Background
The beneficial effects of physical activity for the prevention of a range of chronic diseases are widely acknowledged [
1] and the need to increase public levels of health-enhancing activity underpins key elements of the public health policy in England and Wales [
2]. Physical activity is associated with reduced risk of cardiovascular disease, type 2 diabetes, breast cancer, colon cancer, obesity, [
3] depression [
4] and dementia [
5]. These chronic conditions are most pronounced in economically disadvantaged groups [
6] where physical activity levels are consistently lower [
7].
Economically disadvantaged groups are also less likely to engage with physical activity interventions [
8], and interventions designed to change individual health behaviours are most likely to be taken up by participants who are white, middle class and female[
9]. Even interventions directly targeted at disadvantaged groups are less effective in engaging ethnic minority or low-income populations [
10]. For example, the Walking the way to Health initiative specifically targeted those who took little exercise and/or lived in areas of poor health, yet largely recruited relatively educated and affluent participants [
11]. These reviews reveal that many attempts to improve public health are unlikely to be successful in reducing health inequalities.
The literature relating to participation in physical activity is substantial. Factors that are consistently associated with physical activity behaviour include past exercise behaviours; perceived self-efficacy; social support; self-confidence; access to facilities; physical environment, gender and socio-economic status [
12,
13]. Motivations to engage in physical activity often relate to physical and mental health, weight management and fitness while exercise adherence is more often associated with enjoyment, interest and social interaction [
14,
15]. A number of theoretical models have been studied in an attempt to explain, predict and ultimately change health behaviours. Some link attitudes, normative beliefs, intentions and levels of physical activity (Theories of Reasoned Action and Planned Behaviour) with only limited success, some focus on the stages and processes of change (The Transtheoretical model) [
13,
16,
17]; while others seek to understand the apparent tension between the individual's positive attitudes towards engaging in physical activity and their inclination towards passivity, and the influence of intrinsic and extrinsic motivations (Self Determination Theory) [
18].
There has been limited focus on the physical activity levels of low socioeconomic individuals, a group in the greatest need of change [
12,
13]. Furthermore, much of the existing literature has focused on the mechanisms of successful recruitment into research trials, and has not examined the specific processes of how participants, particularly those in low-income groups, might be effectively recruited into health promotion programmes. Where studies exist, they are often restricted to the difficulties of increasing representation of minorities into research [
19]. The implications of enrolling in research studies which requires dealing with complex paper work including informed consent and data protection statements, and the possibility of being assigned to control groups are quite different. Such recruitment is also affected by factors specific to involvement in trials such as mistrust of research and the medical system, perceived harms of trial participation, the associated time and financial costs and fear [
20] which are not necessarily relevant to recruitment into health promotion interventions. The effectiveness of recruitment and retention strategies affect the success of every field intervention designed to reduce health inequalities, yet the literature available to guide practitioners is therefore limited.
Many community activity programmes are funded but rarely fully evaluated and problems of poor recruitment and retention rates are common [
9]. In order to maximise the health benefits and return on investment of these programmes, and to facilitate their sustainability, recruitment and retention rates need to be increased. To achieve this we need to know which people do and do not attend, their reasons why, and how this information can be used to design successful interventions. In order for effective recruitment strategies to be developed the difficulties of engaging low-income groups in health promotion programmes needs to be fully understood in its broadest sense, rather than as an adjunct to specific individual trials or pilots.
To address the research gaps identified above, this study examined the factors that affect low-income groups' participation in organised physical activity from the perspective of participants, non-participants and activity session leaders in order to understand the barriers and facilitators for both adoption and retention to activity programmes in a high deprivation area in a large city. A mixed methods approach was used to provide an insight that took account of the views of the key stakeholders [
21].
Results
Survey
The survey was piloted and refined prior to being completed by 152 participants at 22 different activity sessions. Participant characteristics are shown in Table
1.
A factor analysis revealed that the 30 items in the MPAM-R measure all loaded above .613 on their hypothesised factors, and alpha scores for each subscale were .88 for interest/enjoyment, .88 for competence, .86 for appearance, .89 for fitness and .84 for social.
