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Effect of exercise referral schemes in primary care on physical activity and improving health outcomes: systematic review and meta-analysis

BMJ 2011; 343 doi: (Published 07 November 2011) Cite this as: BMJ 2011;343:d6462
  1. T G Pavey, associate research fellow1,
  2. A H Taylor, professor of exercise and health psychology2,
  3. K R Fox, professor of exercise and health sciences4,
  4. M Hillsdon, associate professor of exercise and health behaviour2,
  5. N Anokye, research fellow3,
  6. J L Campbell, professor of general practice and primary care1,
  7. C Foster, university research lecturer5,
  8. C Green, associate professor of health economics1,
  9. T Moxham, information specialist1,
  10. N Mutrie, professor of exercise and sport psychology6,
  11. J Searle, chief medical officer7,
  12. P Trueman, professor of health economics3,
  13. R S Taylor, professor of health services research1
  1. 1Peninsula College of Medicine and Dentistry, Universities of Exeter and Plymouth, Exeter EX2 4SG, UK
  2. 2School of Sport and Health Sciences, University of Exeter
  3. 3Health Economics Research Group, Brunel University, Uxbridge, UK
  4. 4Centre for Exercise, Nutrition and Health Sciences, University of Bristol, Bristol, UK
  5. 5Department of Public Health, University of Oxford, Oxford, UK
  6. 6School of Psychological Sciences and Health, University of Strathclyde, Strathclyde, UK
  7. 7Fitness Industry Association, London, UK
  1. Correspondence to: T Pavey toby.pavey{at}
  • Accepted 12 September 2011


Objective To assess the impact of exercise referral schemes on physical activity and health outcomes.

Design Systematic review and meta-analysis.

Data sources Medline, Embase, PsycINFO, Cochrane Library, ISI Web of Science, SPORTDiscus, and ongoing trial registries up to October 2009. We also checked study references.

Study selection Design: randomised controlled trials or non-randomised controlled (cluster or individual) studies published in peer review journals. Population: sedentary individuals with or without medical diagnosis. Exercise referral schemes defined as: clear referrals by primary care professionals to third party service providers to increase physical activity or exercise, physical activity or exercise programmes tailored to individuals, and initial assessment and monitoring throughout programmes. Comparators: usual care, no intervention, or alternative exercise referral schemes.

Results Eight randomised controlled trials met the inclusion criteria, comparing exercise referral schemes with usual care (six trials), alternative physical activity intervention (two), and an exercise referral scheme plus a self determination theory intervention (one). Compared with usual care, follow-up data for exercise referral schemes showed an increased number of participants who achieved 90-150 minutes of physical activity of at least moderate intensity per week (pooled relative risk 1.16, 95% confidence intervals 1.03 to 1.30) and a reduced level of depression (pooled standardised mean difference −0.82, −1.28 to −0.35). Evidence of a between group difference in physical activity of moderate or vigorous intensity or in other health outcomes was inconsistent at follow-up. We did not find any difference in outcomes between exercise referral schemes and the other two comparator groups. None of the included trials separately reported outcomes in individuals with specific medical diagnoses. Substantial heterogeneity in the quality and nature of the exercise referral schemes across studies might have contributed to the inconsistency in outcome findings.

Conclusions Considerable uncertainty remains as to the effectiveness of exercise referral schemes for increasing physical activity, fitness, or health indicators, or whether they are an efficient use of resources for sedentary people with or without a medical diagnosis.


  • Contributors: TGP coordinated the review, with RST (guarantor) and AT as principal investigators. TM developed the search strategy, in consultation with TGP, RST, AHT, KRF, and MH, and undertook the searches. TGP, RST, AHT, KRF, and MH screened abstracts and full papers against the inclusion criteria. TGP appraised the quality of the papers and abstracted data from them. TGP and RST analysed the data and drafted the review. All authors, including the Project Advisory Group (NA, JLC, CF, CG, NM, JS, PT) provided input to interpretation of findings, commented on various drafts of the chapters, and contributed to their editing.

  • Funding: This project was funded by the National Institute for Health Research Health Technology Assessment (NIHR HTA) programme (project number 08/72/01) (

  • Competing interests: All authors have completed the Unified Competing Interest form at (available on request from the corresponding author) and declare: TGP, AHT, KRF, MH, PT, and RST have support from NIHR HTA for the submitted work; JS is chief medical officer of the Fitness Industry Association, which meets his receipted expenses, but the post attracts neither a salary nor fees; no non-financial interests that may be relevant to the submitted work.

  • Ethical approval: not required.

  • Data sharing: no additional data available.

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