Individual differences in needs and responses to NERS
The referral process: motivating patients or identifying motivated patients
Whilst all patients entering NERS had done so following referral from a health professional, approximately half of professionals identified a distinction between patients who sought the programme, and those advised to take part by their health professional. In all such cases, health professional advice was seen as a weaker determinant of adherence than the patient's self-determined decision to seek help.
(8) Even if the doctor has told some clients that they need to go and do some exercise, that's still not enough of a culture shock for them, but the ones that decide, or saw the leaflet in the doctors and had to ask the doctor about it, generally they stick around.
Only one professional described a role for health professional referral as a motivator of change, suggesting the esteemed role of GP may have led patients to act on advice to change.
(5) If they go to their GP and their GP makes them aware of their behaviour, then they think 'oh god this is not my family nagging me now, this is somebody that's medically trained' and it makes them aware of their condition a little bit more.
High levels of drop out in some areas were attributed to failures to identify patients who were sufficiently motivated to benefit from the scheme. Hence, professionals sometimes described a need to focus attentions on patients for whom change was already internally motivated, rather than directing efforts towards motivating patients less ready to change.
(40) The drop out is I think a little bit too high at the moment. But the people that are really motivated coming in, they honestly, their lives have changed so much, it just makes it worthwhile and it is worth doing. If the right people are being referred in.
Most did not explicitly discuss how or at what stage motivation should be identified. One professional however, commented on roles for health professionals and implementers in ensuring that patients' understood the scheme prior to seeking their agreement to refer them through, ensuring that the scheme was offered only to patients interested in taking part.
(37) Quite often I think physios or any other health professional refer us in because they've, for want of a better word, run out of ideas. So they come to us these people, who haven't had the whole thing explained to them, so they're not sure really what's going on. I'm not sure if that means we need to promote it more in the community with more advertising to let people know it's here or whether that's for health professionals to work through.
Demographic patterning in responses to NERS
Following health professional referral, patients' responses to NERS were commonly seen as varying according to their conditions and demographic factors. In particular, professionals commented that whilst benefiting significantly where they did participate, engaging mental health patients in the scheme was often challenging.
(8) People with the mental health issues, if we get them along and keep them coming and keep them interested they see huge benefits but they tend to be the group that drop off.
This was attributed by many to a perceived lack of confidence and additional anxieties about assimilating into the exercise environment among mental health patients. Such anxieties were often also seen as particularly prevalent amongst older patients for whom the environment was more alien, and women or overweight patients, perceived as often particularly self conscious in the exercise environment.
(6) I think people with say like depression, they sort of, they kind of think people are talking about them and stuff like that - that's the sort of feeling I get - I've had one or two actually ask me if so and so was saying something - you know - just a little bit insecure that way. And I mean one or two of the older people, who are retired, they sort of feel that it's a young persons' sort of thing, going to the gym.
However, as most referrals were older women, some professionals commented that younger patients or men sometimes appeared to assimilate less easily into the patient-only classes, benefitting less from social aspects of participation.
(1) I suppose the youngsters that we get through are injuries or depression, do kind of drop off because they probably feel a little bit awkward because of the older people.
When asked whether there was anything about their area that made it harder or easier to implement NERS than it might be elsewhere, more than a third of professionals also identified perceived socioeconomic variations in responses to the scheme. Though one commented that patients in more deprived areas had appeared particularly grateful for the service, most others commented that engaging clients, in terms of both uptake and adherence, had been more difficult in deprived areas. This lower perceived engagement was attributed to factors such as a perceived lower tendency for poorer patients to place value on maintaining health, or a lack of buy in among GPs in more deprived areas.
(6) Its probably one of the hardest valleys to get the GPs to sort of buy into the scheme ... It's an ex-mining valley sort of thing, and it's very negative, it's like 50% unemployment. So they are kind of 'poor me' sort of thing, and they won't do anything to sort of progress themselves, if it doesn't involve say a pub or a restaurant, they're not interested.
Although NERS reduced cost barriers by offering classes at £1, some commented that patients were often not aware of these discounts, whilst others commented that long-term maintenance of attendance after expiry of the discount proved challenging for many.
(37) It's not the most, in terms financially affluent area. So obviously they struggle if anything, they seem to be able to cope with the pound cost for their sessions here, but then the progression afterwards is obviously quite awkward for them. Because once the pound stops if they're not willing to have the £15 for their gym membership, there's very little else to go to that's free.
Facilitating uptake, adherence and long term behavioural change
Promoting uptake through overcoming initial anxieties
Professionals reported that the idea of entering NERS provoked anxiety for many patients, with initial anxieties perceived as stemming from worries about having confidence undermined by the presence of fitter exercisers, fears about assimilating into an unfamiliar social environment or fears of being expected to do exercises they weren't able to do.
