A center-based program for exercise change among black-American families

Do health education initiatives assist socioeconomically disadvantaged populations? A systematic review and meta-analyses

BACKGROUND

Health education interventions are considered critical for the prevention and management of conditions of public health concern. Although the burden of these conditions is often greatest in socio-economically disadvantaged populations, the effectiveness of interventions that target these groups is unknown. We aimed to identify and synthesize evidence of the effectiveness of health-related educational interventions in adult disadvantaged populations.

METHODS

We pre-registered the study on Open Science Framework https://osf.io/ek5yg/ . We searched Medline, Embase, Emcare, and the Cochrane Register from inception to 5/04/2022 to identify studies evaluating the effectiveness of health-related educational interventions delivered to adults in socio-economically disadvantaged populations. Our primary outcome was health related behaviour and our secondary outcome was a relevant biomarker. Two reviewers screened studies, extracted data and evaluated risk of bias. Our synthesis strategy involved random-effects meta-analyses and vote-counting.

RESULTS

We identified 8618 unique records, 96 met our criteria for inclusion - involving more than 57,000 participants from 22 countries. All studies had high or unclear risk of bias. For our primary outcome of behaviour, meta-analyses found a standardised mean effect of education on physical activity of 0.05 (95% confidence interval (CI) = -0.09-0.19), (5 studies, n = 1330) and on cancer screening of 0.29 (95% CI = 0.05-0.52), (5 studies, n = 2388). Considerable statistical heterogeneity was present. Sixty-seven of 81 studies with behavioural outcomes had point estimates favouring the intervention (83% (95% CI = 73%-90%), p < 0.001); 21 of 28 studies with biomarker outcomes showed benefit (75% (95%CI = 56%-88%), p = 0.002). When effectiveness was determined based on conclusions in the included studies, 47% of interventions were effective on behavioural outcomes, and 27% on biomarkers.

CONCLUSIONS

Evidence does not demonstrate consistent, positive impacts of educational interventions on health behaviours or biomarkers in socio-economically disadvantaged populations. Continued investment in targeted approaches, coinciding with development of greater understanding of factors determining successful implementation and evaluation, are important to reduce inequalities in health.

School-based physical activity programs for promoting physical activity and fitness in children and adolescents aged 6 to 18

BACKGROUND

Physical activity among children and adolescents is associated with lower adiposity, improved cardio-metabolic health, and improved fitness. Worldwide, fewer than 30% of children and adolescents meet global physical activity recommendations of at least 60 minutes of moderate to vigorous physical activity per day. Schools may be ideal sites for interventions given that children and adolescents in most parts of the world spend a substantial amount of time in transit to and from school or attending school.

OBJECTIVES

The purpose of this review update is to summarise the evidence on effectiveness of school-based interventions in increasing moderate to vigorous physical activity and improving fitness among children and adolescents 6 to 18 years of age. Specific objectives are: • to evaluate the effects of school-based interventions on increasing physical activity and improving fitness among children and adolescents; • to evaluate the effects of school-based interventions on improving body composition; and • to determine whether certain combinations or components (or both) of school-based interventions are more effective than others in promoting physical activity and fitness in this target population.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, BIOSIS, SPORTDiscus, and Sociological Abstracts to 1 June 2020, without language restrictions. We screened reference lists of included articles and relevant systematic reviews. We contacted primary authors of studies to ask for additional information.

SELECTION CRITERIA

Eligible interventions were relevant to public health practice (i.e. were not delivered by a clinician), were implemented in the school setting, and aimed to increase physical activity among all school-attending children and adolescents (aged 6 to 18) for at least 12 weeks. The review was limited to randomised controlled trials. For this update, we have added two new criteria: the primary aim of the study was to increase physical activity or fitness, and the study used an objective measure of physical activity or fitness. Primary outcomes included proportion of participants meeting physical activity guidelines and duration of moderate to vigorous physical activity and sedentary time (new to this update). Secondary outcomes included measured body mass index (BMI), physical fitness, health-related quality of life (new to this update), and adverse events (new to this update). Television viewing time, blood cholesterol, and blood pressure have been removed from this update.  DATA COLLECTION AND ANALYSIS: Two independent review authors used standardised forms to assess each study for relevance, to extract data, and to assess risk of bias. When discrepancies existed, discussion occurred until consensus was reached. Certainty of evidence was assessed according to GRADE. A random-effects meta-analysis based on the inverse variance method was conducted with participants stratified by age (children versus adolescents) when sufficient data were reported. Subgroup analyses explored effects by intervention type.

