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Removing access fees from gyms and leisure centres with a strong marketing campaign and five extra community health trainers gave 26,400 more physical activity “swim and gym” visits per quarter in a borough of 150,000 people.

Re:fresh, a subsidised access scheme implemented in a socially disadvantaged local authority in England, Blackburn and Darwen, also found increases in monthly gym and swim activity from 3 to 15%, and overall levels of participation were more pronounced in disadvantaged socioeconomic groups.

This scheme cost the NHS about £1 million per year in addition to the £3 million funded by the local authority. Whether subsidised access schemes can achieve the same improvements without the support of outreach teams used here remains to be seen.

Why was this study needed?

In the UK, there are large differences in levels of physical activity across social groups; this can lead to inequalities in health outcomes such as rates of heart attack. Physical inactivity is estimated to cost the NHS £455 million a year. A socioeconomic and geographic gradient in physical activity exists with people living in the least prosperous areas twice as likely to be physically inactive as those living in more prosperous areas. The South East of England has the highest proportion of men and women meeting the recommended levels of physical activity. The North West of England has the lowest.

Removing user charges from gyms and leisure centres has been suggested as a way to increase physical activity and promote public health, but like other reasonable ideas might increase inequalities if taken up more by better-off people.

These researchers looked at one such physical activity scheme, re:fresh, introduced in a deprived local authority in the Northwest of England in 2008, could increase overall levels of physical activity and whether any increase in activity levels vary by socioeconomic group.

What did this study do?

The study used local gym and pool attendance data before and after the re:fresh scheme, covering the nine leisure facilities in Blackburn with Darwen (population 147,489) and separate survey data with a sample of 6,160 local people providing data on physical activity.

Five health trainers were employed for one to one and group sessions. They supported behaviour change through goal setting and motivational interviewing. Two community workers also supported a network of volunteers who ran community events to engage people in taster sessions and increase the awareness of the programme and to act as buddies to accompany people to their first activity sessions.

Outcomes included attendance at swimming and gym sessions, self-reported participation in gym and swim activity and any physical activity. The total quarterly number of gym and swim attendance from 2005 to 2014 were calculated, and national sports activity data from the Active People Survey, was used to gather data for the area and compare it to the rest of England (1,556,563 people). Relative change in gym attendances was analysed before and after the re:fresh intervention compared to the rest of England.

The NHS contributed a total of £6 million on top of the core funding for leisure facilities provided by the council over this period (£22 million). The outreach activities cost approximately £2 million over this time.

What did it find?

  • Eleven per cent of gym and swimming attendances were free before the intervention, which increased to 63% after the intervention.
  • Free leisure was associated with a 64% increase in attendances at swimming and gym sessions (relative risk 1.64, 95% confidence interval [CI] 1.43 to 1.89)
  • This 64% increase equates to an additional 26,400 additional swim and gym attendances per quarter over the 2008-2014 period.
  • Free leisure was associated with an additional 3.9% of local people participating in at least 30 minutes of moderate-intensity gym or swim sessions during the previous four weeks (95% CI 3.6 to 4.1).
  • Free leisure was associated with an additional 1.9% of the population participating in any sport or active recreating of at least moderate intensity for at least 30 minutes on at least 12 days out of the last four weeks (95% CI 1.7 to 2.1).
  • The effect on gym and swim activity and overall levels of participation in physical activity was significantly greater for the more disadvantaged socioeconomic group.

What does current guidance say on this issue?

NICE 2013 advises all adults aged 19 or above to be active daily. Over a week 150 minutes of moderate intensity physical activity in bouts of 10 minutes or more is recommended.

Overall the time spent sedentary for extended periods should also be minimised. Older adults who are at risk of falls should also incorporate physical activity to improve balance and coordination on at least two days a week.

What are the implications?

Pressure to save costs might lead to a reduction of public subsidies to leisure facilities. This study provides evidence that expanding free leisure schemes can increase physical activity, particularly in disadvantaged groups. This can potentially address inequalities in physical and mental health.

Re:fresh had free sessions during 90% of its opening hours, allowing for larger inclusion of people who perhaps are on low-incomes and work full time.

It was also supported by local outreach and marketing activities, and it seems sensible to consider these in any attempts to replicate its success.

Citation and Funding

Higgerson J, Halliday E, Orits-Nunez A, et al. Impact of free access to leisure facilities and community outreach on inequalities in physical activity: a quasi-experimental study. J Epidemiol Community Health. 2018;0:1-7

This project was funded by the National Institute for Health Research [School for Public Health Research, and the Public Health Practice Evaluation Scheme] (project reference: SPHR-LIL-PES-LAL).



Health Education England. Health Trainer. London: Health Education England.

NICE. Physical activity: brief advice for adults in primary care. PH44. London: National Institute for Health and Care Excellence; 2013.

PHE. Physical inactivity: economic costs to NHS clinical commissioning groups. London: Public Health England; 2016.

Produced by the University of Southampton and Bazian on behalf of NIHR through the NIHR Dissemination Centre


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The Active People Survey is a cross-sectional telephone survey based on a random sample from each local authority in England selected using Random Digit Dialling. Outreach refers to work delivered by Health Trainers and a Healthy Communities Partnership. Health Trainers offer both one to one and group sessions to inactive people to support behaviour change using goal setting and motivational interviewing. Health Trainers also run community events aimed to engage people in taster sessions and accompany people to their first physical activity sessions.  
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