Understanding factors that influence uptake to exercise referral schemes: A qualitative study of participant experiences

Background: Physical inactivity has been found to be the fourth leading cause of mortality worldwide. The health benefits of participating in regular physical activity (PA) are well documented. Exercise referral schemes (ERS) promote PA and have been shown to have a positive impact on chronically ill and sedentary individuals, although some individuals do not uptake ERS once referred by a health professional (HP). Understanding barriers and facilitators to these programmes is important if uptake is to be increased and for population health to be enhanced. Due to the minimal qualitative research available of the uptake of ERS, past studies have cited that future research should explore ERS using this type of methodology in order to understand participant experiences. Purpose: To explore participant experiences of referral to an ERS in the Northwest of England to understand the factors that influence uptake, and to understand how Self-Determination Theory (SDT) can explain participants’ decisions whether to uptake, and how these factors relate to the wider Socio-Ecological Model (SEM). Participant experiences will be looked at from the perspectives of ‘uptakers’ (those who go on to start the ERS programme) and ‘DNAs’ (those who do not uptake the ERS programme following their referral). Methods: Individuals referred to the ERS between October and November 2015 were eligible for the study (n=533). A random sample of 140 uptakers and 220 DNAs were invited to take part (DNAs were over-represented to account for the anticipated lower response rate), with the aim of recruiting a sample of approximately 40 participants (20 uptakers, 20 DNAs) to participate in semi-structured interviews, in total 38 interviews were conducted. Interviews explored individuals’ reasons for referral, conversation with their HP and ERS staff and thoughts on improving uptake to the ERS. An inductive thematic analysis was used to explore what factors affect uptake to an ERS, followed by a theoretical analysis, drawing on SDT to understand how this theory can explain participants’ experiences of uptake. Results: The results from this study indicated that factors influencing uptake occur on multiple levels of the SEM (individual, interpersonal and organizational). Participants believed that individual motivation was important to take up the scheme, as was encouragement from the family. Additionally, participants expressed how HP qualities such as empathy, offering choice, especially that within the participant’s capability, coming from their perspective, being given the freedom to make their own decisions as well as actively listening were positive, and were perceived to influence uptake. Lack of control to make personal decisions to uptake as well as organisational barriers such as work commitments were found to be reasons for non-uptake. Conclusion: These results indicate that factors influencing uptake occur across all levels of the SEM. On the individual and interpersonal levels the factors reported by participants were aligned with the tenants of SDT. Participant reports suggested HPs displayed positive autonomy-supportive (eg. coming from patients’ perspective, choice), competence-supportive (eg. offering activities within patients’ capabilities) and relatedness-supportive (eg. actively listening, showing care) behaviours. Whilst it is not known to what extent these interactions with HPs influenced uptake, participant reports suggested positive needs support from HPs facilitated positive decision making. Further quantitative research is needed to understand the relationship between needs support, needs satisfaction and uptake to ERS