MAIN RESULTS

Based on the three new inclusion criteria, we excluded 16 of the 44 studies included in the previous version of this review. We screened an additional 9968 titles (search October 2011 to June 2020), of which 978 unique studies were potentially relevant and 61 met all criteria for this update. We included a total of 89 studies representing complete data for 66,752 study participants. Most studies included children only (n = 56), followed by adolescents only (n = 22), and both (n = 10); one study did not report student age. Multi-component interventions were most common (n = 40), followed by schooltime physical activity (n = 19), enhanced physical education (n = 15), and before and after school programmes (n = 14); one study explored both enhanced physical education and an after school programme. Lack of blinding of participants, personnel, and outcome assessors and loss to follow-up were the most common sources of bias.  Results show that school-based physical activity interventions probably result in little to no increase in time engaged in moderate to vigorous physical activity (mean difference (MD) 0.73 minutes/d, 95% confidence interval (CI) 0.16 to 1.30; 33 studies; moderate-certainty evidence) and may lead to little to no decrease in sedentary time (MD -3.78 minutes/d, 95% CI -7.80 to 0.24; 16 studies; low-certainty evidence). School-based physical activity interventions may improve physical fitness reported as maximal oxygen uptake (VO₂max) (MD 1.19 mL/kg/min, 95% CI 0.57 to 1.82; 13 studies; low-certainty evidence). School-based physical activity interventions may result in a very small decrease in BMI z-scores (MD -0.06, 95% CI -0.09 to -0.02; 21 studies; low-certainty evidence) and may not impact BMI expressed as kg/m² (MD -0.07, 95% CI -0.15 to 0.01; 50 studies; low-certainty evidence). We are very uncertain whether school-based physical activity interventions impact health-related quality of life or adverse events.

AUTHORS' CONCLUSIONS

Given the variability of results and the overall small effects, school staff and public health professionals must give the matter considerable thought before implementing school-based physical activity interventions. Given the heterogeneity of effects, the risk of bias, and findings that the magnitude of effect is generally small, results should be interpreted cautiously.

An online family-based self-monitoring and goal-setting intervention to improve children’s physical activity: the FRESH feasibility trial and three-arm pilot RCT

Background

Family-based physical activity promotion presents a promising avenue for promoting whole-family physical activity, but high-quality research is lacking.

Objectives

To assess the feasibility, acceptability and preliminary effectiveness of FRESH (Families Reporting Every Step to Health), a child-led online family-based physical activity intervention; and to identify effective and resource-efficient family recruitment strategies.

Design

The project consisted of (1) a randomised feasibility trial, (2) a randomised controlled pilot trial and (3) a systematic review and Delphi study.

Setting

Norfolk/Suffolk counties, UK.

Participants

Families, recruited from schools, workplaces and community settings, were eligible to participate if one child aged 7–11 years and one adult responsible for their care provided written consent; all family members could participate.

Interventions

The FRESH intervention, guided by self-determination theory, targeted whole families and was delivered via an online platform. All family members received pedometers and were given website access to select family step challenges to ‘travel’ to target cities around the world, log steps, and track progress as they virtually globetrotted. Families were randomised to FRESH intervention, pedometer-only or control arm.

Main outcome measures

Physical (e.g. blood pressure), psychosocial (e.g. family functioning) and behavioural (e.g. device-measured family physical activity) measures were collected at baseline and at 8- and 52-week follow-up. A mixed-methods process evaluation assessed the acceptability of the intervention and evaluation.

Data sources review

Systematic search of four databases (Cochrane Library, PubMed, PsycINFO and SCOPUS).

Review methods

Articles were screened in duplicate, and data extraction was fully checked. Academic experts participated in the three-round Delphi study. Data were combined to identify effective and resource-efficient family recruitment strategies.

Inclusion criteria

Included generally healthy school-aged children and at least one adult; intervention attempted to change physical activity, sedentary behaviour, screen use, diet, or prevent overweight/obesity in multiple family members; presented relevant measure of effect in children and adults.

Results

The feasibility study (12 families, 32 participants; 100% retention at 8 weeks) demonstrated the feasibility and acceptability of FRESH, but highlighted that adaptations were required. Of 41 families recruited in the pilot study (149 participants), 98% and 88% were retained at the 8-week and 52-week follow-up, respectively. More children in the FRESH arm self-reported doing more family physical activity, and they thought that FRESH was fun. There were no notable between-group differences in children’s outcomes. Change in moderate to vigorous physical activity at 8 weeks favoured FRESH intervention adults [vs. control: 9.4 minutes/week (95% confidence interval 0.4 to 18.4) vs. pedometer only: 15.3 (95% confidence interval 6.0 to 24.5)], and was stronger in fathers, but this was not maintained. In 49 included studies, apart from recruitment settings and strategies used (reported in 84% and 73% of the studies, respectively), recruitment details were scarce. School-based recruitment was predominant. The Delphi study identified a wide range of recruitment settings and strategies.

Limitations

Recruitment was the main limitation of the FRESH studies; generalisability of the proposed recruitment strategies may be limited.

Conclusions

This study has demonstrated the feasibility and acceptability of the FRESH intervention. However, we failed to recruit the target sample size and were unable to demonstrate a signal of effectiveness. Future research should employ a multifaceted recruitment approach.

Future work

Further refinements to intervention delivery and recruitment methods should be investigated.