Table 1
Characteristics of the survey study population (n152)
Participants reporting postcode (n144) living | 144 | 100 |
Within study area | 69 | 45.4 |
Outside study area | 75 | 49.3 |
Age (n140) | | |
<18 years | 23 | 16.4 |
18-34 years | 20 | 14.3 |
35-54 years | 15 | 10.7 |
55 years + | 82 | 58.6 |
Gender (n144) | | |
Male | 32 | 22.2 |
Female | 112 | 77.8 |
BMI (n121) | | |
Underweight | 6 | 5 |
Normal weight | 60 | 49.6 |
Overweight/obese | 55 | 45.5 |
Ethnicity (n139) | | |
White | 126 | 90.6 |
Black/Afro-Caribbean | 7 | 5 |
Asian | 2 | 1.4 |
Other | 4 | 2.9 |
Associations between factors on the MPAM-R measure are summarised in Table
2. There was a weak positive association between attending with a friend and high scores on the interest/enjoyment (r = .203, p = .019) and the social subscale (r = .191, p = .028). Duration (attendance for greater than 3 months) was positively associated with high scores on the interest/enjoyment (r = .306, p = .000) and the social subscale (r = .201, p = .020), and negatively associated with appearance as a motivator (r = -.241, p = .007).
Table 2
Correlations between motivations to exercise on the MPAM-R scale and attending sessions with a friend and extended duration of attendance (>3 mths)
Interest/Enjoyment | .203* | .306** |
Social | .191* | .201* |
Appearance | .104 | -.241** |
Competence | -.005 | .084 |
Fitness | -.022 | .036 |
There were significant differences between the 55 yrs+ age group and all other age groups on the social subscale (
p = .023,
p = .005,
p = .040) with the older age group more motivated by this factor. There were differences between the two middle age ranges (18-34 yrs and 35-54 yrs) and both the younger (<18 yrs) (
p = .015,
p = .024) and older ranges (55 yrs+) (
p = .001,
p = .006) who were motivated more by interest/enjoyment (Table
3). Strength/flexibility session participants were more motivated by interest/enjoyment than those in aerobic sessions (
p = .016) and dancers more than those in aerobic or sport sessions (
p = .000,
p = .004). Participants in dance and strength/flexibility sessions were more motivated by social interaction than those in aerobics sessions (
p = .012,
p = .013) as were those in strength/flexibility sessions compared to sport (
p = .003). Fitness was a greater motivator for those in aerobics and strength/flexibility sessions compared to those engaged in sports (
p = .000) (
p = .003) Motivation based on appearance was also higher among aerobics participants compared to those engaged in dance or sport (
p = .010) (
p = .001) (Table
4).
Table 3
Motivations for exercise as assessed by the MPAM-R scale by different age group (n148)
Interest/Enjoyment | 5.77 (0.96)a, b
| 4.77 (1.63)a, d
| 4.89 (1.35)b, e
| 5.85 (1.15)d, e
|
Social | 3.93 (1.20)c
| 3.67 (1.50)d
| 3.85 (1.54)e
| 4.80 (1.61)c, d, e
|
Appearance | 4.98 (1.12)c
| 5.04 (1.52)d
| 4.69 (1.10) | 3.99 (1.79)c, d
|
Competence | 5.58 (1.12) | 5.16 (1.56) | 5.46 (1.21) | 5.17 (1.53) |
Fitness | 5.96 (0.82) | 5.87 (1.15) | 6.18 (0.75) | 6.15 (1.29) |
Table 4
Motivations for exercise as assessed by the MPAM-R scale by different activity type (n152)
Interest/Enjoyment | 5.07 (1.50)a, b
| 5.99 (0.83)a
| 6.23 (0.85)b, e
| 5.36 (1.34)e
|
Social | 3.89 (1.77)a, b
| 5.01 (1.41)a, d
| 4.87 (1.53)b
| 4.20 (1.14)d
|
Appearance | 4.95 (1.42)b, c
| 4.58 (1.64) | 4.00 (1.78)b
| 3.78 (1.57)c
|
Competence | 5.30 (1.63) | 5.52 (1.13) | 5.60 (1.12)e
| 4.83 (1.40)e
|
Fitness | 6.32 (0.88)c
| 6.48 (0.67)d
| 5.91 (1.29) | 5.31 (1.50)c, d
|
Interviews
A summary of the characteristics of the participants who took part in the Component 2 interviews is presented in Table
5. All participants lived within the designated economically-disadvantaged area (Southmead, Bristol) and the majority were white, a reflection of the predominant ethnicity of the area. The 14 session leaders in Component 3 interviewed represented 17 of the 29 different types of session available in the area.
