Physical activity equals positive effects
1. Introduction
It is well known that physical activity, performed on a regular basis, is associated with significant positive physical and mental effects.
Physical activity plays an important role in the prevention of various chronic diseases, such as cardiovascular disease, ischemic stroke, hypertension, obesity, diabetes mellitus, osteoporosis, colon cancers and fall-related injuries.
The English Chief Medical Officer (CMO) advises that adults should undertake at least 30 minutes of ‘moderate intensity’ (5.0- 7.5 kcal/min) physical activity on at least 5 days of the week to benefit their health.
However, in England the prevalence of physical activity at recommended levels is low. Recent data (2005) show that only 37% of men and 25% of women meet the CMO’s physical activity recommendation.
It is clear that despite these well-known benefits of regular physical activity, sedentary or inactive lifestyle remains a common problem.
To emphasise, at least 60% of the world’s population does not meet the recommended levels of physical activity required to induce health benefits.
In addition, it has been shown that physical inactivity and over-nutrition are associated with a substantial economic burden.
These figures contribute significantly to the World Health Organization data which suggests that globally there are more than one billion overweight and at least 400 million obese adults.
Promotion of physical activity behaviour has therefore become an important objective for the promotion of health and crucial in the prevention of the increasing burden of chronic diseases.
There is a plethora of physical activity interventions in existence and yet there remains little strong evidence as to ‘what works’, particularly in terms of sustainable physical activity behaviour.
Therefore the purpose of this review is to provide a summary of the effectiveness of interventions for physical activity promotion in adults.
This is to enable Durham CSP’s to make informed choices about the provision and promotion of physical activity amongst the communities they serve.
Review of physical activity interventions
2. Method
A synthesis of published work was conducted using a systematic search strategy.
The search strategy employed two main sources to locate published studies of physical activity interventions and given the timescales for this review included meta-analyses and existing qualitative and quantitative systematic reviews of physical activity interventions.
1) Electronic searches of computerised databases (SPORTdiscus, PsychINFO, Medline, Scopus, Highwire Press and PubMed);
2) Citations in papers identified by the electronic searches.
Keyword combinations for the electronic database searches included: physical activity/exercise, physical inactivity, obesity/overweight, treatment, intervention, weight loss/reduction program, promotion, adult and healthy lifestyle program.
The summary report therefore accounts for the evidence detailed in previous reviews in it’s narrative.
2.1Review Process
Searchers yielded 6627 studies of which 904 were reviews.
Importantly, searchers revealed three previously relevant systematic reviews of physical intervention data up to and including 2004 (foster et al., 2005, Hillsdon et al., 2005 and Cavill et al., 2006).
Studies were then evaluated on the basis of abstract and title for suitability based on suitability to review topic and/or intervention design.
As a result 484 studies were identified. The studies were then scrutinised further using the following exclusion criteria, reducing the number to 75 of the most relevant:
primary aim of the study not focused on physical activity promotion
age groups of participants under 16
non-healthy population
non-English language
It was been beyond the scope of this review to provide details of the individual nature of studies.
Instead interventions have been categorised by more general intervention characteristics and where possible salient references to individual interventions have been made.
This report attempts to provide the most up-to-date recommendations regarding future directions of physical activity promotion where at all possible.
The information presented here is supported by a catalogue of pdf’s containing references to all pertinent studies within this review and reviews of a similar nature.
The following summary report outlines the main findings from the review process.
Review of physical activity interventions
3. Evidence for physical activity promotion
3.1 Types of intervention
The evidence for the promotion of physical activity in adults is multi-faceted and varies in terms of quality and intervention design.
Despite the literature growing exponentially there is still a limited resource of high quality effective interventions to promote physical activity.
Generally interventions can be categorised into thee main areas: A brief description of each can be found below with more detailed descriptions including comments on the effectiveness in table 3.1:
3.1.1 Informational approaches
Informational approaches are designed to increase physical activity by providing information necessary to motivate and enable people to change their behaviour, as well as to maintain that change over time.
The interventions use primarily educational approaches to present both general health information, including information about cardiovascular disease prevention and risk reduction, as well as specific information about physical activity and exercise.