Study registration

Current Controlled Trials ISRCTN12789422 and PROSPERO CRD42019140042.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 9, No. 9. See the NIHR Journals Library website for further project information.

A comparative effectiveness education trial for lifestyle health behavior change in African Americans

Obesity and excess weight are significant clinical and public health issues that disproportionately affect African Americans because of physical inactivity and unhealthy eating. We compared the effects of alternate behavioral interventions on obesity-related health behaviors. We conducted a comparative effectiveness education trial in a community-based sample of 530 adult African Americans. Outcomes variables were physical activity (PA) and fruit and vegetable intake. Outcomes were evaluated at baseline and 1-month following interventions about shared risk factors for cancer and cardiovascular disease (CVD) (integrated, INT) or CVD only (disease-specific). Significant increases were found in the proportion of participants who met PA guidelines from baseline (47.4%) to follow-up (52.4%) (P = 0.005). In the stratified analysis that were conducted to examine interaction between education and intervention group assignment, this effect was most apparent among participants who had ≤high school education and were randomized to INT (OR = 2.28, 95% CI = 1.04, 5.00, P = 0.04). Completing the intervention was associated with a 1.78 odds of meeting PA guidelines (95% CI = 1.02, 3.10, P = 0.04). Education about risk factors for chronic disease and evidence-based strategies for health behavior change may be useful for addressing obesity-related behaviors among African Americans.

The Physical Activity Tracker Testing in Youth (P.A.T.T.Y.) Study: Content Analysis and Children's Perceptions

BACKGROUND

Activity trackers are widely used by adults and several models are now marketed for children.

OBJECTIVE

The aims of this study were to (1) perform a content analysis of behavioral change techniques (BCTs) used by three commercially available youth-oriented activity trackers and (2) obtain feedback describing children's perception of these devices and the associated websites.

METHODS

A content analysis recorded the presence of 36 possible BCTs for the MovBand (MB), Sqord (SQ), and Zamzee (ZZ) activity trackers. In addition, 16 participants (mean age 8.6 years [SD 1.6]; 50% female [8/16]) received all three trackers and were oriented to the devices and websites. Participants were instructed to wear the trackers on 4 consecutive days and spend ≥10 min/day on each website. A cognitive interview and survey were administered when the participant returned the devices. Qualitative data analysis was used to analyze the content of the cognitive interviews. Chi-square analyses were used to determine differences in behavioral monitoring and social interaction features between websites.

RESULTS

The MB, SQ, and ZZ devices or websites included 8, 15, and 14 of the possible 36 BCTs, respectively. All of the websites had a behavioral monitoring feature (charts for tracking activity), but the percentage of participants indicating that they "liked" those features varied by website (MB: 8/16, 50%; SQ: 6/16, 38%; ZZ: 11/16, 69%). Two websites (SQ and ZZ) included an "avatar" that the user could create to represent themselves on the website. Participants reported that they "liked" creating and changing their avatar (SQ: 12/16, 75%, ZZ: 15/16, 94%), which was supported by the qualitative analyses of the cognitive interviews. Most participants (75%) indicated that they would want to wear the devices more if their friends were wearing a tracker. No significant differences were observed between SQ and ZZ devices in regards to liking or use of social support interaction features (P=.21 to .37).

CONCLUSIONS

The websites contained several BCTs consistent with previously identified strategies. Children "liked" the social aspects of the websites more than the activity tracking features. Developers of commercial activity trackers for youth may benefit from considering a theoretical perspective during the website design process.

A 6-Month Pilot Study of Effects of a Physical Activity Intervention on Life Satisfaction with a Sample of Three Generations of Women

This pilot study assessed possible changes in Life Satisfaction across three generations of women after a 6-mo. physical activity intervention. The primary purpose of the study was to test the study design and discover critical issues that should be controlled for or changed in a follow-up study. A quasi-experimental design was used to assign randomly a convenience sample of participant triads into two groups: a home-based group ( n = 27) and a control group ( n = 9). Daughters were premenarcheal ( n = 13, M = 10.1 yr., SD = 1.5), mothers were premenopausal ( n = 13, M = 37.2 yr., SD = 4.2), and grandmothers were postmenopausal ( n = 11, M = 61.5 yr., SD = 4.4). Life Satisfaction was measured using the Satisfaction with Life Scale. Participation in physical activity was measured using the Physical Best Physical Activity Questionnaire and a pedometer to count the number of steps taken per day. Compared with the control group, participants in the home-based group generally increased physical activity but their scores for Life Satisfaction did not increase. Recommendations concerning the study design, reducing limitations, and hypotheses for further study are given.

