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Combating inactivity with exercise referral

School Of Personal Training Posted Aug 08, 2016 Future Fit Training

PHE and HM Government (HMG) estimate physical inactivity as costing the UK £7.4billion per year, with 24% of people currently less active than in 1961.

Combating inactivity with exercise referral

Physical inactivity is recognised as a serious health problem defined by Public Health England (PHE) as completing under thirty minutes of physical activity per week.

Current evidence suggests that the prevalence of inactivity stands at 1 in 5 in men and 1 in 4 in women. Physical inactivity exhibits as the fourth largest cause of disease and disability in the UK citing coronary heart disease, the primary cause of death globally at 30%, as one of the major risks. In addition, physical inactivity is linked to sedentary behaviour, a behaviour trait in its own right typified by excessive time spent in low energy expenditure positions such as sitting or lying and independently linking to increased mortality levels.

In order to combat physical inactivity, government policies have recently shifted some of the emphasis away from sport and exercise into an umbrella term of “physical activity” binding the three settings to simplify the movement message. Figure 1 (below) demonstrates how these activity types can overlap based on methods of consumption.

Physical Activity
(expenditure of calories, raised heart rate)

Everyday Activity
Active Recreation
  • Active travel (cycling/walking)
  • Heavy housework
  • Gardening
  • DIY
  • Occupational activity (active/manual work)
  • Recreational walking
  • Recreational cycling
  • Active play
  • Dance
  • Sport walking
  • Regular cycling (≥30 min/week)
  • Swimming
  • Exercise & fitness training
  • Structured comptetitive activity
  • Individual pursuits
  • Informal sport

Figure 1: Physical activity framework (DoH, 2011)

The evidence suggests that although each method of activity has certain similarities and differences, the overall theme revolves around bodily movement and energy expenditure above rest. Therefore, the umbrella term of physical activity suggested by DoH and eluded to by the HMG, could be used as the vehicle to explore the impacts on inactivity from physical, psychological and sociological perspectives.

Exercise referral can assist in addressing these perspectives. However, when evaluating current scheme protocols, vital consideration is required to both facilitators and barriers to adherence. In a review of 41 relevant studies relating to exercise referral scheme success, identification of both intrinsic / extrinsic barriers and facilitators became evident (figure 2) with three primary recommendations for future planning made to commissioners.




Professional advice and supervision (during and after ERS)  
Encouragement and support from peers and family or friends  
Social engagement with other participants  ✓  
Accessible location  ✓  
Good public transport links  ✓  
Loud music/TV in gym  ✓  ✓
Gym environment    ✓
Complex gym equipment    ✓
Poor quality facilities    ✓
Cost    ✓
Timing and content    
Variety of exercise options  ✓  
Flexible session times  ✓  
Tailored exercise programmes  ✓  
Lack of cultural awareness and language difficulties    ✓
Goals and motivation    
Perceived benefits in physical mental health  ✓  

Figure 2: Facilitators and barriers to ERS adherence (Morgan et al. 2016)

Social support facilitation was an over-riding recommendation, highlighting that schemes should provide links with family, friends and peers to allow patients to feel comfortable in their behaviour change processes. A second point related to behaviour change, with a need to operate ERS with a certain level of autonomy in relation to the patient activity options. It was shown that a level of self-determination theory input could provide patients with increased likelihood of finding enjoyable activities, alongside similar-abled peers with common interests and possibly backgrounds. Finally, the delivery methods need to be expanded away from traditional ERS gym-based programmes, but incorporate group based sessions in differing settings. Although, it was essential that activity was specific to each patient, the delivery form could be adapted removing the perceived isolation found in the gym-based settings.

Whichever way you utilise ERS as a mechanism to address inactivity, just providing activity options is not enough in itself. Unfortunately, more consideration needs to be given to patient needs to fully utilise the potential of preventive interventions.

Recommended reading:

Aked, J., Marks, N., Cordon, C. and Thompson, S. (2008) Five Ways to Well-being: The Evidence. London: New Economics Foundation

Buckley, J.P., Hedge, A., Yates, T., Copeland, R.J., Loosemore, M., Hamer, M., Bradley, G. and Dunstan, D.W. (2015) The sedentary office: A growing case for change towards better health and productivity. Expert statement commissioned by public health England and the active working community interest company. Br J Sports Med, 0, 1-6

Designed to move (2014) Designed to move: A physical activity agenda

HM Government (2015) Sporting futures: A new strategy for an active nation.London: HMG.

Public Health England (2014) Everybody active, every day: An evidence- based approach to physical activity. PHE publications.

Morgan, F., Battersby, A., Weightman, A., Searchfield, L., Turley, R. Morgan, H., Jagroo, J. and Ellis, S. (2016). Adherence to exercise referral schemes - What do providers and commissioners need to know? A systematic review of barriers and facilitators. BMC public health, 16:227.

Written by Anthony Crozier

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