“Better to hunt in fields, for health unbought, than fee the doctor for a nauseous draught. The wise, for cure, on exercise depend; God never made his work, for man to mend.” John Dryden (1631–1700)

Despite accumulating evidence for the health benefits of regular physical activity, the adult population is mainly sedentary. The World Health Organization has estimated that inactivity causes 22% of ischaemic heart disease worldwide.1 In England and Wales only 29% of adults achieve recommended levels of physical activity for the prevention of cardiovascular disease.2 3 This recommended level is at least 30 minutes of moderate intensity aerobic physical activity (defined as expending 5.0–7.5 Kcal/min of energy) on at least 5 days of the week.4 One way to address this public health problem is by involving primary care.

THE IMPORTANCE OF THE PRIMARY CARE SETTING

Primary care is in a good position to promote increased physical activity for a number of reasons. Health promotion is an integral part of the primary care consultation.5 In the UK a large proportion of patients registered with a general practitioner (GP) consult every year,6 which presents an opportunity for promoting physical activity to a large proportion of the population across: age groups, gender, ethnic identities, socioeconomic groups and differing states of physical and mental health. Indeed, patients with chronic disease such as diabetes, ischaemic heart disease, asthma or chronic obstructive pulmonary disease, or with important risk factors such as hypertension, are invited to attend for regular review appointments, which could include physical activity promotion. A simple screening questionnaire has been developed to record physical activity level during primary care consultations (GP-PAQ).7 The quality and outcomes framework,8 which is part of GPs’ contract in the UK has been used to standardise care in these chronic disease groups and could be used to direct clinicians’ management towards effective physical activity interventions.

However, a variety of barriers exists to primary care clinicians. Evidence for effective interventions is lacking and it is not certain that this is a good use of busy clinicians’ time. Clinicians may have a moral objection to giving such lifestyle advice, as it could be seen as a further example of the increasing medicalisation of life.9 They may also restrict their advice to those patients that they perceive to be more receptive. Whether they exercise regularly and have positive attitudes towards physical activity themselves will influence the advice they give.10 Also, primary care clinicians will vary in their confidence in their counselling skills, and they are less likely to advise about physical activity than other health behaviours such as smoking and diet.11 In particular, they may be uncertain about the type, frequency, duration and intensity of exercise to advise in different patient groups, and may be concerned about the possibility of introducing exercise-related morbidity and even mortality.12

INTERVENTIONS FOR PROMOTING PHYSICAL ACTIVITY

A systematic review of randomised controlled trials (RCT), comparing different interventions to encourage sedentary adults not living in an institution to become physically active, found that such interventions had a moderate effect on self-reported physical activity and cardiorespiratory fitness in the short to medium term.13 The pooled standardised mean difference was 0.31 for physical activity and 0.4 for cardiorespiratory fitness. The combined odds ratio for achieving a predetermined threshold of physical activity was not statistically significant. As a result of clinical and statistical heterogeneity only limited conclusions could be drawn about the effectiveness of individual components of the interventions. These included: individual or group counselling and advice; self-directed or prescribed physical activity that was supervised or unsupervised, based at home or in a healthcare or leisure facility. Physical activity could be supported by face-to-face or telephone contact, written educational or motivational material, or by self-monitoring. The interventions were delivered by doctors, nurses, health educators, counsellors, exercise professionals or peers. There were also limitations to the external validity of many of the studies, as they recruited volunteers who responded to newspaper advertisements, or underwent screening before randomisation, which would have selected more motivated participants than those commonly consulting in primary care. What about the effectiveness of interventions that are available to primary care clinicians? These can be broadly separated into two groups: advice or counselling and exercise referral.

EXERCISE ADVICE OR COUNSELLING

The distinction between advice giving and counselling is blurred in practice, but counselling is usually longer, more structured, more patient centred and based on theories of behaviour change.14 15 A good example of exercise counselling in primary care is the physician-based assessment and counselling for exercise (PACE) programme in the USA.16 A review17 of four systematic reviews of primary care physical activity promotion18^–21 reported that brief advice from a GP, supported by written materials, resulted in a modest short-term effect on physical activity, lasting 6–12 months. The most effective interventions were those that focused on promoting physical activity, rather than general lifestyle advice, and encouraged moderate intensity physical activity such as walking.18^–21 One of these reviews also reported that brief counselling lasting 3–10 minutes was as effective as more lengthy counselling. Also, tailoring interventions to patient characteristics such as readiness to exercise, baseline levels of physical activity, or physical activity preferences resulted in greater short-term improvements. However, there was no evidence that interventions based on the theories of behaviour change were more effective than those that were not.20

A recent RCT that was published after these reviews compared tailored advice and information on physical activity, with either supervised exercise classes, or instructor-led walking programmes. Although the advice intervention was marginally less effective, it was cheaper and therefore more cost-effective than the supervised interventions.22

EXERCISE REFERRAL SCHEMES

In the UK, exercise referral schemes have been introduced to encourage exercise participation in sedentary adults, particularly those with chronic ill health. They can be defined as referral by a primary care clinician to a programme that encourages increased physical activity or exercise, involving an initial assessment, a programme tailored to individual need, as well as monitoring and supervision throughout the programme. Two methods of referral have been used. Eligible patients were either referred during routine consultation, or in a case-finding approach following a search of the primary care medical record database. There has been a proliferation of such schemes involving supervised exercise sessions, which mainly take place in public leisure facilities such as leisure centres or swimming pools,23 but also involve activities such as cycling, gardening or walking.24 A national quality assurance framework for exercise referral schemes has been published.25