Informational approaches aim to:
§ Change knowledge about physical activity benefits
§ Increase awareness of how to increase physical activity in the community
§ Explain how to overcome barriers and negative attitudes about physical activity
§ Increase taking part in community-based activities
3.1.2 Behavioural and social approaches
Behavioural and social approaches focus on increasing physical activity by teaching widely applicable behavioural management skills and by structuring the social environment to provide support for people trying to initiate or maintain behaviour change.
Interventions often involve individual or group behavioural counselling and typically include the friends or family members that constitute an individual’s social environment.
Skills focus on recognising cues and opportunities for physical activity, ways to manage high-risk situations, and ways to maintain behaviour and prevent relapse.
Interventions also involve making changes in the home, family, school, and work environments.
3.1.3 Environmental and policy approaches
Environmental and policy approaches are designed to provide environmental opportunities, support, and cues to help people develop healthier behaviours.
The creation of healthful physical and organisational environments is attempted through development of policy that lends itself to creating supportive environments and strengthening community action.
To affect entire populations, interventions in this category are not directed to individuals but rather to physical and organisational structures.
The goal is to increase physical activity through changing social networks, organisational norms and policies, the physical environment, resources and facilities, and laws.
Review of physical activity interventions
Table 3.1 – Table of types of Physical Activity Interventions (adapted from Kahn et al., 2002)
Intervention typeBrief description of interventionComments on effectiveness
Informational approachesto increasing physical activity
Point of decision prompts
Signs placed by lifts and escalators to motivate people to use nearby stairs.
Messages on the signs recommend stair use for health benefits or weight loss.
Signs are thought to be effective in one of two ways: by reminding people already predisposed to becoming more active, for health or other reasons, about an opportunity at hand to be more active or by informing them of a health benefit from taking the stairs
There is some evidence to suggest that point-of-decision prompts are effective in increasing levels of physical activity in the short term.
This is taken as a measurement of increase in the percentage of people choosing to take the stairs rather than a lift or escalator.
There is no long-term evidence for this approach.
Customising the sign to appeal to specific populations may increase intervention effectiveness
Community-wide campaigns
Community-wide campaigns involve many community sectors in highly visible, broad-based, multiple intervention approaches to increasing physical activity.
Campaign messages are generally directed to large and relatively undifferentiated audiences through diverse media, including television, radio, newspaper columns and inserts, direct mailings, billboards, advertisements in transit outlets, and trailers in movie theatres.
Messages are often communicated in the form of paid advertisements, donated public service announcements, press releases, the creation of feature items, or a combination of two or more of these approaches.
Over the short-term this type of intervention is likely to be effective across diverse settings and population groups.
Effectiveness is enhanced when community members are involved in developing their own ongoing local initiatives (such as walking groups, small community events and sports teams).
Community-wide campaigns require careful planning and coordination, well-trained staff, and sufficient resources to carry out the campaign as planned.
Success is greatly enhanced by community buy-in, which can take a great deal of time and effort to achieve.
Inadequate resources and lack of professionally trained staff may affect how completely and appropriately interventions are implemented.
Community-wide education campaigns may also produce other benefits that can improve health and build social capital in communities i.e. a greater sense of cohesion and collective self-efficacy.
Social networks may also be developed or strengthened to achieve intervention goals, and community members may become involved in local government and civic organisations, thereby increasing social capital.
Mass Media Campaigns
Mass media campaigns are interventions that address messages about physical activity to large and relatively undifferentiated audiences.
The campaigns are designed to increase knowledge, influence attitudes and beliefs, and change behaviour.
Messages are transmitted by using channels such as newspapers, radio, television, and billboards singly or in combination.
Mass media strategies have been found to result in increased knowledge and motivation but have little sustained effect on physical activity participation unless they are combined with other community based strategies.
Mass media campaigns might play important roles in changing awareness of opportunities for and benefits of activity.
Can be used to build support for environmental and policy changes that improve physical activity behaviour and fitness, or both.
Behavioural and social approaches to increasing physical activity
Family-based social support
Family-based interventions attempt to change health behaviour through the use of techniques that increase the support of family members for behaviour change.
Moreover, a supportive social environment has been shown to increase maintenance of behaviour change.
These interventions typically target factors in the social environment and interpersonal and behavioural patterns that are likely to influence physical activity behaviours.
Interventions may be targeted to families with children or to spouses or partners without children. Programs typically include joint or separate educational sessions on health, goal-setting, problem-solving, or family behavioural management and will often incorporate some physical activities.
