Review
Levels and predictors of exercise referral scheme uptake and adherence: a systematic review Toby Pavey,1,7 Adrian Taylor,2 Melvyn Hillsdon,2 Kenneth Fox,3 John Campbell,1 Charlie Foster,4 Tiffany Moxham,1 Nanette Mutrie,5 John Searle,6 Rod Taylor1 < An additional appendix is
published online only. To view this file please visit the journal online (http://jech.bmj.com/ content/66/8.toc). 1
Peninsula College of Medicine and Dentistry, University of Exeter, Exeter, UK 2 School of Sport and Health Sciences, University of Exeter, Exeter, UK 3 Centre for Exercise, Nutrition and Health Sciences, University of Bristol, Bristol, UK 4 Department of Public Health, University of Oxford, Oxford, UK 5 School of Psychological Sciences and Health, University of Strathclyde, Glasgow, UK 6 Fitness Industry Association, London, UK 7 School of Human Movement Studies, University of Queensland Correspondence to Dr Toby Pavey, School of Human Movement Studies, University of Queensland, St. Lucia Campus, Brisbane, QLD 4072, Australia;
[email protected] Accepted 11 March 2012 Published Online First 6 April 2012
ABSTRACT Background The effectiveness of exercise referral schemes (ERS) is influenced by uptake and adherence to the scheme. The identification of factors influencing low uptake and adherence could lead to the refinement of schemes to optimise investment. Objectives To quantify the levels of ERS uptake and adherence and to identify factors predictive of uptake and adherence. Methods A systematic review and meta-analysis was undertaken. MEDLINE, EMBASE, PsycINFO, Cochrane Library, ISI WOS, SPORTDiscus and ongoing trial registries were searched (to October 2009) and included study references were checked. Included studies were required to report at least one of the following: (1) a numerical measure of ERS uptake or adherence and (2) an estimate of the statistical association between participant demographic or psychosocial factors (eg, level of motivation, self-efficacy) or programme factors and uptake or adherence to ERS. Results Twenty studies met the inclusion criteria, six randomised controlled trials (RCTs) and 14 observational studies. The pooled level of uptake in ERS was 66% (95% CI 57% to 75%) across the observational studies and 81% (95% CI 68% to 94%) across the RCTs. The pooled level of ERS adherence was 49% (95% CI 40% to 59%) across the observational studies and 43% (95% CI 32% to 54%) across the RCTs. Few studies considered anything other than gender and age. Women were more likely to begin an ERS but were less likely to adhere to it than men. Older people were more likely to begin and adhere to an ERS. Limitations Substantial heterogeneity was evident across the ERS studies. Without standardised definitions, the heterogeneity may have been reflective of differences in methods of defining uptake and adherence across studies. Conclusions To enhance our understanding of the variation in uptake and adherence across ERS and how these variations might affect physical activity outcomes, future trials need to use quantitative and qualitative methods.
BACKGROUND Primary care is a key potential setting for the promotion of physical activity.1 One popular primary care-based model of promoting physical activity interventions is the exercise referral scheme (ERS). First established in the early 1990s,2 the number of schemes in the UK has grown to over 600.3 In the context of cardiovascular risk, ERS is characterised by a member of the primary care team identifying and referring a sedentary J Epidemiol Community Health 2012;66:737e744. doi:10.1136/jech-2011-200354
individual with evidence of at least one cardiovascular risk factor to a third-party service (often a sports centre or leisure facility), where the thirdparty service prescribes and monitors an exercise programme tailored to the individual needs of the patient.4 Although beneficial effects of ERS have been shown,5e8 effectiveness is influenced by the proportion of those referred who initially participate in an ERS (‘uptake’) and, of these individuals, how many continue to participate (‘adherence’). A recent UK survey reported a range of uptake across schemes, with 30e98% of referred patients attending the initial exercise referral consultation.3 The same survey identified that scheme ‘completion rates’ ranged from 20% to 90%. In a qualitative review, factors appearing to predict adherence and scheme completion include baseline activity, extent of obesity and increasing age.5 Two previous systematic reviews have considered the issue of uptake and adherence to ERS. Williams concluded that uptake and adherence were low, with 33% of individuals not participating in the scheme and 12e42% completing a 10e12-week period of ERS.7 Gidlow et al9 reported uptake rates of 23e60% with approximately 80% of participants dropping out before the end of the scheme. It may be that those most in need of physical activity advice have the lowest uptake and adherence, and thus ERS schemes could run the risk of increasing health inequalities.10 11 Furthermore, low uptake and adherence have important costeffectiveness implications that may put such schemes at a disadvantage when competing for already scarce resources. The identification of factors influencing low uptake and adherence could lead to the refinement of schemes to optimise investment. It is therefore important to understand the factors that might influence ERS uptake and adherence. The aims of this systematic review were to quantify, for the first time, the levels of ERS uptake and adherence and to identify factors predictive of uptake and adherence. Given the potential bias in terms of sample recruited that a randomised controlled trial (RCT) may introduce, we also aimed to identify differences in uptake and adherence between those recruited into observational studies and RCTs.