Beliefs as Motivational Influences at Stages in Behavior Change

A problem for health education practice is how to interest people in making a health behavior change and maintain that interest throughout the behavior change process. Beliefs can provide motivational force for people to perform health behaviors. Five theories: 1) Diffusion of Innovations (DIT); 2) Health Belief Model (HBM); 3) Reasoned Action (TRA); 4) Locus of Control (LOC); and 5) Social Learning (SLT), are reviewed for motivational factors in promoting health behavior changes at each of six stages in the behavior change process: precontemplation, decision, training, initiation, and maintenance. A degree of overlap and complementariness are identified among the theories resulting in a syntheoretical model of beliefs as motivators in the behavior change process. The common emphasis among the theories on expectancies or cost-benefit calculations is highlighted, suggesting several strategies for employing these considerations in health education campaigns. The paucity of motivational ideas for promoting change among the externally controlled—late majority is noted. Further research must be conducted before these ideas should be generally implemented in practice.

Factors Related to Condom Use among Young People in Kenya

Survey questionnaires were provided to a convenience sample of 197 students in four educational settings. When regressing the knowledge score on the independent variables, it was found that the knowledge score increased with years of education, the practice of Islam, getting HIV/AIDS information from a radio, worrying about contracting HIV/AIDS, and receiving AIDS education or family life education in school. The knowledge score was negatively related with age. When regressing condom use on the independent variables, including the knowledge score, the likelihood that a respondent would use a condom significantly increased when the respondent was willing to use a condom, when a sexual partner requested it, when the respondent knew where to purchase condoms, and when the respondent had received education in school on family planning and AIDS education. The likelihood of using condoms was negatively related with age and the statement “real men do not wear condoms.”

Effects of an afterschool community center physical activity program on fitness and body composition in obese youth

Physical activity (PA) promotes health in obese youth and is an important adjunct to medical weight management. Access to structured fitness programmes for obese, low-income youth is limited and potential benefits of such programmes are poorly understood. We describe an urban afterschool fitness programme for obese youth and participants' changes in fitness and body composition. A case series of 30 youth (age: 11.5 ± 2.5 years) with BMI ≥95th percentile and physician referral received a 24-wk programme scholarship. The programme, offered 4 times a week for 90-min.session, included aerobic, strength, and self-organised PA. Primary outcomes, measured at baseline (BL) time 1 (4-8 wk) and time 2 (12-16 wk) were BMI, per cent body fat (%BF), fat-free mass (FFM), heart rate during a treadmill test, and muscular strength (one repetition maximum (1RM)) and endurance (reps at 70% of 1RM) on the leg press (LP) and chest press (CP). Average participation was 1.5 ± 0.6 visits per week for 18.7 ± 6.5 weeks. Between BL and time 2, LP and CP 1RM and endurance significantly improved (P < 0.05). Additionally, there was a significant interaction for %BF with boys losing 5.2% (P > 0.05) while girls lost 0% (>0.05). Obese youth attending an urban fitness programme for at least three months improved strength and body composition, but average attendance was below planned levels.

A Community-Based Physical Education and Activity Intervention for African American Preadolescent Girls: A Strategy to Reduce Racial Disparities in Health

Physical activity habits fostered and developed early in life tend to persist into adulthood, reducing the incidence of chronic diseases associated with a sedentary lifestyle in later life. This is of particular importance for racial and ethnic minority populations who experience significant disparities in rates of chronic disease. Thus, promoting physical activity in minority children is an effective strategy for reducing these health disparities. Unfortunately, however, recommendations for effective implementation of such programs are sorely lacking. This article describes the development and implementation of Lively Ladies, a physical education and activity intervention targeted to low-income, preadolescent, African American girls in a community-based youth services organization. Low-income, minority girls face the catch-22 situation of being at higher risk for physical inactivity while having limited or no access to physical fitness programs. This article demonstrates that community-based youth organizations can play an important role in changing this situation. The authors’ experience with Lively Ladies indicates the effectiveness of a theory-based program addressing modifiable psychosocial and environmental determinants of behavior. They provide recommendations to guide future design and implementation of community-based physical education and activity interventions for a population group that tends to have increased risk for physical inactivity and limited access to fitness programs and facilities.

Process Evaluation of the Project SHINE Intervention for African American Families: An Integrated Positive Parenting and Peer Monitoring Approach to Health Promotion

This study describes the process evaluation of Project SHINE, a randomized family-based health promotion intervention that integrated parenting and peer monitoring for improving sedentary behavior, physical activity, and diet in African American families. Adolescent-parent dyads (n = 89) were randomized to a 6-week behavioral, positive parenting, and peer monitoring skills intervention or a general health education comparison condition. Process evaluation included observational ratings of fidelity, attendance records, psychosocial measures, and qualitative interviews. Results indicated that the intervention was delivered with high fidelity based on facilitator adherence (>98% of content delivered) and competent use of theoretically based behavior change and positive parenting skills (100% of ratings >3 on a 1-4 scale). Although only 43% of peers attended the "bring a friend" session, overall attendance was high (4.39 ± 1.51 sessions) as was the retention rate (88%). Parents in the intervention condition reported significant improvements in communication related to adolescents' engagement in health behaviors both on their own and with peers. These findings were supported by qualitative themes related to improvements in family communication and connectedness. This study provides an innovative example of how future family-based health promotion trials can expand their process evaluation approaches by assessing theoretically relevant positive parenting variables as part of ongoing monitoring.