Families have the potential to influence activity levels of all generations but there is currently limited evidence about the effectiveness of interventions that target families.
The family is a major source of influence for children in the modelling of health behaviours and is, therefore, an appropriate target for intervention. However, the applicability of this type of intervention on adult physical activity participation has yet to be determined.
Social support interventions in community settings
These interventions focus on changing physical activity behaviour through building, strengthening, and maintaining social networks that provide supportive relationships for behaviour change.
This change can be achieved either by creating new social networks or working within pre-existing networks in a social setting outside the family, such as the workplace.
Interventions typically involved setting up a “buddy” system, making a “contract” with others to achieve specified levels of physical activity, or setting up walking or other groups to provide companionship and support while being physically active.
They are effective in helping people gain the skills and confidence needed to start or
resume regular physical activity.
They are effective in increasing physical activity participation in the short term.
Social support strategies also enhance education and skill development by up to 44 per cent.
Social support strategies have been found to be particularly effective for women and
minority community groups
Individually-adapted health behaviour change programs
Individually-adapted health behaviour change programs are tailored to the individual’s readiness for change, specific interests, and preferences.
These programmes teach participants specific behavioural skills that enable them to incorporate moderate-intensity physical activity into daily routines.
Behaviours may be planned (e.g., a daily scheduled walk) or unplanned (e.g., taking the stairs when the opportunity arises).
Many or most of these interventions use constructs from one or more established health behaviour change models such as Social Cognitive Theory,119 A Bandura, Social foundations of thought and action: a social-cognitive theory, Prentice-Hall, Englewood Cliffs, NJ (1986). the Health Belief Model or the Trans-theoretical Model of change These programs generally incorporate the following behavioural approaches:
setting goals for physical activity and self-monitoring of progress toward goals
building social support for new behavioural patterns
behavioural reinforcement through self-reward and positive self-talk
structured problem-solving geared to maintenance of the behaviour change
prevention of relapse into sedentary behaviours
The majority of these interventions are delivered face-to-face either individually or in groups.
Education and skill development programmes delivered either to an individual or in a group settings have been found to be effective in helping people increase and maintain physical activity in the short term.
They are most effective when they are based on an established theory of behaviour change and include social support strategies.
Structured interventions are resource intensive and rely on individual contact with programmes and practitioners. On their own, they do not have a significant public health impact because their reachis limited to the programme participants.
There is no evidence that more intensive counselling (up to 60 minutes) is any more effective than brief, opportunistic counselling (three to 10 minutes).
Brief advice from a health professional, supported by written materials, is likely to be effective in producing a modest, short-term (6-12 weeks) effect on physical activity
Environmental and policy approaches to increasing physical activity
Policy and environmental interventions focus less on individuals and more on the whole community and organisations (such as schools, workplaces and sporting clubs).
These strategies have considerable potential to increase community-wide physical activity levels by reducing social and environmental barriers to physical activity, and by ensuring the provision of facilities and resources for people to be active.
Policy approaches are needed to bring about changes in social and physical environments, and to act as catalysts for local decision making/makers to support physical activity development.
Characteristics of effective environmental and policy interventions include:
comprehensive long term strategies that focus on the social, physical, economic and policy environment
the involvement of multiple stakeholders from many sectors beyond health, including urban planners, local government, the transport sector, environmental protection agencies, criminal justice organisations, community organisations and special interest groups
the use of interdisciplinary teams and coalitions, including target groups and user groups.
multiple level interventions that focus concurrently on the social, physical, economic and policy environments – these interventions are most likely to be effective and have the potential to yield more sustainable change
the appropriate allocation of resources, given that considerable time is needed to establish policy and effect environmental change
evaluation that includes indicators for changes in attitudes and knowledge, as well as for changes in physical activity behaviour
the use of baseline, monitoring and long term follow-up measures.
Potential barriers to environmental and policy interventions include:
building new facilities is time and resource intensive
enhancing access to facilities requires careful planning, coordination and resources
success is enhanced by community “buy-in”, which takes time, resources and political commitment
in-adequate resources and lack of trained staff may affect the quality of the intervention and its evaluation.
Although limited evidence is available regarding the effectiveness of specific policy components, the literature indicates that a range of policy and environmental have considerable potential to increase community-wide physical activity.
Although the magnitude of change may seem modest compared with that produced by discrete programmes and individual behaviour change interventions, the number of people reached and the sustainability of change represents huge potential for a long term impact.