(1) They are just worried about what people will think of them, they think the people there, everyone there is going to be fit, in their lycra and looking really smart but so that's the main thing, they just don't know, it's the fear of the unknown, they don't know what we are going to do with them
Hence, for some, development of strategies to overcome anxieties was seen as central to facilitating scheme uptake and adherence, sometimes beginning in the time between referral and entry to the exercise programme. One professional for example commented that during initial telephone contact, advertising the availability of patient-only classes in which fitter mainstream users would not be present had led to good responses, whereas another talked of sending out information packs about what the scheme would entail prior to scheme entry.
(22) They say yes it's quite daunting coming into the leisure centre for the first time, they're not too sure what they are going to be doing ...so we are trying to design a leaflet now which we are going to put out with the card itself saying exactly what they are required to do.
Initial consultations were often cited as an opportunity to reassure patients that professionals would serve as a familiar point of contact, as well as offering assurance that patients would not be expected to do anything that they were not confident about doing or which made them uncomfortable. Highlighting at this stage that the patient would be surrounded by others in the same position was seen as playing a substantial role in assuaging anxieties.
(39) They're very often afraid of the gym so we try and take away those barriers by being beside them in the gym for the first couple of weeks. We explain that we're going to be there and it's going to be a regular familiar face. They're quite reassured to know that whoever else is with us, are in the same position as they are.
Supporting confidence and motivation through education and interpersonal support
Patients were often described as lacking the knowledge of how to exercise safely given their medical conditions, with education crucial in allowing them to become independent exercisers without aggravating existing illnesses or injuries. However, whilst professionals varied in the emphasis they placed on educational or interpersonal support functions of their role, comments regarding a need for education were commonly inseparable from talk of the need to provide interpersonal support for confidence and motivation.
(5) Because of the training we've been through. Knowledge about conditions and what exercise then would suit them. Like I say, all the professionals here are supportive of their client's needs and understanding towards different problems that may occur, maybe anxiety, or confidence, or other problems with illnesses.
Indeed, some commented that instructional aspects became secondary to interpersonal support roles, given the vulnerabilities of the client group.
(19) My role is a motivator and mentor almost and um a support and someone that people can relate to and talk to openly about their situation so, I would say that's the first thing and then you are almost a fitness instructor second. Because the clients are quite vulnerable.
As described above, mental health patients were commonly described as facing particular difficulties assimilating into the exercise environment. Nevertheless, while some commented that this led to lower uptake or adherence, several others described particular successes engaging mental health patients. These professionals argued that additional barriers had been addressed through provision of additional interpersonal support or actively fostering interactions with other patients, with mental health patients then benefiting from improvements in confidence via exercise and socialisation.
(25) Just give them that little bit more support when they come in just chat to them a little bit more and make sure they work in pairs...I find that they are the ones most likely to stick at it more to be honest because they reap the benefits...the first couple of weeks are hard but they're the ones that stick at it
However, though typically speaking positively about the opportunities for training and development within NERS, several professionals identified a perceived need for further training to help them achieve similar successes in engaging these patients in the scheme.
(14) If they are depressed and you have the days you don't feel like coming, you are not going to come. You know again, the mood thing, their barriers as well are harder to break down. So a little bit more training in that area would be useful.
Some spoke of becoming valued components of patients' social networks as they supported them through the programme, with patients often seeking someone they could trust and with whom they could discuss issues affecting their wellbeing which were not always related to exercise.
(27) I had a client this week who I only said 'are you ok' and she started crying to me, so it was clearly nothing to do with the gym, but she felt that she could just talk to us and I suppose let off her emotions so. So yeah, clients look for us to be able to help them, but also I suppose be like a friend you know, be their support network.
However, while most appeared happy to offer this level of support, a minority expressed discomfort with the notion of becoming 'counsellors' to patients, with this seen as distracting from the main aim of promoting activity.
(34) You know listening, it's a good idea to listen but, you know when you've got your clients who want go into too much depth over things, and a bit too personal... it's not what you're here for, I don't think.
Hence, some commented on the need to balance potential benefits of providing the interpersonal support necessary to maintain motivation and confidence, against risks of patients coming to depend on an unsustainable level of support.
(14) Certainly with the older ones, there is a slight dependency trap with them, they do still like to come when you are there. It's quite hard sometimes to get them to exercise on their own.
Indeed, concerns about some patients' inability to maintain adherence without ongoing support had led to widespread tendencies for allowing some patients, particularly those perceived as being most vulnerable, to continue attending NERS classes after they had been officially exited from the programme.
