Exercise Referral Schemes (ERSs) have been implemented across Western nations to stimulate an increase in adult physical activity but evidence of their effectiveness and cost-effectiveness is equivocal. Poor ERS uptake and adherence can have a negative impact on effectiveness and cost-effectiveness and, if patterned by socio-demographic factors, can also introduce or widen health inequalities. Different modes of ERS delivery have the potential to reduce costs and enhance uptake and adherence. This study aimed to examine 1) the effect of delivery mode, in addition to other socio-demographic and programme-related factors, on scheme uptake, adherence, and outcomes, and 2) the impact of delivery mode on expected resource and corresponding costs of delivering core parts of the programme.

This was an observational cohort study with cost analysis. Routine monitoring data covering a three-year period (2020-2022) from one large UK ERS (number of patients=28,917) were analysed. During this period, in response to the Covid-19 pandemic, three different modes of delivery were operated in succession: face-to-face, remote, and modified (all sessions face-to-face, all remote, or a mixture of the two). Multi-level binary and linear regression were performed to examine the effect of mode of delivery and socio-demographic characteristics on uptake, adherence, physical activity, and a range of health outcomes. Cost data were sourced from regional-level coordinators and through NERS audits supplied by national-level NERS programme managers, and summarised using descriptive statistics.


In comparison to face-to-face delivery, the modified group had lower programme uptake and higher adherence, while the remote group had lower levels of adherence. There was a small positive effect on levels of physical activity measured at scheme completion with programme type having no effect on this. There were also small positive effects on all health outcomes examined, with evidence of remote delivery resulting in poorer average effects on heart rate and quality of life in comparison to standard delivery. Being older and coming from an area of lower deprivation increased the likelihood of uptake and adherence, whereas being female increased the chance of uptake but was associated with lower adherence. Patients referred to the programme from secondary care were more likely to take up the programme than those referred from primary care for prevention purposes, however their attendance at exercise sessions was lower. There were small positive effects on all health outcomes examined, with evidence of remote delivery resulting in poorer average improvements in heart rate and quality of life in comparison to standard delivery. Cost per participant for the full 16-week programme was substantially higher when content was delivered virtually than when it was delivered face-to-face.

This study strengthens existing evidence concerning the effect of socio-economic factors on ERS uptake and adherence and contributes new evidence concerning the effect of delivery mode. The findings direct the attention of ERS providers towards specific patient sub-groups who, if inequalities are to be addressed, require additional intervention to support uptake and adherence. At a time when providers may be considering alternative modes of delivery, these findings challenge expectations that implementing virtual delivery will necessarily lead to cost savings.
Original languageEnglish
JournalBMC Public Health
Early online date25 Apr 2023
Publication statusE-pub ahead of print - 25 Apr 2023


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