Approaches to increase physical activity: reviewing the evidence for exercise-referral schemes
Introduction
Physical inactivity is associated with increased cardiovascular disease, hypertension, being overweight and the development of type 2 diabetes.1 In the UK, it is estimated that as much as 37% of coronary heart disease is due to physical inactivity.2 To maintain cardiorespiratory fitness, the Department of Health recommends at least 30 min of moderate-intensity activity on 5 or more days of the week.3 However, approximately 70% of the population of England are not active at this level.4
Despite the significance for public health, effective strategies to encourage people to become more active have yet to be identified. Kahn et al.5 identified three types of intervention to promote physical activity in the community (Fig. 1). Informational approaches aim to increase physical activity by providing information that will motivate people to change their behaviour. These approaches often complement the medical model of disease management, for instance by supporting the management of cardiovascular disease. Behavioural and social approaches are often based on health-promotion models in order to change individual and group behaviour. A third approach aims to increase opportunities for physical activity by providing access to exercise facilities or activities. In the UK, many National Health Service (NHS) primary care organizations have adopted the latter approach. These schemes, often called exercise-referral or exercise-prescription schemes, offer a diverse range of exercise activities and facilities to which clinicians in general practice can refer their patients. This paper reviews current evidence for the effectiveness of exercise-referral schemes.
Section snippets
Methods
The following electronic databases were searched: MEDLINE 1966–2002, Excerpta Medica (EMBASE) 1980–2002 and Cumulative Index of Nursing and Allied Health Literature (CINAHL) 1982–2002. Key words included ‘exercise’, ‘physical fitness’, ‘primary health care’, ‘referral’, ‘prescription’ and ‘physical activity’. Only English language publications were included. Bibliographies of all relevant papers were searched to identify further papers. Studies were reviewed if they met the following criteria:
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Results
Three reviews of exercise interventions were identified. Two papers by Hillsdon and Thorogood7, 8 did not focus specifically on exercise-referral schemes but rather on the promotion of physical activity in the community. A third review by Riddoch et al.9 considered promotion of physical activity in primary care. However, only three studies included in their review met our inclusion criteria. These studies were also identified by our search strategy. In total, 159 studies were identified. One
UK studies
Taylor et al.15 conducted a randomized controlled trial within an existing general-practitioner-referral scheme. A total of 389 patients aged 40–70 years who were smokers, hypertensive or overweight were identified from medical records. Both control and intervention groups received leaflets about the prevention of coronary heart disease. In addition, the intervention group was referred to a local leisure centre for a 10-week period without formal supervision. Physical activity was measured by
Non-UK studies
King et al.17 randomized healthy, sedentary men and women aged 50–65 years in California to receive either group-based or home-based exercise interventions over 12 months. A random-digit telephone survey and advertisements identified 357 predominantly white (89%) individuals of which about 20% were current smokers. Participants were allocated at random into four treatment arms: assessment-only controls, low-intensity home-based exercise (five 30-min sessions/week), high-intensity home-based
Discussion
In general, the UK studies evaluated interventions similar to those currently found in primary care, while the non-UK studies would be difficult to reproduce in a service setting. Recruitment in most non-UK studies was via media advertising or telephone surveys rather than from general practice lists, and potential participants were more likely to be excluded on health grounds (usually cardiovascular). This may have resulted in recruitment of a highly select group of volunteers who were
Conclusion
Exercise-referral schemes appear to increase physical activity levels in certain populations, although the effect may wear off over time. Low recruitment and adherence has important cost-effectiveness implications that may put such schemes at a disadvantage when competing for already scarce NHS resources. However, exercise-referral schemes mainly use existing infrastructure and, when targeted at ‘almost-active’ populations, they may present an important public health opportunity. Nevertheless,
Acknowledgements
I would like to thank Dr Melanie Smith for her comments on successive drafts. Oliver Morgan is funded by the National Health Service London Deanery of Postgraduate Dental and Medical Education.
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