Active Scotland Outcomes Framework
Outcome 1: We encourage and enable the inactive to be
more active
Summary Evidence Account
This account sets out the key evidence that informs our understanding of:
i. Who the inactive are in Scotland, and;
ii. What works in encouraging the inactive to be more active.
What do we know about inactivity in Scotland?
About a fifth (21%) of Scotland’s adult population were inactive in 2013, no change from
2012. Adults who participate in only 30 minutes or less physical activity per week are
considered to be inactive.1 The trends in the proportion of the population who are inactive
have been stable since 2008. Ten percent of children in Scotland were inactive in 2013, a
slight decrease from 12% in 2012. Children who are active for less than 30 minutes per day
are considered to be inactive.
A quarter of the inactive adults in Scotland are aged over 75 and 42% of the inactive group
are retired. Those with a long term limiting illness or disability make up 62% of the inactive
group.
The majority of inactive children fall into the oldest and youngest age groups. 35% of the
group were made up of those aged 13-15 years, 24% were aged 2-4 years. A higher
proportion of girls are in the inactive group compared to boys (56% vs 44%). 2
We know that the risk of being inactive is not evenly spread across all groups in the
population. Analysis that takes into account the relationships between factors shows that,
in Scotland, the following groups are most at risk of being physically inactive those with a
disability and/or long-standing poor health; older age groups3; women and teenage girls.
Those experiencing socioeconomic disadvantage may also be at risk of inactivity compared
to those more socioeconomically advantaged. However, the evidence for this is less clear
than for the groups above.
In those aged 2-15 years there is no difference in achieving physical activity
recommendations by household income or area deprivation, although there is a difference
in sport participation. A quarter of inactive children are in households in the lowest
equivalised income band compared to 13% in the highest band, but there is no clear pattern
1
About another fifth of the population do some activity, but insufficient amounts to meet the guidelines.
In-house bivariate analysis based on combined Scottish Health Survey data for the years 2008-2012 (five
years data)
3
The risk of being inactive increases in the over 45 age group and is extremely high in the over 75 age group
2
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observed with area deprivation. In adults, economic activity status (largely the inability to
work) is the only remaining socioeconomic factor of importance once a range of
demographic, socioeconomic and health and lifestyle factors have been controlled for.4
It is clear, however, that participation in leisure time physical activity is higher in more socioeconomically advantaged groups. There is, therefore, potential for wider socio-economic
inequalities in physical activity in the future if leisure time physical activity becomes more
important to total physical activity (given, for example, longer term trends of decline in the
manual labour sector and decreasing housework activity due to labour saving devices).
Evidence on why inactive groups are inactive points to a range of factors at individual, social
and environmental levels. Some reasons are common across different inactive groups:
 Lack of time;
 Cost of some leisure activities;
 Lack of interest;
 Lack of awareness of opportunities.
Some deterrents are particular to certain groups. Barriers to activity for disabled people
and those with long standing health problems include a lack of peers to be active with, lack
of appropriately trained professionals and facilities lacking policies related to disability.
For women, barriers to activity include family responsibilities, lack of peers to participate
with and personal safety fears. Literature on teenage girls cites challenges around
increasing body consciousness, a perception of activity as no longer fun and limited choice
of activity.
While these barriers above have been described separately, it is important to note the
complexity of issues that can prevent people at individual and population level from
becoming more active, and that for some groups multiple barriers may be in place.
What do we know about what works to reduce inactivity?
There is a growing evidence base on what works to increase physical activity in the whole
population. It is well understood that to increase population levels of physical activity
action is required on multiple fronts in key settings including schools, transport and the
environment, health care, the workplace and communities. This is the essential message of
the 7 Best Investments for Physical Activity5 accompaniment to the Toronto Charter, on
which Scotland’s Physical Activity Implementation Plan is based.
4
Scottish Government (2014) Physical Activity Topic Report.
http://www.scotland.gov.uk/Publications/2014/11/8722
5
http://64.26.159.200/icpaph/en/documents/GAPA_PAInvestmentsWork_FINAL.pdf
2
In building design, point of decision prompts to encourage people to use the stairs rather
than take a lift have been shown to be effective6. At an environmental level, the following
measures work to enable greater physical activity7:
 Traffic calming;
 Reallocation of roadspace to cyclepaths and wider pavements;
 Safe routes to schools;
 Access to quality greenspace;
 Street design that promotes walking.