Table 5
Characteristics of interview participants (n33)
Male | 1 | 9 |
Female | 11 | 12 |
18-24 yrs | 0 | 3 |
25-34 yrs | 2 | 6 |
35-44 yrs | 5 | 6 |
44-54 yrs | 4 | 5 |
55 yrs + | 1 | 1 |
White/Caucasian | 12 | 19 |
Asian | 0 | 1 |
Black British | 0 | 1 |
Other | 0 | 0 |
Meet exercise recommendations (30 mins a day, 5 times a week) | 0 | 3 |
Yes | 12 | 18 |
No | | |
Table
6 summarizes the key themes from the Component 2 interviews indicating interviewees' attitudes and motivations to exercise; reasons for not participating in organised activity sessions; key enablers that may support them in overcoming these barriers and mechanisms associated with session awareness. The same table shows the key themes from Component 3 interviews i.e. the session leaders' perceptions of the same issues.
Table 6
Key themes from interviews (n = 47)
Attitudes
| | Good awareness of benefits of exercise |
| | Attitudes largely positive but some negative and some feelings of exercise being irrelevant |
Motivations
| weight issues and physical health particularly in older adults | weight issues, physical and mental health, fitness |
| socialising and enjoyment | |
Barriers
| lack of confidence | lack of confidence |
| fear of stepping into an activity session alone | reluctance to attend alone |
| perceived lack of competence | perceived lack of competence |
| Cost | Cost |
| | requirement for and concerns regarding childcare |
| | low priority, issues of time and work patterns |
Enablers
| fun, friendship and socialising | attending with a friend |
| integration of sessions into the community | self confidence |
| | Low cost, good availability |
Awareness
| | good awareness of benefits of exercise |
| | patchy awareness of available sessions |
| power of networking and personal contact as recruitment tool | power of word-of-mouth as a communications channel |
Perceptions of physical activity
Almost all interviewees revealed awareness of the benefits of being physically active. However, there appeared to be no links between this and participation in activity.
'I think it's really, really important to be healthy and active but it's not like the be all and end all ...'(Female, 35-44 yrs)
Some felt that exercise was not something that related to them,
'My partner sort of found out about the gym ... but I've never really thought of anything for me'. (Female, 35-44 yrs)
while others viewed it as a low priority, or not something they enjoyed.
'I'd rather be doing something else. I know that sounds awful ......' (Female, 45-54 yrs)
Many people appeared to have very positive attitudes to exercise,
'I used to do keep fit a couple of years ago. It was great, you feel active, you feel fit'
'I think there's a gym .... I'm going to find out how much it is to join and get back involved' (Male, 25-34 yrs)
and being active did not appear to be out of line with local social norms.
'I don't have any limitations of what I do off family and friends' (Female, 45-54 yrs)
Preferred activities varied from gentle activities for older adults and those with health problems to swimming; different types of dance; the gym and aerobics; with some people interested in more challenging activities such as outward bound or assault courses.
Motivations to exercise
Positive effects on mental well-being were mentioned almost as often as those on physical well-being.