It is important to note that major infrastructure changes are expensive and can be only implemented gradually through planning and policy change.
The evidence suggests that responsibility must be shared across stakeholder groups, such as the health sector, the transport sector, decision makers in urban design, local government, environment groups and special user groups.
Smaller scale changes can be implemented with relatively low cost, such as strategies to address traffic and personal safety, walking trails, signage and access to walking maps.
There are still issues regarding what specific characteristics of a community are necessary for the optimal implementation of policy and environmental interventions.
It is also as yet undetermined whether creating or improving access to opportunities to be active is sufficient to motivate sedentary people to become active, give those who are already active an increased opportunity to be active, or indeed both.
Review of physical activity interventions
Case study 1: An active transport approach in Australia
4 Physical activity interventions
In general, current evidence suggests that the majority of programmes to promote physical activity in the UK can be sectioned into four categories.
NICE (2006) recently published a report that identified the most commonly used intervention strategies for increasing physical activity as:
§ physical activity referral schemes (PARS) and community based exercise programmes for walking and cycling
§ brief interventions
§ the use of pedometers to promote physical activity
The majority are delivered in or through healthcare/community environments and utilise specialist support.
Table 4.1 provides an overview of the evidence from the categories of interventions listed above.
4.1 What is the evidence like?
In general, despite the number and diversity of approaches to promote physical activity, current evidence presents a limited picture in terms of ‘what works’.
In a recent NICE review commissioned by the HDA (Hillsdon et al., 2005), reviewers concluded that whilst short term changes might be achievable based on current intervention design, long term change (represented by maintained physical activity participation) is much more difficult to achieve.
The review did however; identify key components of interventions that were deemed necessary to promote behaviour change. These were as follows:
§ interventions should be based on theories of behaviour change
§ interventions should teach participants skills relating to the control of behaviour
§ interventions need to tailor the content of the programme to the needs of the individual
§ interventions should seek to promote moderate physical activity and should not be solely focused on facility based physical activity
Interventions are most effective when participants receive regular contact with an exercise specialist, even in brief 3 to 10 minutes sessions. However, this does not represent a long term cost-effective approach.
Review of physical activity interventions
Table 4.1: Overview of the evidence of commonly used physical activity interventions in the UK
InterventionDescription of activitiesSummary of evidenceKey references
Physical activity Referral Schemes (PARS)
An exercise referral scheme typically directs individuals to a service offering an assessment of need, development of a tailored physical activity programme, monitoring of progress and a follow-up.
These programmes are typically 12 weeks in duration.
PARS are often local authority run and funded.
In addition PARS often share a community based physical activity programme element (walking or cycling groups). This is to say that individuals from local communities engage in physical activity together.
These additional (to PARS) community based programmes are often owned by the communities themselves but invariably run under the banner of PARS.
The Fitness Industry Association estimates that there are around 600 schemes in England.
A recent national survey reported that 89% of primary care organisations in England had an exercise referral programme.
It is common, but not exclusive, for PARS to include walking and cycling schemes.
These components are often defined as organised walks or rides and include national initiatives such as ‘walking the way to health’.
These elements of regular participation in moderately intense activity, such as brisk walking and cycling, are associated with health benefits.
They also represent activities that can become part of every day life, such as walking or cycling to work or school,
They are thus perceived more likely to be sustained than activities that require attendance at specific venues.
Despite the number of PARS schemes currently in existence, there is no solid evidence base for their effectiveness
Exercise-referral schemes have a small effect on increasing physical activity in sedentary people, but it is not certain that this small benefit is an efficient use of resources
Adherence to these schemes can be as low as 20-30%
Where increases in physical activity are evidenced these are rarely maintained
PARS also tend to focus on the needs of specific populations i.e. those referred for CHD risk factors, osteoporosis, arthritis, obesity, hypertension.
It is unlikely that these schemes will be of benefit to all individuals
One of the key assumptions with PARS is that individuals will be motivated to participate in physical activity as a consequence of receiving a prescription/advice from the GP
However, current evidence suggests that many individuals lack the lifestyle skills to be able to sustain behaviour change
The key challenges for future schemes are to increase uptake and improve adherence, perhaps by considering readiness to engage in behavioural change, or by considering individual differences in self-determination and behavioural regulation.
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