Exercise Referral Schemes Evaluation Essay

Introduction

Section:

The benefits of physical activity (PA) for health and well-being are well documented (e.g. Biddle and Mutrie, 2001; Brukner and Brown, 2005; Burns and Murray, 2012; Warburton et al., 2006) and the consequences of physical inactivity and sedentary living have also been addressed from both a health implication and an economic cost perspective (e.g. Department of Health (DH), 2004a, 2009a; Garrett et al., 2004). The Health Survey for England data (HSE, 2003) show that in 2003, only 37 per cent of men and 24 per cent of women met the PA guidelines suggested by the Government at that time (DH, 2005). These levels raised marginally in 2008 to 46 per cent of men and 36 per cent of women meeting the guidelines (HSE, 2008). A subsequent re-analysis of the 2008 data using the most recent PA guidelines indicated that 65–66 per cent of men and 53–56 per cent of women met the revised (DH, 2011) PA guidelines (HSE, 2012). As a result, PA is increasingly being considered the best investment in health and has been included into a series of public health policy publications (DH, 2004a, 2004b, 2005

Participant flow

A total of 2233 referrals were made between July 2009 and October 2010. A total of 19% (n=422) referrals were non-starters. Of these, 409 did not attend a consultation and 13 were excluded after the prescheme consultation. Eighty-one per cent (n=1811) of referrals were admitted to the scheme after the initial assessment (uptake). Of these 46.5% (n=843) dropped out in the first 12 weeks, 53.5% (n=968) attended the 12-week consultation, 10.5% (n=191) dropped out between weeks 13 and 24 and 42.9% (n=777) attended the 24-week consultation.

Baseline data

Table 2 shows personal and referral characteristics of participants. Referrals were predominantly female (59%), with a mean age of 53 years (15.9 SD). The main referrers were general practitioners (58%, n=1278) and the most common reasons for referral were overweight/obesity (42%, n=913) and cardiovascular disease primary/secondary prevention (CVD) (30%, n=649).

Table 2

Descriptive characteristics of referrals

Differences in personal and referral characteristics between non-starters and starters

Descriptive characteristics of referrals can be seen in table 2. There were significant differences in demographics (age t(2231) =−9.60, p<0.001; IMD t(2211) =−5.40, p<0.001; employment status X2=40.43, p<0.001) and in referral characteristics (reason for referral X2=31.2, p<0.001, secondary reason for referral X2=20.8, p<0.001 and leisure site X2=38.0, p<0.001) for starters compared to non-starters.

Characteristics associated with uptake, adherence and completion

A logistic regression analysis was conducted to predict uptake of the ERS using age, gender, IMD quintile, reason for referral, secondary reason for referral, profession of referrer and leisure site as predictors. A test of the full model against a constant only model was statistically significant, indicating that the predictors as a set reliably distinguished between acceptors and decliners of the offer (X2(31) =168.53, p<0.001).

Nagelkerke's R2 of 0.12 and Cox & Snell R2 of 0.08 indicated an adequate relationship between prediction and grouping. Prediction success overall was 81.5% (99.5% for starters and 4.3% for non-starters). The Wald criterion demonstrated that age (35–44 years, B=0.705, SE=0.247, 45–54 years, B=0.657, SE=0.240, 55–64 years, B=1.113, SE=0.249, 65–74 years, B=1.429, SE=0.274, 75+ years, B=2.002, SE=0.421), gender (female B=0.341, SE=0.122), IMD quintile (61–80%, B=0.533, SE=0.215, 81–100% least deprived B=0.348, SE=0.204), secondary reason for referral (metabolic/endocrine B=1.104, SE=0.409) and leisure site (site F, B=0.855, SE=0.304, site H, B=0.925, SE=0.387, site I B=0.664, SE=0.315) made significant contributions to the model.

A second logistic regression analysis was conducted to predict 12-week adherence among starters using the same predictors as in regression one, but with the addition of prescheme BMI. A test of the full model against a constant only model was statistically significant, indicating that the predictors as a set reliably distinguished between dropouts and 12-week adherers (X2(34)=261.82, p<0.001).

Nagelkerke's R2 of 0.19 and Cox & Snell R2 of 0.14 indicated an adequate relationship between prediction and grouping. Prediction success overall was 66.9% (62.1% for dropouts and 70.8% for adherers). The Wald criterion demonstrated that age (55–64 years, B=1.382, SE=0.302, 65–74 years, B=1.734, SE=0.302, 75+ years, B=1.173, SE=0.354), IMD (61–80%, B=0.412, SE=0.195, 81–100% least deprived B=0.671, SE=0.199), profession of referrer (cardiac rehabilitation nurse, B=0.829, SE=0.254), BMI (35+ kg/m2 B=−0.437, SE=0.218) and leisure site (site G, B=−1.393, SE=0.391, site H, B=−1.185, SE=0.341, site I, B=−0.961, SE=0.299) made significant contributions to the model.

The final logistic regression was conducted to predict 24-week completion among 12-week adherers using the same predictors as regression two. A test of the full model against a constant only model was statistically significant, indicating that the predictors as a set reliably distinguished between those who dropped out between 12–24 weeks and completers (X2(34)=159.16, p<0.001).

Nagelkerke's R2 of 0.25 and Cox & Snell R2 of 0.19 indicated an adequate relationship between prediction and grouping. Prediction success overall was 82.2% (24.2% for dropouts and 96.5% for adherers). The Wald criterion demonstrated that BMI (30–34.9 kg/m2 B=−1.164, SE=0.377, 35+ kg/m2 B=−0.921, SE=0.395) and leisure site (site G, B=−1.336, SE=0.377, site H, B=−2.102, SE=0.533, site I, B=−1.709, SE=0.473) made significant contributions to the model (table 3).

Table 3

Binary logistic regression outcomes

Physical activity levels

Self-reported physical activity for those who completed the scheme was measured through the GLTEQ26 prescheme and postscheme. Mean prescheme weekly activity scores were 17.43 units/week (15.82 SD) and postscheme scores were 27.11 units/week (20.46 SD). This equated to 52 min of moderate activity per week prescheme and 81 min postscheme, (a mean increase in moderate activity of 29 min/week). Participants who completed significantly increased their self-reported physical activity levels (t(638)= −11.55, p<0.001).

Attendance at supervised ERS sessions

Mean attendance across sites for dropouts before 12 weeks was 4.28 sessions (5.68 SD), for 12-week adherers was 13.06 sessions (9.2 SD) and for completers was 22.87 sessions (12.47 SD). For completers, this equated to 47.7% of potential attendances (maximum 48), however, there were large variations between sites. Highest mean attendance for completers at a single site (A) was 31.18 (11.87 SD) sessions and the lowest (H) 15.37 (6.69 SD) sessions.

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