Exploring the role of community engagement in improving the health of disadvantaged populations: a systematic review

BACKGROUND

Although community engagement (CE) is widely used in health promotion, components of CE models associated with improved health are poorly understood. This study aimed to examine the magnitude of the impact of CE on health and health inequalities among disadvantaged populations, which methodological approaches maximise the effectiveness of CE, and components of CE that are acceptable, feasible, and effective when used among disadvantaged populations.

DESIGN

The systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We carried out methodological assessments of the included studies using rating scales. The analysis focussed on model synthesis to identify the key CE components linked to positive study outcomes and comparative analysis between positive study outcomes, processes, and quality indicators of CE.

RESULTS

Out of 24 studies that met our inclusion criteria, 21 (87.5%) had positively impacted health behaviours, public health planning, health service access, health literacy, and a range of health outcomes. More than half of the studies (58%) were of good quality, whereas 71% and 42% of studies showed good community involvement in research and achieved high levels of CE, respectively. Key CE components that affected health outcomes included real power-sharing, collaborative partnerships, bidirectional learning, incorporating the voice and agency of beneficiary communities in research protocol, and using bicultural health workers for intervention delivery.

CONCLUSIONS

The findings suggest that CE models can lead to improved health and health behaviours among disadvantaged populations if designed properly and implemented through effective community consultation and participation. We also found several gaps in the current measurement of CE in health intervention studies, which suggests the importance of developing innovative approaches to measure CE impact on health outcomes in a more rigorous way.

Cultural relevance of physical activity intervention research with underrepresented populations

This article describes cultural relevance in physical activity intervention research with underrepresented populations. Seventy-one extant studies which tested interventions to increase physical activity among underrepresented adults were included. Verbatim descriptions of efforts to enhance cultural relevance of study designs and interventions were extracted and then content analyzed. We found strategies to enhance cultural relevance of interventions as soliciting input from population members, linking intervention content with values, addressing language and literacy challenges, incorporating population media figures, using culturally relevant forms of physical activity, and addressing specific population linked barriers to activity. Methodological approaches included specialized recruitment and study locations, culturally relevant measures, underrepresented personnel, and cost-awareness study procedures to prevent fiscal barriers to participation. Most reported activities were surface matching. Existing research neither compared the effectiveness of cultural relevance approaches to standardized interventions nor addressed economic, education, geographic, or cultural heterogeneity among groups.

Parent-targeted mobile phone intervention to increase physical activity in sedentary children: randomized pilot trial

Background

Low levels of moderate-to-vigorous physical activity are associated with adverse health consequences.

Objective

The intent of the study was to determine the feasibility and efficacy of a 12-week physical activity promotion program targeting children, which was delivered to parents through mobile phones.

Methods

Potential participants were recruited through advertisements placed in the newspaper, local hospitals and schools, and an email listserv. Sedentary children aged 6-10 years were randomly assigned to a minimal (MIG) or intensive (IIG) intervention group. Parents in the MIG were given a goal to increase (within 1 month) and maintain their child’s activity at 6000 pedometer steps/day above their baseline levels and to monitor their child’s steps daily. Parents in the IIG were given the same steps/day and monitoring goals, in addition to text messages and articles containing additional behavioral strategies (based on the Social Cognitive Theory) designed to promote their child’s physical activity. The intervention components were delivered via mobile phone. Anthropometrics, body composition, and questionnaires were administered in a clinic. Children wore a New Lifestyles pedometer (NL-1000) each day throughout the intervention and parents were to monitor their child’s step counts daily.

Results

Out of 59 children who screened for the study, a total of 27 children (mean age 8.7, SD 1.4 years; 56%, 15/27 female; 59%, 16/27 African American) were enrolled and completed the study. Overall, 97.90% (2220/2268; 98.20%, 1072/1092 for MIG; 97.60%, 1148/1176 for IIG) of expected step data were successfully entered by the parent or study coordinator. Parents in the MIG and IIG were sent approximately 7 and 13 text messages per week, respectively, averaged over the course of the study. IIG parents accessed an average of 6.1 (SD 4.4) articles over the course of the intervention and accessed a fewer number of articles in the last month compared to the first 2 months of the study (P=.002). Children in both the MIG and IIG significantly increased their physical activity, averaged over 12 weeks, by 1427.6 (SD 583.0; P=.02) and 2832.8 (SD 604.9; P<.001) steps/day above baseline, respectively. The between group difference was not statistically significant (P=.10; effect size=.40), nor was the group by time interaction (P=.57). Regardless of group assignment, children who significantly increased their physical activity reported greater increases in physical activity enjoyment (P=.003). The number of behavioral articles accessed by IIG parents was significantly correlated with change in children’s steps/day (r=.575, P=.04). Changes in children’s steps/day were unrelated to changes in their body composition, mood, and food intake.

Conclusions

Parent-targeted mobile phone interventions are feasible, yet more intense interventions may be needed to support parents’ efforts to increase their children’s physical activity to levels that approximate national recommendations.