For individuals, there is evidence to support counselling and brief interventions in primary
health care settings8, potentially particularly relevant for inactive groups with a disability or
long standing health problem. For example, brief interventions in primary care, i.e. a
consultation session with a clinical professional of less than 30 minutes, with goal-setting
and follow-up, successfully increases physical activity in the short-term and is a costeffective intervention9.
There is also promising effectiveness from motivational interviewing involving at least five
60 minute sessions10. In contrast, the evidence for GP exercise referral schemes is
inconclusive and such interventions are not considered cost-effective, with evidence to
indicate poor participation and compliance rates (for a wide variety of reasons) 11. New
NICE guidelines recommend primary care practitioners should only refer people who are
sedentary or inactive and have existing health conditions to an exercise referral scheme12.
Much of the existing evidence is structured around settings and focussed on what works to
create whole population shifts in activity. The evidence base on what works to increase
activity in the specifically identified inactive groups above is less well developed.
6
Heath GW, Parra DC, Sarmiento OL, Andersen LB, Owen N, Goenka S, Montes F, Brownson RC; Lancet
Physical Activity Series Working Group (2012) Evidence-based intervention in physical activity: lessons from
around the world. Lancet. 380(9838):272-81.
http://www.sciencedirect.com/science/article/pii/S0140673612608162
7
National Institute of Health and Care Excellence. 2008 Physical Activity and the Environment: NICE public
health guidelines 8. . http://www.nice.org.uk/guidance/ph8
8
NICE 2013 Physical Activity: brief advice for adults in primary care. NICE Public Health Guidelines 44.
http://www.nice.org.uk/guidance/ph44
9
NICE (2013). Physical activity: brief advice for adults in primary care (NICE public health guidance 44)
underpinning evidence documents. http://www.nice.org.uk/guidance/ph44/resources/physical-activity-briefadvice-for-adults-in-primary-care-review-of-effectiveness-and-barriers-and-facilitators2
10
Rubak, S., Sandboek, A., Lauitzen, T., & Christensen, B. (2005). Motivational interviewing: a systematic
review and meta-analysis. British Journal of General Practice, April, 305-312.
11
Williams N, Hendry M, France B, Lewis R, Wilkinson C (2007) Effectiveness of exercise-referral schemes to
promote physical activity in adults: systematic review. British Journal of General Practice. VOL:57. pp979-986
12
NICE (2014) Exercise referral schemes to promote physical activity, NICE guidelines [PH54]
http://www.nice.org.uk/guidance/ph54/chapter/1-recommendations
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There are some common themes in the literature on what works at an individual level and
these are also found to be relevant to inactive groups. Evidence suggests successful
interventions:
•
Consult and engage with the target of interventions –. Effective interventions
invariably involved participants in the planning and implementation stages
• Use existing social structures - Interventions that used the existing social structures
of a community, such as schools, workplace or the weekly meetings of older adults,
reduced barriers to implementation.
• Engage with trusted figures or institutions – for example, community leaders in
community and religion related programmes. 13,14
In addition, evidence suggests including a social element is important for inactive groups –
for example, the potential for social interaction was found to be the main motivator for
older people to engage in walking interventions15,16. Similarly, a focus on fun and noncompetitive provision is cited as important in studies of increasing activity in disabled
groups and women and teenage girls17,18.
Flexible options were of particular importance to disabled people and to women. Flexible
options enable participants to take part when they want and pay as they attend, rather than
commit to regular outgoings.
Offering variety, new and appropriate opportunities is cited as effective across different
groups at risk of inactivity. For example, including alternative classes for teenage girls
during core Physical Education (PE), like dance or fitness training19.
There is also evidence indicating that free or subsidised access to opportunities can be
effective for older people, women, teenage girls and those who are socioeconomically
13
WHO (2009) Intervention on diet and physical activity: What works summary report
http://www.who.int/dietphysicalactivity/summary-report-09.pdf?ua=1
14
Public Health England (2014) Identifying what works for local physical inactivity interventions.
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/374560/Whatworksv1_2.pd
f
15
NICE (2012). Walking and cycling: local measures to promote walking and cycling as forms of travel or
recreation. http://www.nice.org.uk/Guidance/PH41/Evidence
16
Public Health England (2014) Identifying what works for local physical inactivity interventions.