'I want to make sure I'm healthier for my kids, that I don't get ill from my diabetes or anything, if I don't control my weight properly'(Female, 25-34 yrs)
'I get mental illness as well so the gym is very good for me'. (Female, 35-44 yrs)
Some were motivated at least partially by a wish to be 'fit' but in association with good health or being able to keep up with young children.
'Yeah just to get fitter so that I can run around with the kids at football, instead of dying just carrying the water bottles'(Female, 35-44 yrs)
Wanting to lose weight was very closely associated with exercise for women and for some men.
'I was very slim before I had children and didn't see the point in bothering to do it'
'I need to exercise to get rid of some of the weight' (Female, 25-34 yrs)
'Well obviously I started doing that in general to lose weight'(Female, 18-24 yrs)
Overweight for some was related closely to physical health whereas for others it was wholly about appearance.
A large number of people had been active in the past. Cost, change in lifestyle or work patterns, lack of time and enjoyment were the other main factors cited as negatively affecting on-going participation.
'I just couldn't afford it. Every time I thought oh I'll go put some money on my card and then it's like oh no I've got to buy nappies, oh no I've got to do this, oh no the phone bill needs paying'(Female, 18-24 yrs)
'but I get fed up and so I give up.... you go there and it's just boring'(Female, 45-54 yrs)
Session leaders' perceptions of motivations to exercise were slightly different to those of participants. So central was weight as a motivator that some session leaders perceived that not being overweight was a serious disincentive.
'Quite a few of the ones that are really difficult are the ones that aren't quite overweight' (Session leader)
Few local people discussed enjoyment or socialising as motivations to exercise while most of the session leaders believed that both had a substantial impact on participant retention.
'They come for a giggle, for a chat, they come to have fun and keeping fit is almost by the by really' (Session leader)
Barriers to starting activity
Cost is very commonly perceived to be a major barrier to initiating activity,
'I really do enjoy exercise and activity but the only other reason I don't do it is moneywise'. (Female, 35-44 yrs)
and was the most common cause of dropping out of sessions.
'...it was only £17 but Christmas, kids and all that'. (Female, 35-44 yrs)
Not wanting to attend alone was a prominent barrier, particularly amongst women.
'I don't like going places on my own.... I don't like mixing unless I've got someone to talk to'. (Female, 45-54 yrs)
'Wouldn't go on my own' (Female, 35-44 yrs)
'I'd do it. I'd have to have someone go with' (Female, 45-54 yrs)
It was associated with lack of confidence,
'If I was to come on my own I don't think I would because I'm not a very confident person'. (Female, 25-34 yrs)
This was something that was also observed and acknowledged by a number of session leaders.
Childcare was an issue although the cost of a creche and a reluctance to leave children with strangers were also concerns for some.
'I would go to a gym or fitness classes, if I knew if I could get someone to have the children. I would do it, I would' (Female, 25-34 yrs)
'I would feel wary about my little ones with someone I didn't really know' (Female, 25-34 yrs)
Time was a commonly referenced issue particularly relevant to employed men and those with large families. Session times often made them difficult to fit into life and work patterns.
'...so there just aren't enough hours in the day'(Female, 35-44 yrs)
'You get home and tidy up after eight, it leaves not a lot of time left'(Female, 35-44 yrs)
'I haven't got much spare time. I work and we're foster parents'(Male, 35-44 yrs)
Some potential participants felt restricted by health issues. Some were concerned about not being as competent or fit as existing attendees
'you just feel like you're pulling the group down and it's not enjoyable then'. (Female, 35-44 yrs)
'you tell yourself negative things. Oh there's people there who've been training for a while, they're all a lot fitter than you' (Male, 25-34 yrs)
Session leaders' perceptions of barriers to activity largely related to cost issues,
'if ... they're freezing cold and no track suit we ain't going to take a pound off them' (Session initiator)
though some had reservations about free sessions.
'a lot of communities get a lot of free courses and I do wonder about that. You know, the level of commitment'. (Session leader)
Enablers of attending physical activity sessions
As attending alone presents a barrier, attending with a friend enables participation, but almost exclusively amongst females. This was discussed as a pre-requisite of future participation by those who were non-joiners,
'Like walking into a room with a lot of people you usually feel quite nervous. 'Coming along with a friend for support makes it easier' (Female, 45-54 yrs)
and had proven to be an enabler of current participation by those who had joined non-exercise groups.