Trial Registration

Clinicaltrials.gov NCT01551108; http://clinicaltrials.gov/show/NCT01551108 (Archived by WebCite at http://www.webcitation.org/6TNEOzXNX).

Community engagement to reduce inequalities in health: a systematic review, meta-analysis and economic analysis

Background

Community engagement has been advanced as a promising way of improving health and reducing health inequalities; however, the approach is not yet supported by a strong evidence base.

Objectives

To undertake a multimethod systematic review which builds on the evidence that underpins the current UK guidance on community engagement; to identify theoretical models underpinning community engagement; to explore mechanisms and contexts through which communities are engaged; to identify community engagement approaches that are effective in reducing health inequalities, under what circumstances and for whom; and to determine the processes and costs associated with their implementation.

Data sources

Databases including the Cochrane Database of Systematic Reviews (CDSR), The Campbell Library, the Database of Abstracts of Reviews of Effects (DARE), the Health Technology Assessment (HTA) database, the NHS Economic Evaluation Database (NHS EED) and EPPI-Centre’s Trials Register of Promoting Health Interventions (TRoPHI) and Database of Promoting Health Effectiveness Reviews (DoPHER) were searched from 1990 to August 2011 for systematic reviews and primary studies. Trials evaluating community engagement interventions reporting health outcomes were included.

Review methods

Study eligibility criteria: published after 1990; outcome, economic, or process evaluation; intervention relevant to community engagement; written in English; measured and reported health or community outcomes, or presents cost, resource, or implementation data characterises study populations or reports differential impacts in terms of social determinants of health; conducted in an Organisation for Economic Co-operation and Development (OECD) country. Study appraisal: risk of bias for outcome evaluations; assessment of validity and relevance for process evaluations; comparison against an economic evaluation checklist for economic evaluations. Synthesis methods: four synthesis approaches were adopted for the different evidence types: theoretical, quantitative, process, and economic evidence.

Results

The theoretical synthesis identified key models of community engagement that are underpinned by different theories of changes. Results from 131 studies included in a meta-analysis indicate that there is solid evidence that community engagement interventions have a positive impact on health behaviours, health consequences, self-efficacy and perceived social support outcomes, across various conditions. There is insufficient evidence – particularly for long-term outcomes and indirect beneficiaries – to determine whether one particular model of community engagement is likely to be more effective than any other. There are also insufficient data to test the effects on health inequalities, although there is some evidence to suggest that interventions that improve social inequalities (as measured by social support) also improve health behaviours. There is weak evidence from the effectiveness and process evaluations that certain implementation factors may affect intervention success. From the economic analysis, there is weak but inconsistent evidence that community engagement interventions are cost-effective. By combining findings across the syntheses, we produced a new conceptual framework.

Limitations

Differences in the populations, intervention approaches and health outcomes made it difficult to pinpoint specific strategies for intervention effectiveness. The syntheses of process and economic evidence were limited by the small (generally not rigorous) evidence base.

Conclusions

Community engagement interventions are effective across a wide range of contexts and using a variety of mechanisms. Public health initiatives should incorporate community engagement into intervention design. Evaluations should place greater emphasis on long-term outcomes, outcomes for indirect beneficiaries, process evaluation, and reporting costs and resources data. The theories of change identified and the newly developed conceptual framework are useful tools for researchers and practitioners. We identified trends in the evidence that could provide useful directions for future intervention design and evaluation.

Funding

The National Institute for Health Research Public Health Research programme.

Project SHINE: effects of parent-adolescent communication on sedentary behavior in African American adolescents

OBJECTIVE

This study examined parenting variables (communication, monitoring) as moderators of a family-based intervention for reducing sedentary behavior (SB) in African American adolescents. As a secondary aim, a similar model was tested using adolescent weight status as the outcome.

METHODS

African American adolescents (n = 73; 12.45 ± 1.45 years; 60% girls; 63% overweight/obese) and caregivers were randomized to a 6-week interactive, parent-based intervention or general health condition. Parent-adolescent communication and monitoring of health behaviors were self-reported by parents. Adolescent SB was self-reported by youth.

RESULTS

There was a significant intervention by communication interaction, such that intervention families with more positive communication showed lower adolescent SB than those with less positive communication or those in the comparison condition. No effects were found for monitoring on SB or for the model with weight status as the outcome.

CONCLUSIONS

Parent-adolescent communication may be an effective component to integrate into health promotion programs for African American adolescents.

