A mixed methods investigation into the Barriers and Facilitators of Exercise Referral Schemes-implications for enhancing participant experience

Background: Exercise Referral Schemes (ERS) have been used to promote physical activity in individuals who are at risk of, or who have developed, health conditions associated with a sedentary lifestyle. However, participant adherence to ERS has been highlighted as an issue, typically around 50% across published studies. There is limited understanding of what characteristics predict adherence, beyond gender or age, and minimal understanding about why adherence is limited. This thesis utilises a multistage explanatory sequential mixed method design to: investigate adherence, and the predictors of adherence within the South Tyneside ERS (study one); understand what the barriers and facilitators to adherence are, and explore why they are present (study two); use the findings to design and implement an intervention to increase adherence (study three). Study one: A retrospective cohort study (n = 6796) revealed that 50.7% of participants starting the scheme adhered, and the majority of dropout (36.9%) occurred within the first six weeks. Males, older participants, primary care referrals, participants with mental health conditions and nutrition referrals were associated with dropout. Smokers and tier 3 referrals predicted dropout, whereas increasing age, drinking alcohol, being a secondary care referral, or citing a lack of motivation, or a lack of childcare as a barrier to adherence, decreased the likelihood of dropout. Study two: Semi-structured interviews and a focus group were undertaken and analysed using framework analysis. The semi-structured interviews consisted of participants (n =11) aged under 55 years, who dropped out of the ERS within the first six weeks. The focus group included seven males, all aged over 64 years who completed the ERS. The interviews identified barriers to adherence, issues with communication, facilitators, and directions for the future to improve the scheme. Communication appeared to be a significant issue, with limited collaboration between staff and participants, resulting in untailored programmes for participants and consequences which contributed to a negative experience for participants. The focus group identified barriers to adherence that they overcame, facilitators to adherence, what participants felt were keys to success, and suggestions to improve the scheme in the future. Finance, exercising with other gym users and feeling embarrassed were barriers, whereas social contact, staff and being older/retired were viewed as facilitators. Effort, commitment and perseverance were cited among the keys to successful adherence. The interviews and focus group identified a need and request by participants, to have more education and support relating to nutrition and exercise, to facilitate a more autonomous approach to being physically active. Study three: an educational pamphlet containing content informed by study two and the wider evidence base, was designed and developed for the Healthy Lives class, a replacement for the decommissioned ERS. The pamphlet was assessed using a quasi-experimental pilot trial, to assess the potential impact on fitness class attendance and on the patient activation measure (PAM). The acceptability of the pamphlet was assessed using a focus group containing participants that had been issued with the pamphlet. Participants in the intervention group (n = 13) were provided with the pamphlet for ten weeks, while the control group (n = 6) were provided the pamphlet at the study’s conclusion. Recruitment was limited, making interpretation of the findings difficult. PAM scores increased, in both groups, with the intervention group making a greater increase compared to the control group. The focus group participants (n = 9) deemed that the pamphlet, including its design and content, was acceptable for use in the Healthy Lives classes. Conclusion: Adherence to ERS remains problematic, particularly for younger participants. Limited communication appears linked to dropout, and participants desire more education about nutrition and exercise, to support physical activity. Educational pamphlets appear to be appreciated by participants, however their impact on adherence remains unknown