Provision of exercise referral schemes in Wales

A survey of exercise referral schemes in 2006 found that a range of local schemes was available throughout Wales. These were mainly based in local authority leisure centres and swimming pools, but also involved walking for health groups and green gyms, which are programmes that combine exercise with environmental conservation work (Hendry MA, et al. Survey focusing on exercise referral schemes. Unpublished report for the Welsh Assembly Government, 2006). They all accepted referral from GPs and usually from other health professionals; only a minority allowed clients to refer themselves. There was a large variation in the number of patients seen and the proportion that completed a course, which typically lasted between 10 and 16 weeks. A variety of incentives was available to encourage continuation after completing this first course, such as discounted follow-up sessions. All schemes accepted patients with coronary heart disease risk factors; most schemes accepted patients with minor mental health problems, lifestyle factors, asthma, diabetes and musculoskeletal problems; few schemes offered cardiac rehabilitation. Since 2007 the Welsh Assembly Government has established a national exercise referral scheme, which is being rolled out throughout Wales in three phases.26

Systematic review of exercise referral schemes

In preparation for an evaluation of this national exercise referral scheme, we completed a systematic review of exercise referral schemes.27 Six randomised controlled trials, all from the UK, were identified. Three compared gym-based exercise referral schemes in leisure centres lasting 10–12 weeks with an information sheet; one compared exercise classes in church halls or community centres with no intervention; one compared a walking scheme with exercise advice; another compared a gym-based exercise referral scheme with a walking scheme or with advice.

The results from five of these RCT were combined in a meta-analysis and there was a statistically significant increase in the numbers of sedentary people becoming moderately active (combined risk ratio of 1.20). However, the absolute risk reduction was moderate, with 17 sedentary people needing to be referred for one to become moderately active. There was no statistically significant improvement in anthropometric, physiological or biochemical outcomes, apart from skin-fold thickness. Motivation to exercise improved more quickly in the exercise group in the first 6 months in two RCT, but in one RCT that measured the level of motivation in the longer term, by 12 months the control group had caught up. The small effect of the exercise interventions could at least partly be explained by poor rates of uptake and adherence to the schemes. Poor rates of attendance had also been found in a previous systematic review.28

Only one RCT incorporated a thorough health economic evaluation, which reported that the exercise intervention was more costly and only marginally more effective than advice alone and was probably not an efficient use of resources.22 However, in this RCT the control group received tailored advice about physical activity, and there was a degree of contamination, with 24% of controls participating in the walking programme and 32% attending gym sessions.

Four observational studies reported in the review by Williams et al27 found a variable effect on long-term physical activity levels. Greater expectation of exercise outcome, not smoking, and convenient location of the exercise scheme predicted long-term participation in one of these. Six process evaluations provided data on typical exercise schemes that were not influenced by any controlled study and found that uptake was low, with only one third of referred patients participating and only 12–42% completing a 12-week programme.

Qualitative studies reported in the review by Williams et al27 gave participants’ views about the exercise schemes and reasons for adherence or non-adherence. Satisfaction was largely attributable to the professional, supportive and friendly service provided by the staff. Dissatisfaction related to inconvenient opening hours, congested facilities, lack of staff, intimidating gym environment, narrow range of activities and limited social interaction. Reasons for non-adherence included lack of self-efficacy, poor body image, poor scheme organisation, poor personal organisation, poor social support, feeling uncomfortable in the gym environment and lack of motivational skills in the leisure centre staff.

These findings were in concordance with the public intervention guidance from the National Institute for Health and Clinical Excellence, which stated that exercise referral schemes should only be recommended if they are part of a properly designed and controlled research study.29 The challenge for future exercise schemes is to increase uptake and improve adherence by addressing the barriers identified in the qualitative studies, incorporating psychological theories of behaviour change, and tailoring the intensity and variety of the exercise programmes on offer to match individuals’ preferences.

Evaluation of the national exercise referral scheme in Wales

As stated previously a national exercise referral scheme is being rolled out throughout Wales. In accordance with National Institute for Health and Clinical Excellence guidance the effectiveness of the scheme is being evaluated in a pragmatic RCT.30 Participants will be invited to participate during routine primary care consultations with their GP or practice nurse. Those referred with coronary heart disease risk factors or minor mental health complaints such as anxiety or depression will be invited to participate in the trial. Trial participants (n  =  ∼2400) will be randomly assigned to either immediate access to the exercise referral scheme, which lasts for 16 weeks, or an exercise advice booklet with an option to access the scheme in 12 months’ time. The precise content and running of the scheme will be assessed with a concurrent process evaluation. Outcomes will include measures of physical activity level, health-related quality of life, mental health and motivation to exercise. The final outcome measurement will be at 12 months. A concurrent health economic evaluation will compare the cost-effectiveness of the two interventions by measuring health utility and costs, including the cost of the exercise programme and costs to the health service.

The future funding of exercise referral schemes in Wales will depend upon the results of this evaluation. It remains to be seen whether these schemes provide the wisdom for the cure.