METHODS This review was conducted and reported in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement.12 737
Review Search strategy The following electronic databases were searched: MEDLINE InProcess (Ovid) and MEDLINE (Ovid) 1950 to October 2009, EMBASE (Ovid) 1980e2009 week 28, Cochrane Library (Wiley) 2009 Issue 3 (CDSR, DARE, CENTRAL NHS EED and HTA database), SportsDiscus (Ebsco) 1990 to October 2009, ISI Web Of Knowledge 1900 to October 2009, Science Citation Index Expanded (SCI-EXPANDED) 1900 to October 2009, Social Sciences Citation Index 1898 to October 2009. In order to maximise the specificity, an initial scoping search was undertaken to develop ‘exercise referral’ and related synonym terms which were then combined with ‘primary care’ search terms and a controlled trial filter. Studies were also sought by reviewing the bibliographies of included studies and those known to the researchers involved in this study. Limitations were also applied for English language and year of publication (1990 onwards) (see Pavey et al8 for full search strategies).
titles and abstracts. At stage 2, two reviewers (TP and RT or KF or MH or AT) then independently screened the remaining titles and abstracts. At stage 3, full papers of abstracts categorised as potentially eligible for inclusion were then screened in a consensus meeting of at least two reviewers (TP and RT or KF or MH or AT) and disagreements were resolved in real time by consensus.
Data extraction Data were extracted by one reviewer (TP) using a standardised data extraction form and checked by another (RT). Discrepancies were resolved by discussion with involvement of a third reviewer when necessary. Data extracted included: patient level characteristics (eg, age, disease diagnosis); intervention characteristics (eg, duration, location, intensity and mode of the exercise intervention delivered); and reported estimates on the association and mediators of uptake and adherence to ERS.
Inclusion and exclusion criteria
Data analysis and synthesis
Studies were considered eligible for inclusion if they met the following criteria: < Study design: RCTs or observational studies (including nonrandomised controlled and uncontrolled studies). < Population: any individual with or without a medical diagnosis. < Intervention: an ERS was defined as comprising three core components: (1) referral by a primary care healthcare professional to a third-party service provider with the aim of achieving an increase in physical activity or exercise; (2) physical activity/exercise programme tailored to individual needs; and (3) initial assessment and monitoring throughout the programme. The ERS exercise/physical activity programme was required to be more intensive than simple advice and needed to include one or a combination of counseling (face-to-face or via telephone), written materials and supervised exercise training. < Outcomes: outcomes were defined as follows: ‘uptake’ is the proportion of those individuals offered entry to ERS who participate in an initial consultation with a ‘qualified exercise professional’ or participate in a first exercise session; ‘adherence’ is the proportion of those individuals who take up ERS that participate in at least 75% of the programme sessions available. Studies were sought that reported (1) a numerical measure of ERS uptake or adherence and (2) an estimate of the statistical association (eg, correlation or regression coefficient) between participant demographic (eg, age, medical diagnosis), participant psychosocial factors (eg, level of motivation, self-efficacy), programme factors (eg, centre vs home-based delivery, group vs individual sessions, dose of exercise) and uptake or adherence to ERS. We excluded studies not published in a peer review journal (eg, annual reports of ERS programmes), editorials, opinions and studies available only as meeting abstracts; programmes or systems of exercise referral initiated in secondary or tertiary care such as conventional comprehensive cardiac or pulmonary rehabilitation programmes; and exercise programmes where individuals were recruited from primary care but there was no clear statement of referral by a member of the primary care team.
Meta-analysis was used to pool data on the levels of uptake and adherence across studies. Randomised and observational studies were pooled separately. A random effects meta-analysis model was used in order to take into account the clinical and statistical heterogeneity in studies and the various definitions of uptake and adherence across studies. Given the range of methods of reporting predictors of ERS uptake and adherence, it was not possible to quantitatively pool these data across studies. Instead, we categorised findings in each study based on the strength and direction of the association.13 Analyses were conducted using STATA V.11.0.
Study selection process Titles and abstracts were screened in a three-stage process. At stage 1, a single reviewer (TP) initially excluded clearly irrelevant 738
RESULTS Identification and selection of studies A total of 20 studies were included, six RCTs and 14 observational studies. Figure 1 summarises the selection process. In addition, our searches identified a published protocol for a further ERS trial.14 Although not made fully available to us and unpublished at the time of this review, a report of the trial is available as a press release15 and has therefore been included. A list of excluded studies is reported elsewhere.8
Characteristics of included studies The majority of studies were undertaken in the UK (n¼17). Sample sizes ranged widely across studies from 28 to 6610 participants (median 419). Participants in individual studies were predominately middle aged (mean age 51e64 years) and female (57e100%).
ERS uptake and adherence levels Uptake was broadly defined in one of two ways: attendance at the initial consultation with the exercise professional or attendance at $1 exercise session (see appendix in online supplement). The level of uptake in ERS ranged from 28% to 100% across studies. The pooled level of uptake in ERS was 66% (95% CI 57% to 75%) across observational studies and 81% (95% CI 68% to 94%) across RCTs (figure 2). There was evidence of a high level of statistical heterogeneity for observational studies (I2¼99.4%, p
