008 [20] | Qualitativea
| Physiotherapy referred ERS - 3 schemes | LC | Not stated | South England; N = 9; age range 18–78 years; 1 F 8 M; stroke survivors; plus 15 physios, 6 scheme providers |
Wiles 2007 [61] | |||||
Wormold 2004 [33] | Qualitativeb
| GP referred ERS – 4 schemes | LC | 10 | North Yorkshire; N = 30; Age range 25–84; 20 F 10 M |
Wormold 2006 [34] | Qualitativeb
| Active Lifestyles service including ERS | Varied | 10–12 | Kingston upon Hull; N = 16; Mean age 53; range 15–73; 11 F 5 M; urban deprived; |
Findings from included studies
I. Extrinsic factors
Support
‘I feel that if you were exercising and suddenly something happens, were they around? I didn't notice anyone (Participant). You were worried about harming yourself? (Researcher) Yes that's what it boiled down to’ (Beverly, aged 64) [24].
‘It would be so easy to not bother when on your own’ [44].
....most participants who dropped out of exercise post-completion of referral cited the removal of this Exercise Professional as the primary motivating factor [35].
‘It is nice because you have got a mixture of people you have got some people who are older than me and some who are younger than me, but we have that bit of a repartee between us, you know and we get on the bike and we say "we are off to high town now, come on all on your gears” So we make a laugh of it you see’ [23].
Some said they found it encouraging that the group was made up of friendly participants with similar health conditions, and this is also mentioned as a stimulus for continuing to exercise: 'If she can do it, maybe I can too’ [28].'gym is a lonely place' [26].
Scheme setting and accessibility
‘I felt very uncomfortable every time I entered the gym to the extent I felt like a freak (F/38/460)’ [21].Alison ‘I thought it was probably going to be all, you know, young and beautiful who were all frightfully good at everything’ (2 fg1 122–3). Claire ‘I didn’t know what to expect you know, but I have felt a bit like you that it might be all beautiful young things in their leotards and what not’ [22].
‘The technology totally overwhelmed me’ (Participant 0201). ‘I ruined one machine; I’m just not inclined that way’ (Participant 0205) [35].
Timing and content of sessions
‘…I need to be able to fit it around my work … they need to provide times at the weekends or in the evening.’ (Female, Black, 45–50) [32].
A number of participants referred to exercise sessions as being `boring', often citing the monotony of the programme, or the machines as the root cause [35].
II. Intrinsic factors
Individualisation
‘I don't like particularly just being a number I like the fact that someone was paying attention to me’ (Yvonne, aged 65, at week five of the programme) [24].‘They were interested in dovetailing it to me personally…feel healthier as a result.’ (Male, White, 51–65) [32].
The health and fitness adviser was also aware of possible religious barriers, specifically the need for Muslim women to exercise in a men-free environment, thus respecting male–female dynamics within Islam. In addition, it was important not to hold women only sessions on Fridays (Jumma), the Muslim holy day [19].
Goals and motivation
‘I don't want to be sitting in a wheelchair do I in another ten years. I just want to be active and keep going’ [23].
… ‘I feel totally at one, totally alive and totally happy’ [Mary, 1i3 73] [22].
When recalling ERS participation, interviewees expressed the importance of their own personal qualities to successful recovery and increasing independence, attributing improvements to internal factors such as motivation, willpower and self-determination [29]
'I've started walking to the shops, where I took the car in the past’ [34].
…others expressed concerns that they might struggle to maintain motivation without a commitment to exercise in a set time and place and the loss of social support [27].
III. Framework for successful implementation of exercise referral schemes
Dimensions | LOW implementation (Barriers) | HIGH implementation (Facilitators) |
---|---|---|
Context
Socioecological context of ERS patients (eg personal characteristics, home, work and family) |
Concerns about worsening health problems was a barrier to adherence for some participants
Lack of time as a result of personal commitments to work, family, role as a carer or social demands
Loss of social support after the intervention
Lack of external support from family members, particularly a spouse
Not accommodating cultural/religious requirements : eg, language problem and the inability to communicate effectively with providers |
External support from family members particularly a spouse
Cultural/religious sensitivity such as women-only activities and consideration of religious holy days
Maintaining routine: Making exercise a habit was viewed as important to ongoing physical activity beyond the ERS scheme |
Evidence Could include research evidence, clinical experience, patient experience and local data |
Participant experience
Perceived poor/negative outcomes of ERS included general and mental health, exacerbation of specific health problems, disappointment over failure to lose weight and not benefitting from increased social engagement
Poor perceptions of the intervention atmosphere and environment: Feeling uncomfortable in an ‘intimidating gym environment‘; Dislike of music/tvs in gyms; Difficulties operating gym equipment; Poor quality facilities
Dislike of gym-based exercise due to boredom, preference for being outside |
Participant experience
Perceived improvements: Physical health improvements were the most commonly described; Others included weight-loss and physical activity, mental wellbeing and personal autonomy, social engagement - both during and after the programme
Liking for gym-based activities because of its safe environment and weather independence
Desire for range of different types of physical activities including dance, aerobics, yoga, swimming, or outdoor activities such as walking and cycling
Group activities valued, with participants liking being in the company of like-minded companions rather than solitary exercise |
Facilitation
Factors related to the presence or absence of how the ERS scheme facilitates participation and progress |
Perceived lack of sufficient support and supervision from providers
High cost of exercise facilities, particularly after a subsidised ERS scheme
Inconvenient scheduling eg activity timings clashing with work hours or child care
Lack of ongoing professional support after the ERS
Venue Location Problems: Long distance to travel, difficulties with public transport, perceptions of venue locations not being safe for women |
Support and supervision from providers to help guide safe and efficient exercise, provide equipment, knowledge and motivation
Peer support highly valued, specifically in relation to (i) having a companion/buddy to do the activity with during the scheme; (ii) engagement with others aiding integration and enjoyment
Individualised and personalised service including an exercise programme tailored to user needs, ability, health status, preferences, goals and values
Off-peak scheduling: The gym environmental was perceived to be less intimidating during off-peak hours. However, this was inconvenient for day-time workers
Continuing professional support after the ERS programme was desired and described as a facilitator |
Discussion
Limitations
Conclusion
Theme | Facilitator | Barrier |
---|---|---|
Support | ||
Professional advice and supervision (during and after ERS) | √ | |
Encouragement and support from peers and family or friends | √ | |
Social engagement with other participants | √ | |
Setting/accessibility | ||
Accessible location | √ | |
Good public transport links | √ | |
Loud music/TV in gym | √ | √ |
Gym environment | √ | |
Complex gym equipment | √ | |
Poor quality facilities | √ | |
Cost | √ | |
Timing and content | ||
Variety of exercise options | √ | |
Flexible session times | √ | |
Individualisation | ||
Tailored exercise programmes | √ | |
Lack of cultural awareness and language difficulties | √ | |
Goals and motivation | ||
Perceived benefits in physical and mental health | √ |