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Cohort differences in exercise adherence among primary care patients referred for mental health versus physical health conditions

  • Patrick Tobi (a1), Philip Kemp (a2) and Elena Schmidt (a3)
Abstract Aim

To compare the characteristics of mental health and physical health participants attending an exercise referral scheme (ERS) and investigate associations with their adherence to exercise.


While people referred to an ERS with a mental health diagnosis have similar initial rates of uptake as physical health participants, they are more likely to drop out. Comparisons of the groups to understand their differences and how these might impact on their adherence have been limited by the typically low numbers of mental health referrals in many schemes.


Retrospective analysis of a participant cohort. Data were extracted on all participants enrolled over a 12- month period (n = 701) and included measurements at baseline, mid-point (13 weeks) and end of programme (20-26 weeks). Differences were explored between the mental health (n=141) and physical health (n=560) subcohorts, and between adherers and non-adherers in each group. Binomial logistic regression estimated the effect of group-level factors associated with adherence.


Mental health referrals were more likely to be younger, White and unemployed, and had a lower mean body mass index and lower proportion of participants with high blood pressure. They were also more likely to drop out. While occupation was associated with exercise adherence among the physical health group, no predictive factors were identified in the mental health group.


Participants referred for mental health disorders are more likely to drop out of exercise referral schemes than those with physical health problems. While no factors were found to be predictive of their exercise adherence, an understanding of their distinguishing characteristics and attendance behaviour can guide in making better referral decisions concerning them and planning more appropriately tailored support.