'It is quite nervy walking in to an established group and thinking am I going to fit in but thankfully my neighbour asked me to come along so...' (Female, 35-44 yrs)
Having the confidence to attend, particularly alone, was more common in males, yet they still were not currently active, so other barriers remained.
'I think in general people like someone with them... myself I don't really care'. (Male, 35-44)
A variety of individuals from the session leader to friends and even professionals appear to be viable supporters of attendance.
'If maybe someone who was running the group came around to see me and said come along then a familiar face...that would be quite nice but...'' (Female, 35-44)
Only a few session leaders mentioned attending with a friend as a potential enabler directly but many of them referred to the appeal of the social aspects of attending.
'a lot of them just enjoy meeting up with their friends, having a laugh' (Session leader)
Awareness of opportunities
Awareness of activity sessions was very patchy. People felt uninformed about what was available locally. The vast majority of participants, joiners and non-joiners, referred to word of mouth as their main source of information.
'everything is word of mouth....it is the biggest thing because you get a review of it then at the same time as hearing about it.' (Female, 25-34 yrs)
Some people read posters in public places and flyers that came through their doors and the internet was well used by some but not others, but it was often not considered to be a source of local information.
'I'd never think of using the internet for something round here' (Female, 18-24 yrs)
Discussion
The purpose of this study was to increase understanding of participation, or non-participation, in physical activity programmes by low income groups, and so to inform design of strategies to increase programme recruitment and retention. This study revealed several barriers, enablers and motivations which are consistent with previous research [
12,
13,
15], but that some of these factors have greater impact on the behaviour of low-income groups than other groups.
The key reported barriers were cost, access to childcare, lack of time and low awareness. Each of these presents practical barriers, but these are simple and straightforward concerns to articulate so it is possible they may mask other barriers to change. It is therefore not clear if engagement would increase if these barriers were addressed. In addition, perceptions lack of social support, and low perceived confidence and competence was widespread, particularly amongst women. Key enablers, largely revealed by those who had been or were currently active, were high levels of social interaction, interest and enjoyment. With the exception of concerns around competence, reported barriers, enablers and motivations to participate in exercise groups were very similar to those expressed by participants who had joined groups not related to exercise. Clearly, the difficulties people experience in joining a group, and barriers to participating in exercise, both need to be addressed, as both would affect recruitment and retention into physical activity sessions.
The UK Coalition government's recent Public Health White Paper targets health inequalities and advocates increasing choice and using a 'nudge' approach to behaviour change [
29]. Amongst the many and varied issues involved in this complex decision-making and behaviour change process there are clearly many barriers to engagement in physical activity a simple positive nudge in terms of availability, information, and choice may not be sufficiently powerful on its own, to tip the balance, particularly for hard-to-reach and health needy populations. Such an approach appears to leave the psychological and social barriers that are particularly relevant in low-income groups unaddressed, and as such may widen health inequalities.
The cost to the individual of organised structured exercise activities has been associated with reduced participation [
30,
31]. Issues of cost have a proportionately greater impact on low-income groups. Where a more affluent individual can reprioritise exercise ahead of other leisure activities this is likely to be more difficult for people with less financial resource who would have to reallocate funds from what for them are more important or essential purchases. The groups in which 'joiners' currently participated were all free or very low cost. While cost presents such a prominent and easily articulated obstacle it is difficult to fully understand to what extent addressing cost issues would positively affect recruitment or whether other barriers would still prevent behaviour change.
Lack of childcare can be a greater barrier where a partner, or close family, may not be present and the cost of childcare is prohibitive, while some 'lack of time' concerns may relate to 'lack of child-free time'.