What might work? Exploring the perceived feasibility of strategies to promote physical activity among women living in socioeconomically disadvantaged neighbourhoods

This study aimed to investigate preferences for, perceived feasibility of and barriers to uptake of hypothetical physical activity promotion strategies among women from socioeconomically disadvantaged neighbourhoods. Semi-structured interviews were conducted with 20 purposively recruited women (18-45 years) living in socioeconomically disadvantaged urban and rural areas of Victoria, Australia. Participants indicated the most and least appealing of nine hypothetical strategies, strategies most likely to use and strategies most likely to increase physical activity. Interviews were digitally recorded and transcribed verbatim. Thematic and interpretive content analyses were used to identify emergent common and contrasting themes. A community centre-based program with free childcare, the provision of a cleaner while physical activity is undertaken and a neighbourhood-based program were the three most popular strategies. Mobile-telephone-delivered text messages, an online interactive diary and subsidized gym memberships were considered least useful. Irrespective of the strategy, components of importance commonly identified were social support; being accountable to someone; having the option of a structured or flexible attendance design; integration of multiple strategies and financial considerations. Issues around trust and privacy and weight loss also emerged as important. The findings provide important insights for the development of physical activity programs targeting socioeconomically disadvantaged women.

Effectiveness of interventions to promote physical activity among socioeconomically disadvantaged women: a systematic review and meta-analysis

Physical activity is important for preventing weight gain and obesity, but women experiencing socioeconomic disadvantage are at high risk of inactivity. This study aimed to determine the effectiveness of interventions to increase physical activity among women experiencing disadvantage, and the intervention factors (i.e. physical activity measure, delivery mode, delivery channel, setting, duration, use of theory, behavioural techniques, participant age, risk of bias) associated with effectiveness. We conducted a meta-analysis of controlled trials using random-effects models and meta-regression. Seven databases were searched for trials among healthy women (18-64 years), which included a physical activity intervention, any control group, and statistical analyses of a physical activity outcome at baseline and post-intervention. Nineteen studies were included (n = 6,339). Because of substantial statistical heterogeneity (χ(2) = 53.61, df = 18, P < 0.0001, I(2) = 66%), an overall pooled effect is not reported. In subgroup analyses, between-group differences were evident for delivery mode, which modestly reduced heterogeneity (to 54%). Studies with a group delivery component had a standardized mean difference of 0.38 greater than either individual or community-based delivery. Programs with a group delivery mode significantly increase physical activity among women experiencing disadvantage, and group delivery should be considered an essential element of physical activity promotion programs targeting this population group.

School-based physical activity programs for promoting physical activity and fitness in children and adolescents aged 6 to 18

BACKGROUND

The World Health Organization (WHO) estimates that 1.9 million deaths worldwide are attributable to physical inactivity and at least 2.6 million deaths are a result of being overweight or obese. In addition, WHO estimates that physical inactivity causes 10% to 16% of cases each of breast cancer, colon, and rectal cancers as well as type 2 diabetes, and 22% of coronary heart disease and the burden of these and other chronic diseases has rapidly increased in recent decades.

OBJECTIVES

The purpose of this systematic review was to summarize the evidence of the effectiveness of school-based interventions in promoting physical activity and fitness in children and adolescents.

SEARCH METHODS

The search strategy included searching several databases to October 2011. In addition, reference lists of included articles and background papers were reviewed for potentially relevant studies, as well as references from relevant Cochrane reviews. Primary authors of included studies were contacted as needed for additional information.

SELECTION CRITERIA

To be included, the intervention had to be relevant to public health practice (focused on health promotion activities), not conducted by physicians, implemented, facilitated, or promoted by staff in local public health units, implemented in a school setting and aimed at increasing physical activity, included all school-attending children, and be implemented for a minimum of 12 weeks. In addition, the review was limited to randomized controlled trials and those that reported on outcomes for children and adolescents (aged 6 to 18 years). Primary outcomes included: rates of moderate to vigorous physical activity during the school day, time engaged in moderate to vigorous physical activity during the school day, and time spent watching television. Secondary outcomes related to physical health status measures including: systolic and diastolic blood pressure, blood cholesterol, body mass index (BMI), maximal oxygen uptake (VO2max), and pulse rate.

DATA COLLECTION AND ANALYSIS

Standardized tools were used by two independent reviewers to assess each study for relevance and for data extraction. In addition, each study was assessed for risk of bias as specified in the Cochrane Handbook for Systematic Reviews of Interventions. Where discrepancies existed, discussion occurred until consensus was reached. The results were summarized narratively due to wide variations in the populations, interventions evaluated, and outcomes measured.