Corresponding author
Correspondence to: Patrick Tobi, Principal Research Fellow, Institute for Health and Human Development, University of East London, Stratford, UK. Email:
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BHF National Centre. 2009: A toolkit for the design, implementation and evaluation of exercise referral schemes. Guidance for referring health professionals, exercise referral professionals and exercise referral scheme commissioners, Draft Consultation Report. Loughborough: Loughborough University, British Heart Foundation National Centre for Physical Activity and Health.
Bhui K., Warfa N., Edonya P., McKenzie K. and Bhugra D. 2007: Cultural competence in mental health care: a review of model evaluations. BMC Health Services Research 7, 15.
Bock B.C., Albrecht A.E., Traficante R.M., Clark M.M., Pinto B.M., Tilkemeier P. and Marcus B.H. 1997: Predictors of exercise adherence following participation in a cardiac rehabilitation program. International Journal of Behavioral Medicine 4, 6075.
Craig R., Mindell J. and Hirani V. 2009: The Health Survey for England 2008: Physical activity and fitness. London: NHS Information Centre for Health and Social Care.
Crone D. and Guy H. 2008: ‘I know it is only exercise, but to me it is something that keeps me going’: a qualitative approach to understanding mental health service users’ experiences of sports therapy. International Journal of Mental Health Nursing 17, 197207.
Crone D., Johnston L.H., Gidlow C., Henley C. and James D.V. 2008: Uptake and participation in physical activity referral schemes in the UK: an investigation of patients referred with mental health problems. Issues in Mental Health Nursing 29, 10881097.
Crone D., Smith A. and Gough B. 2005: ‘I feel totally at one, totally alive and totally happy’: a psycho-social explanation of the physical activity and mental health relationship. Health Education Research 20, 600611.
Department of Health. 2001. Exercise referral systems: a national quality assurance framework. London: Department of Health.
Department of Health. 2011. Start active, stay active: a report on physical activity in the UK. London: Department of Health.
Din N.U., Moore G.F., Murphy S., Wilkinson C. and Williams N.H. 2015: Health professionals’ perspectives on exercise referral and physical activity promotion in primary care: findings from a process evaluation of the National Exercise Referral Scheme in Wales. Health Education Journal 74, 743757.
Directorate of Health Promotion. 2003: Lyme Brook and Newcastle borough council exercise referral pilot; evaluation report. Newcastle: Staffordshire Moorlands, North and South Stoke PCTs.
Dugdill L., Graham R.C. and McNair F. 2005: Exercise referral: the public health panacea for physical activity promotion? A critical perspective of exercise referral schemes; their development and evaluation. Ergonomics 48, 13901410.
Ellis N., Crone D., Davey R. and Grogan S. 2007: Exercise interventions as an adjunct therapy for psychosis: a critical review. British Journal of Clinical Psychology 46, 95111.
Fountain J. and Hicks J. 2010: Delivering race equality in mental health care: report on the findings and outcomes of the community engagement programme 2005–2008. Preston: International School for Communities, Rights and Inclusion (ISCRI), University of Central Lancashire.
Gidlow C., Johnston L.H., Crone D., Morris C., Smith A., Foster C. and James D.V. 2007: Socio-demographic patterning of referral, uptake and attendance in Physical Activity Referral Schemes. Journal of Public Health (Oxford England) 29, 107113.
Greenwich Teaching Primary Care Trust. 2008: Building health into the future: a report on health inequalities in Greenwich, The Annual Report of the Director of Public Health 2008. London: Directorate of Public Health, Greenwich TPCT.
Her Majesty’s Government. 2014. Moving more, living more: the physical activity Olympic and Paralympic legacy for the nation. London: HMG.
James D.V., Johnston L.H., Crone D., Sidford A.H., Gidlow C., Morris C. and Foster C. 2008: Factors associated with physical activity referral uptake and participation. Journal of Sports Sciences 26, 217224.
Ma Y., Olendzki B.C., Li W., Hafner A.R., Chiriboga D., Hebert J.R., Campbell M., Sarnie M. and Ockene I.S. 2006: Seasonal variation in food intake, physical activity, and body weight in a predominantly overweight population. European Journal of Clinical Nutrition 60, 519528.
Marshall S.J. and Biddle S.J. 2001: The transtheoretical model of behavior change: a meta-analysis of applications to physical activity and exercise. Annals of Behavioral Medicine 23, 229246.
McKenna J. and Mutrie N. 2003: Emphasizing quality in qualitative papers. Journal of Sports Science 21, 955958.
Myron R., Street C., Robotham D. and James K. 2009. Moving on up. London: Mental Health Foundation.
National Institute for Health and Clinical Excellence (NICE). 2005: Obesity: guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children. NICE clinical guideline 43. London: NICE.
National Institute for Health and Clinical Excellence (NICE). 2006a: Four commonly used methods to increase physical activity: brief interventions in primary care, exercise referral schemes, pedometers and community-based exercise programmes for walking and cycling. Public Health Intervention Guidance No. 2. London: NICE.
National Institute for Health and Clinical Excellence (NICE). 2006b: Hypertension: management of hypertension in adults in primary care (partial update of NICE clinical guideline 18). NICE clinical guideline 34. London: NICE.
Office of the Deputy Prime Minister. 2004. The English indices of deprivation 2004. London: Stationary Office.
Pavey T., Taylor A., Hillsdon M., Fox K., Campbell J., Foster C., Moxham T., Mutrie N., Searle J. and Taylor R. 2012: Levels and predictors of exercise referral scheme uptake and adherence: a systematic review. Journal of Epidemiology and Community Health 66, 737744.
Peacock J. and Kerry S. 2006. Presenting medical statistics from proposal to publication: a step-by-step guide. Oxford: Oxford University Press.
Richardson C.R., Faulkner G., McDevitt J., Skrinar G.S., Hutchinson D.S. and Piette J.D. 2005: Integrating physical activity into mental health services for persons with serious mental illness. Psychiatric Service 56, 324331.
Scholes S. and Mindell J. 2013: Physical activity in adults. In Craig, R. and Mindell, J. editors, Health Survey for England 2012 Chapter 2, Volume 1. Leeds: Health and Social Care Information Centre, 179.
Seime R.J. and Vickers K.S. 2006: The challenges of treating depression with exercise: from evidence to practice. Clinical Psychology: Science and Practice 13, 194197.
Stathopoulou G., Powers M.B., Berry A.C., Smits J.A.J. and Otto M.W. 2006: Exercise interventions for mental health: a quantitative and qualitative review. Clinical Psychology: Science and Practice 13, 179193.
Thomas J.R., Silverman S. and Nelson J. 2015. Research methods in physical activity, seventh edition. Champaign, IL: Human Kinetics.
Tobi P., Estacio E.V., Renton A., Yu G. and Foster N. 2012: Who stays, who drops out? Biosocial predictors of longer term adherence in participants attending an exercise referral scheme in the UK. BMC Public Health 12, 347.
Tucker P. and Gilliland J. 2007: The effect of season and weather on physical activity: a systematic review. Public Health 121, 909922.
Vandenbroucke J.P., von Elm E., Altman D.G., Gøtzsche P.C., Mulrow C.D., Pocock S.J., Poole C., Schlesselman J.J. and Egger M., for the STROBE Initiative. 2007: Strengthening the Reporting of Observational Studies in Epidemiology (STROBE): explanation and elaboration. PLoS Medicine 4, e297.
Varney J., Brannan M. and Aaltonen G. 2014. Everybody active, every day: an evidence-based approach to physical activity. London: Public Health England.
Williams N.H., Hendry M., France B., Lewis R. and Wilkinson C. 2007: Effectiveness of exercise-referral schemes to promote physical activity in adults: systematic review. British Journal of General Practice 57, 979986.
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Primary Health Care Research & Development
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