Social support has been shown to be positively associated with exercise levels [
13] with low confidence and low self-efficacy negatively associated [
14,
15]. Interestingly this study extended these findings to show how a perceived lack of competence, low levels of self-confidence, and a powerful need for a sense of relatedness within a group situation, were often addressed through attending with a friend. This applied to those contemplating initiation and was strongly corroborated by those already attending a non-exercise related group.
Enablers to exercise
Awareness of the health benefits of exercise was high and attitudes to exercising were largely positive. Though these factors do not necessarily lead to behaviour change they provide an important basis for individual change. The current government approach of 'guiding people's choices' may reinforce this awareness but offers little in support for the key step from knowledge to action [
29].
Fun, enjoyment and socializing are commonly quoted motivations to exercise [
14]. Session leaders' perception of participants' motivation supported this while participants who were not currently exercising reported fitness, weight-loss and health-related motivations. This may relate to session leaders observing the enjoyment and sociability occurring in a session, while non-attendees are not currently party to this experience. These different motivations underpinning recruitment and retention have been recognised [
32], with initiation motivations relating to optimistic expectations of future outcomes of taking part while maintenance is more affected by the actual outcomes of the new behaviour [
33]. For example, initial weight and health-related motives appear to quickly change to fun and socialising [
15]. Though the survey provides only weak support for an association between attendance with a friend and long term participation, attendance with a friend is associated with high levels of interest, enjoyment and socialising, which in turn support retention. Interviews with joiners of non-exercise groups also strongly highlighted the positive impact on attendance and adherence of attending with a friend. A further consideration is that many commonly available activities such as aerobics and spin sessions appear to offer lower levels of enjoyment and sociability than dance and sport sessions and this may also have an impact on retention.
Session awareness
There is no central source of information on session availability in the study area but thirty-seven weekly sessions were found to be available, so the perception of a lack of availability can be at least partially attributed to low awareness. Promotion was largely limited to posters, flyers, the local newspaper and word of mouth. Word of mouth was widely quoted as the most common source of knowledge regarding community activities. However, its apparent importance as a communications channel may be partially due to a lack of any effectively implemented alternative promotional strategy.
Theoretical models
Although this research was not grounded in an individual theory of behaviour, it offers several findings that suggest a particular theoretical framework may apply to exercise behaviours in this population. In common with other studies [
13], there was little support shown here for a link between attitudes, normative beliefs, intentions and levels of physical activity, which indicates that theories based on these constructs, such as that of Reasoned Action and Planned Behaviour, would have only partial application in understanding behaviour and underpinning behaviour change in this group [
16,
17]; rather the findings here link more closely with the tenets of Self Determination Theory (SDT). Recently applied in exercise and weight loss settings [
34], SDT seeks to understand the degree to which the health behaviour contributes to satisfying the basic psychological needs of feeling competent, autonomous (in control as an agent of the behaviour) and relatedness or belonging[
18].
Findings from this study support the substantial base of applied research that demonstrates that enjoyment, confidence, competence, intrinsic motivation, and autonomous regulation are consistently correlated with regular participation in physical activity [
35‐
37]. The evidence also clearly supports SDT's premise that an individual's intrinsic motivational tendencies usually require external support to result in maintained behaviour change, and that these tendencies are easily reversed by a non-supportive environment [
38]. In particular, the interviews with non-exercise session participants, clearly indicated the influence of support and a sense of relatedness within a group (attending with a friend, influence of peers) that was required to enable participation. The power of the influences beyond the self is clearly evident.
Implications for recruitment and retention
Many in the target group wee aware that being physically active is beneficial to physical and mental health, and many expressed a positive attitude towards engaging in organised activity, but were not currently doing so. Other issues are clearly at play, and it is these issues that need to be addressed if recruitment, and ultimately retention, rates are to be improved. The key issues revealed by the three components of this study; potential solutions to these issues that were suggested by participants or implied by findings and potential challenges that may need to be addressed if these solutions are to be implemented are all outlined in Table
7 and discussed below.