(30) It's just a shame that we have to let them go at 16 weeks. But as I say, they've all got classes to go into and I wouldn't let anyone go who I thought was uncapable of being by themselves, which is why I have kept a few on, and they probably won't ever leave. But that's fine. If I didn't do that I wouldn't be safe in the knowledge that they'd be out by themselves.
Modifying the exercise environment to minimise anxieties throughout the programme
Whilst some described the aforementioned anxieties relating to the exercise environment as arising from preconceptions which dissipated once the professional accompanied patients and allowed them to see that their concerns were unfounded, anxieties were commonly seen as lasting to some degree throughout the programme. Hence, professionals commented on a need to structure classes in a manner which made patients feel at ease. While most areas limited group classes to patients, supervised gym sessions were most commonly held during public opening hours, with professionals therefore describing strategies such as arranging sessions during quiet times, to reduce the number of mainstream exercisers in the gym.
(7) We try to look at trying to get them in during quieter times when the age range is more mixed or more for their age range, as opposed to coming in at peak time when there are a lot of students here working at a lot higher intensity than they would be.
About a quarter of professionals served centre's operating a fully exclusive model, with separate gyms for referred patients, or the main gym closed to the public during NERS sessions; a model seen as highly beneficial in promoting programme adherence.
(3) It is an exclusive gym for that type of client, it tends to make it easier for the person to sort of integrate, and come in on board, whereas in the mainstream gym, they may have pre-conceived ideas about who's going to be in there, how many's going to be in there, what they are going to be doing, so that tends to sort of put them off really.
However, whilst perceived as beneficial in maintaining scheme adherence, some expressed concerns that allowing patients to entirely avoid mainstream exercise environments rather than providing a supported introduction, meant that patients continued to feel intimidated by these environments after the programme.
(1) The negative side is they don't want to go into the main gym, so it's kind of, they're wrapped in cotton wool because they've got their own which is great for the first sixteen weeks, but then we do have to try and push them on slightly, to integrate them in the main gym.
Fostering social networks supportive of long-term change
As described above, exercising with other patients was seen as helping to assuage patients' anxieties about the exercise environment, facilitating social assimilation. All professionals commented on a role for patients in supporting one another's adherence. Some spoke of the empathy patients offered to one another, having been referred for similar reasons and suffering similar limitations, removing the stigma associated with the process of struggling to overcome illness during classes.
(7) It's knowing that they are not on their own really the group tend to motivate themselves, and they will talk about what works for them, if they are having a bad day they will say they're having a bad day, they don't seem to be intimidated, they have got problems, it seems to be quite natural and they are not on their own.
Experiencing the scheme with other patients was seen as providing patients with realistic role models. New patients were able to observe others who had been in the programme longer than them doing things they weren't yet capable of, and could be encouraged to believe that they too were capable of achieving those improvements given time, rather than having their sense of competence thwarted by comparisons with healthier mainstream exercisers.
(40) They realise they're not the only person that's put weight on for example, that feels uncomfortable coming in. That there's several people that come into the gym and they say 'I've had this, I've had that' whereas not everybody wants to say why they're there but they're sort of 'look at me now' and you know 'I'm doing this and I'm doing that' and it sort of helps them to think that they can achieve their goals.
Whilst some saw interpersonal support as emerging spontaneously through group structures, describing a more passive role in facilitating interaction between patients, others saw explicit efforts to foster interaction during exercise classes as key to avoiding the aforementioned 'dependency trap', with emerging social support allowing professionals to gradually reduce support as patients progressed through the programme.
(29) I find that as an instructor they tend to follow you around 'will you be teaching the session'. 'Oh I'll miss that one then and wait for you to come back. You tend to get people like that ... I try and partner them up with a stronger person that I know. It's like putting them with someone in a similar situation that will also give them support.
Many commented that patients often continued to exercise with friends they had made after completing the scheme, although some remarked that loss of social aspects of patient classes were key reasons why some struggled to adhere to exercise in the long term.
(26) They love the people that they're with and they feel comfortable in that surroundings. And they're obviously feeling comfortable with myself. So you know what it's like, they don't like. A lot of people don't like change do they?
Hence, explicit efforts to foster emergence of social networks which lasted beyond the programme were seen by some as crucial in allowing patients to maintain adherence to exercise. Some talked of organising regular social events where current patients could meet one another, or others who had been through the scheme, or of strategies such as exiting patients from the scheme in clusters, and filtering patients into maintenance classes together.
(31) I never finish one on their own, even if it means that I keep them after assessing them another couple of weeks until someone else is exiting the scheme. I always try and buddy them...because we're feeding into maintenance classes, we find that a lot easier because there's the ones who've come off the scheme maybe a month before them there and then you've got maybe four more going in, and so they're really just the same group but at a different timeslot.