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/374560/Whatworksv1_2.pd
f
17
EFDS (2013) Disabled People’s Lifestyle Survey: Understanding disabled people’s lifestyles in relation to
sport. Defining current participation, preferences and engagement to provide more attractive offers in sport.
Report for sportengland.
18
House of Commons; Culture Media and Sport Committee (2014) Women and Sport: First Report of Session
2014–15 (HC 513 [incorporating HC 809, session 2013-14] TSO, London
http://www.publications.parliament.uk/pa/cm201415/cmselect/cmcumeds/513/513.pdf
19
Gorely et al Institute ofYouth Sport (2011) Understanding Psycho-Social Attitudes towards Sport and Activity
in Girls. Final Research Report.
http://www.wsff.org.uk/system/1/assets/files/000/000/489/489/060b82e7f/original/Appendix_I__Final_Research_Report.pdf
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disadvantaged20. These options can include providing subsidised rates, or free of charge
options, or providing flexible ways to pay21.
A fuller evidence review is in draft which reviews in more depth the literature on the four
key inactive groups identified above.
What don’t we know?
As already mentioned, the evidence for settings based interventions is more developed and
robust than on specific groups and a large number of systematic reviews of primary
research, or reviews of reviews, focus on settings. Differential effects of such settings-based
interventions on the identified inactive groups is perhaps less well understood.
Little research was encountered that explored cost-effectiveness of settings based
interventions or sustainability of impacts beyond one year.
What are the implications of the evidence for existing interventions in Scotland?
It is important to note that Scotland is already doing something, at least in some parts and
to some extent, on all the interventions that evidence suggests help improve population
physical activity levels. The room for improvement, therefore, is around the scale and pace
and reach of interventions and the extent to which interventions target inactive groups.
NICE public health guidance cites strong evidence for interventions to make the
environment more enabling of activity. Developing and implementing the actions detailed in
existing plans (especially the Physical Activity Implementation Plan, National Walking
Strategy and Cycling Action Plan for Scotland) should all work to make the natural and built
environment in Scotland more enabling of physical activity. 22
For example, while contained 20mph zones (with traffic calming) have been developed in
certain limited areas across all local authorities in the last ten years, more extensive 20mph
speed limit areas (controlled just by signage) are much less common and there is much
potential for increasing the scale and pace of these initiatives.
More broadly, there is wide variation in the extent to which local authorities have developed
active travel policies. Five out of 32 local authorities have an existing strategy and 11 more
local authorities are expected to have developed one by April 2015.
20
Re:fresh your health and wellbeing year 3 report (2011).
http://www.instituteofhealthequity.org/projects/refresh
21
StreetGames, 2011 - Mobilising young women and girls from disadvantaged communities. StreetGames
research http://www.streetgames.org/www/sgplus/content/mobilising-young-women-and-girlsdisadvantaged-communities
22
There is some evidence that activity in natural environments has greater mental health benefits than activity
in other places like gyms: Mitchell, R. (2013)Is physical activity in natural environments better for mental
health than physical activity in other environments?Social Science and Medicine, 91 . pp. 130-134. ISSN 02779536 (doi:10.1016/j.socscimed.2012.04.012)
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Similarly, while some buildings in the public sector, especially the health sector, have pointof-decision prompts on staircases, evidence would support every building have such signage
– local authority buildings, schools, government buildings, libraries, leisure centres etc
Brief Interventions in primary care settings are also being developed in Scotland. An NHS
Physical Activity Pathway has been developed to aid the delivery of physical activity brief
interventions across the Scottish health care system. A feasibility study assessing the
implementation of the pathway was conducted in 16 primary care settings across Scotland
and its findings are currently under consideration.
Conclusion
If a priority is to focus on inactive groups, then existing interventions could be enhanced to
include more activities that evidence suggests would target and appeal to the inactive and
address barriers that deter inactive groups. This could include, for example, community
sports hubs expanding activities like walking groups for older age groups.
Equally, mainstream provision of leisure services could expand the programmes focussed on
inactive groups. There are many examples of good practice of joint working between local
authority leisure services and health boards aimed at inactive groups. These include, for
example, Lochee Family Splash in Dundee, Good Move in Glasgow, Steady Steps in
Edinburgh, Care about Swimming in Perth and Kinross and others. There is, however, scope
for expansion of these types of approaches.
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