Table 7
Issues for recruitment and retention from Components 1, 2 and 3
Cost | Low cost/free sessions | Unsustainability. May mask other barriers |
Childcare | Low cost, accessible childcare | Unsustainability. May mask other barriers |
Low confidence | Use of friends/contacts as support. Recruit via pre-existing group, venue or target friendship groups | Difficult to reach more isolated individuals |
Low perceived competence | Provide clearly branded beginners session | Participants will become more competent - may disincentivise those who join later |
Lack of time | Accessible sessions at times to suit the target group | May require provision of activities at a wide range of times |
Enjoyment | Consumer research into, and provision of, preferred activities | May require provision of wide variety of activities |
| Focus on those associated with enjoyment and sociability | |
Session awareness | Investment in good communications strategies | Up front and on-going investment, expertise and commitment required |
Initial health and weight related motivations | Initial recruitment to include appeals to these motivations, sessions to deliver enjoyment and sociability to aid retention | On-going challenge to maintain enjoyment as initial enthusiasm declines - and across a mixed ability group |
Targeted interventions | Research and Segmentation. Low income groups are not amorphous - an understanding of key sub groups is required to underpin effective interventions | Time consuming and expensive |
The impact of addressing issues of cost by offering very low cost sessions, as part of a well-designed intervention, has not been thoroughly tested. Therefore although there are issues about the long-term sustainability of subsidised approaches there is a need for research to examine if such campaigns can work. The need for individuals to shift priorities between exercise and other competing activities and the relatively greater demands on financial resources, requires even more effective strategies to enhance the attractiveness of the benefits that distinguish the desired behaviour from competing activities [
39].
It may be possible, to some extent, to circumvent the very complex issues relating to self-confidence, by attracting the attendance of existing friendship groups. Recruiting from other established groups or at a venue where people have already gathered, such as a children's centre or the school gates, may help eliminate the fear of 'walking in alone' and provide continued support for attendance.
Clearly branded beginners' sessions which require no expertise, experience or fitness, where participants are all starting out together, could go some way to tackling issues of self-efficacy and competence. Practically this may be effective for early joiners of a programme but after a period these 'beginners' may have developed levels of competence which deter new participants.
Session timing should be carefully considered so that competing demands on time are minimised. For example in target groups where full-time employment levels are lower, daytime sessions may be more accessible. Sessions aimed at mothers could follow directly from the school run; an additional journey out of the house is not required and other daily activities are only delayed by the minimum amount of time.
Formative research with the target group, provision of appropriate activities and good availability enable choice so that participants can opt for an activity they will enjoy and can access. However it is important to consider the different motivations involved in initial participation (weight and health issues) and retention (enjoyment and sociability) and ensure each is fully addressed at the appropriate stage.
In low-income populations, where issues of literacy and low reading culture are more likely to be present, properly targeted and well-designed communications strategies specifically addressing these issues, and generating and supporting word of mouth promotion, may be particularly important. Such a communications strategy would require a reasonable start-up and ongoing financial investment.
Noticeably this, and many of the other issues outlined above, could effectively be addressed within the structure of a social marketing approach. Over recent years social marketing techniques have shown promise as a means of improving the development and promotion of health programmes [
40] and are now supported by UK government policy [
41]. The central concept of the 'marketing mix', also defined as the 4 Ps (product, price, place and promotion), focuses on the development of the most appealing product at the right price, delivered at an accessible and appealing place (and time) and effectively promoted, all underpinned by thorough consumer research and effective segmentation [
42]. However although community level social marketing interventions have been developed, implemented and reported these have largely been non-academic studies and have lacked rigorous analysis, evaluation and published results [
43]. It is an approach that appears to have potential in increasing recruitment and retention of low-income groups but further research into its effectiveness at a community level is required.
The evidence presented here suggests that a government strategy designed to go further than 'enabling and guiding people's choices' will be required if low-income groups are to be effectively supported in changing their health behaviours [
29].
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
The study was designed by JW, RJ and KF. Analysis was performed by JW. The first draft of the paper was written by JW and all authors provided critical input and revisions of all further drafts.