Adherence to exercise referral schemes by participants – what do providers and commissioners need to know? A systematic review of barriers and facilitators
Goals and motivation
Studies exploring scheme members’ goals and motivations reported a range of views from which few clear themes emerged. However, a range of perceived improvements in physical health and mental well-being were reported.
Despite the nature of the intervention, increased physical activity was not the main goal for participants when joining a scheme. More common motivations were improved health, reducing existing health problems or avoidance of ill health, as reported in seven [20–24, 27, 39] of the nine studies [20–24, 27, 33, 39, 45] discussing goals. For example,
‘I don’t want to be sitting in a wheelchair do I in another ten years. I just want to be active and keep going’ [23].
Participants tended to focus on having better fitness levels [21, 23, 24, 33], or aimed to lose weight [21, 22, 24, 33]. Social inclusion goals, such as ‘getting out of the house’ or ‘making friends’ were reported in three studies [21, 22, 24].
Motivation was explored in 17 studies [19, 21–28, 32, 34–36, 40, 45, 47, 48] and varied without clear themes emerging other than that participants felt they should exercise [24, 26, 28] and lacked self-motivation [21, 24–26, 32, 48]. Lack of time as a result of personal commitments was identified as a barrier in all four studies [21, 24, 32, 40] exploring the theme. Personal commitments to work, family or social demands made it difficult to find time to exercise. Whether enjoyment of exercise was perceived by participants as a crucial factor for joining or completing ERS programmes is unclear: studies [21, 22, 24, 26, 35] exploring this theme reported that some participants enjoyed the activity itself [21, 22, 24, 26, 35] whereas others, whilst not enjoying the activity, appreciated the associated benefits such as satisfaction in maintaining willpower to achieve their goals [22, 24] or the physical benefits [22, 24, 26, 35]. Eleven studies [21, 23–26, 31, 32, 34, 40, 41, 47] explored health concerns, which were reported as a facilitator for those desiring health improvement [21, 24, 26] but a barrier for those with concerns of injury or exacerbation of a condition [21, 23–26, 32, 41, 47].
Participants in twenty-one studies [21–27, 29, 31–37, 39, 40, 42–44, 50] described outcomes resulting from participating in an ERS. A range of improvements in physical health and mental well-being were reported. The most common improvements were to aspects of physical health (general physical fitness [21–24, 26, 27, 29, 31–35, 40, 42], general health benefits [21–24, 31–34, 36, 37, 39, 40, 42, 44, 50], weight loss or improved tone [21, 23, 24, 26, 27, 32, 34, 42, 50] and increased physical activity [24, 31–35, 40, 43, 50]). Notably, improvements in mental well-being were reported in 14 studies [21–24, 26, 27, 29, 31, 33, 34, 36, 40, 42, 50].
… ‘I feel totally at one, totally alive and totally happy’ [Mary, 1i3 73] [22].
Respondents also described improved social engagement [22, 24, 31, 33, 34, 40, 42, 50] and an increase in personal autonomy [21, 22, 24, 26, 27, 29, 31, 33, 34].
When recalling ERS participation, interviewees expressed the importance of their own personal qualities to successful recovery and increasing independence, attributing improvements to internal factors such as motivation, willpower and self-determination [29]
Five studies [21, 27, 31, 33, 37] noted a perceived poor or negative outcome of ERS. Participants reported negative effects on general health and mental health [21], an exacerbation of specific health problems [37], a disappointment over failure to lose weight [27] and the view that not all could benefit from increased social engagement. Lack of benefit from social engagement was an issue for those with caring commitments or because a gym setting was found less conducive to engagement [31, 33].