Exercise referral schemes in the United Kingdom
: initial observations from The National Referral Database

    Student thesis: Doctoral ThesisDoctor of Philosophy


    Exercise referral schemes are a widespread intervention aimed to increase physical activity levels in patients referred with medically diagnosed health conditions or risk factors. However, despite evidence of the benefits of physical activity, the clear evidence of whether exercise referral schemes are an effective approach to increase physical activity behaviour is currently limited.

    The National Referral Database is a newly formed resource for exercise referral specialists to upload patient data including a variety of health and physical activity outcomes for patients, both pre-and post-exercise referral participation. This database contains data from a large cohort of referral patients to schemes across the United Kingdom. Previous research has never reviewed data from such a large cohort across the United Kingdom. This thesis aims to provide initial observations of what may contribute to an effective exercise referral scheme, by examining key schemes’ characteristics, examining whether exercise referral increases physical activity levels, and to review patients’ characteristics as predictors of the likelihood of dropout in a larger sample than previously analysed.

    This thesis provides novel, scientifically relevant research, as it contains one of the first large-scale studies based on exercise referral, with robust methodologies. These studies provide insights to the varied design, delivery, implementation and evaluation of schemes at present. Firstly, before this research was conducted, there was little recent evidence delivering insights into what is currently happening on the ground, in terms of actual delivery approaches used within schemes. The first study aims to provide insights which would bridge this gap in the literature. It was found that schemes were typically 12 weeks in length, offering participants bi-weekly (twice a week), unsupervised exercise sessions in a fitness gym, using a combination of cardiovascular, resistance, free weights and body weight exercises. Evaluation techniques varied, along with various methods used to check the fidelity of schemes.

    Secondly, there was a lack of literature examining the change in physical activity levels of participants upon completion. The second study found that participants did report a statistically significant change in the total physical activity, which was mostly accounted for by increases in moderate-vigorous physical activity. However, participants were classified as moderately active before participation, therefore, participants did not see sufficient changes to move them from the moderately active, to the highly active category.

    Finally, there was a lack of literature examining patients’ characteristics to predict the likelihood of dropout in a large cohort. Results found that the key predictors of dropout included reporting mixed ethnicity, reporting disability as a mental health condition, being a student or permanently sick/disabled, referred by a specialist doctor or pharmacist or referred from a medical centre. Characteristics which reduced the likelihood of dropout included being male, aged 30 years or over, retired, reporting moderate physical activity levels, referred by an exercise specialist or health improvement services, or referred from an outreach service. Some of these results show an agreement with past literature, validating findings in a larger cohort than previously examined, but also provides new evidence of some characteristics which have not been associated with dropout previously. This study provides initial evidence from the national database, which could be used to develop prescriptions of exercise which focus on key patients’ characteristics to avoid dropout.

    The findings from this thesis have identified that there are issues which need to be addressed within the design, delivery, implementation and evaluation of schemes and exercise prescriptions to provide consistent and rigorous evidence for the effectiveness of exercise referral schemes. This thesis also identified that there are issues with national guidelines which at present, are broad; however, without the evidence-base and examples of best practice to enhance guidelines, these national guidelines are potentially ineffective. To clarify, there needs to be a more standardised approach to the implementation of schemes, but allowing for variation in the delivery of individualised exercise prescriptions. Thus, being something that needs further exploration and adaptation within guidelines.
    Date of AwardJun 2020
    Original languageEnglish
    Awarding Institution
    • Coventry University
    SupervisorElizabeth Horton (Supervisor) & Alfonso Jimenez (Supervisor)

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