Intended actions, unintended consequences: towards a processual understanding of exercise referral schemes

Whilst the benefits of physical activity have been well documented, many in the UK population remain insufficiently active to substantively benefit their health, placing individuals at greater risk of developing a range of non-communicable diseases and conditions. As a large percentage of the population accesses primary care, at least on an annual basis, the use of this health care sector to advocate increased physical activity has become widespread. Exercise referral schemes (ERSs) have enabled primary care professionals to refer their patients, typically to a local leisure facility, for supervised exercise. ERSs have seen prolific growth across the UK since their conception in the 1990s and yet their effectiveness has remained in question. Despite a variety of research designs being employed, evidence regarding schemes’ effectiveness continues to be inconclusive. Within the existing research literature, the complexity of context within which ERSs operate has remained largely overlooked; specifically, how individual interpretations of ERSs might be co-produced according to the interactions between those central to the service, and how this might influence both service delivery and impact. This study, therefore, aimed to address these lacunae by exploring participants’ understanding of ERSs, and how these perceptions contoured ERS service provision. The research focused on one case-study ERS in the East of England. Semi-structured interviews were employed through a combination of group and one-to-one interviews, with 27 participants (15 patients, 7 exercise practitioners, 5 health professionals) who were central to the ERS at a delivery level, and a further 5 (1 ii district manager, 2 representatives from the County Sports Partnership and 2 representatives from Public Health) one-to-one interviews were conducted with individuals who represented the strategic management of ERSs. A process sociological lens was adopted to provide novel insights into participants’ perceptions of ERSs, their role and their ability to influence ERS service provision. Data were also supported by self-elicited reflections born from the researcher’s ‘insider’ position to the County’s ERS. Thematic analysis generated salient themes that showed conflicting interpretations of ERS service provision, and perceptions of scheme receipt and impact. Data highlighted that the networks of relationships in which individuals were situated not only contoured participant experiences but shaped the delivery processes of ERSs. Individual ‘I’ identities were situated within interdependent networks of ‘we’ and ‘they’ relationships, where identifiable groups were formed according to individuals’ perceived role within the scheme. Relationships between individuals and groups were in a tensile state, marked by power balances that had impacted on service provision but also the associated meaning of ERSs, producing interesting, yet unexpected and unintended outcomes. Such findings could prove useful to policy-makers, those responsible for commissioning ERSs, and practitioners, as well as those in similar roles for other multi-agency interventions. By facilitating enhanced understanding of the complexities of this physical activity intervention, findings suggest how the actions and interpretations of those central to a service can fundamentally alter delivery mechanisms and receipt, potentially influencing the very existence of the intervention, or in this case ERSs