MAIN RESULTS

In the original review, 13,841 records were identified and screened, 302 studies were assessed for eligibility, and 26 studies were included in the review. There was some evidence that school-based physical activity interventions had a positive impact on four of the nine outcome measures. Specifically positive effects were observed for duration of physical activity, television viewing, VO2 max, and blood cholesterol. Generally, school-based interventions had little effect on physical activity rates, systolic and diastolic blood pressure, BMI, and pulse rate. At a minimum, a combination of printed educational materials and changes to the school curriculum that promote physical activity resulted in positive effects.In this update, given the addition of three new inclusion criteria (randomized design, all school-attending children invited to participate, minimum 12-week intervention) 12 of the original 26 studies were excluded. In addition, studies published between July 2007 and October 2011 evaluating the effectiveness of school-based physical interventions were identified and if relevant included. In total an additional 2378 titles were screened of which 285 unique studies were deemed potentially relevant. Of those 30 met all relevance criteria and have been included in this update. This update includes 44 studies and represents complete data for 36,593 study participants. Duration of interventions ranged from 12 weeks to six years.Generally, the majority of studies included in this update, despite being randomized controlled trials, are, at a minimum, at moderate risk of bias. The results therefore must be interpreted with caution. Few changes in outcomes were observed in this update with the exception of blood cholesterol and physical activity rates. For example blood cholesterol was no longer positively impacted upon by school-based physical activity interventions. However, there was some evidence to suggest that school-based physical activity interventions led to an improvement in the proportion of children who engaged in moderate to vigorous physical activity during school hours (odds ratio (OR) 2.74, 95% confidence interval (CI), 2.01 to 3.75). Improvements in physical activity rates were not observed in the original review. Children and adolescents exposed to the intervention also spent more time engaged in moderate to vigorous physical activity (with results across studies ranging from five to 45 min more), spent less time watching television (results range from five to 60 min less per day), and had improved VO2max (results across studies ranged from 1.6 to 3.7 mL/kg per min). However, the overall conclusions of this update do not differ significantly from those reported in the original review.

AUTHORS' CONCLUSIONS

The evidence suggests the ongoing implementation of school-based physical activity interventions at this time, given the positive effects on behavior and one physical health status measure. However, given these studies are at a minimum of moderate risk of bias, and the magnitude of effect is generally small, these results should be interpreted cautiously. Additional research on the long-term impact of these interventions is needed.

A systematic review of intervention effects on potential mediators of children's physical activity

Background

Many interventions aiming to increase children’s physical activity have been developed and implemented in a variety of settings, and these interventions have previously been reviewed; however the focus of these reviews tends to be on the intervention effects on physical activity outcomes without consideration of the reasons and pathways leading to intervention success or otherwise.

To systematically review the efficacy of physical activity interventions targeting 5-12 year old children on potential mediators and, where possible, to calculate the size of the intervention effect on the potential mediator.

Methods

A systematic search identified intervention studies that reported outcomes on potential mediators of physical activity among 5-12 year old children. Original research articles published between 1985 and April 2012 were reviewed.

Results

Eighteen potential mediators were identified from 31 studies. Positive effects on cognitive/psychological potential mediators were reported in 15 out of 31 studies. Positive effects on social environmental potential mediators were reported in three out of seven studies, and no effects on the physical environment were reported. Although no studies were identified that performed a mediating analysis, 33 positive intervention effects were found on targeted potential mediators (with effect sizes ranging from small to large) and 73% of the time a positive effect on the physical activity outcome was reported.

Conclusions

Many studies have reported null intervention effects on potential mediators of children’s physical activity; however, it is important that intervention studies statistically examine the mediating effects of interventions so the most effective strategies can be implemented in future programs.

Factors influencing attendance in a structured physical activity program for Aboriginal and Torres Strait Islander women in an urban setting: a mixed methods process evaluation

Background

Aboriginal and Torres Strait Islander women experience higher rates of obesity, chronic disease, and are less active than non-Indigenous Australian women. Lifestyle programs designed to increase physical activity and encourage healthy eating are needed to ameliorate this disparity. The aim of this study was to identify participants’ perceived barriers and enablers to attend group exercise classes as part of a 12-week fitness program.

Methods

To understand the factors that influence attendance, a mixed method process evaluation was undertaken in which a quantitative measure of attendance in the group exercise classes was used to identify cases for further qualitative investigation. Aboriginal and/or Torres Strait Islander women aged 18 to 64 years were recruited to a research trial of a fitness program. The 12-week program included two 60-minute group exercise classes per week, and four nutrition education workshops. Semi-structured interviews were conducted at program completion. Participants were stratified by attendance, and interviews from the highest and lowest 25 percentiles analysed. Rigour was strengthened through use of multiple data analysts, member checking and prolonged engagement in the field.

Results

Analyses of the post-program interviews revealed that participants enrolled in the program primarily for the perceived health benefits and all (with one exception) found the program met their needs and expectations. The atmosphere of classes was positive and comfortable and they reported developing good relationships with their fellow participants and program staff. Low attendees described more barriers to attendance, such as illness and competing work and family obligations, and were more likely to report logistical issues, such as inconvenient venue or class times.

Conclusions

Attendance to the ‘Aboriginal and Torres Strait Islander Women’s Fitness Program’ was primarily influenced by the participant’s personal health, logistics and competing obligations. Low attendees reported more barriers during the 12-week period and identified fewer enabling factors than high attendees.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN12610000224022

Physical activity interventions with healthy minority adults: meta-analysis of behavior and health outcomes

This meta-analysis is a systematic compilation of research focusing on various exercise interventions and their impact on the health and behavior outcomes of healthy African American, Hispanic, Native American, and Native Hawaiian adults. Comprehensive searching located published and unpublished studies. Random-effects analyses synthesized data to calculate effect sizes (ES) as a standardized mean difference (d) and variability measures. Data were synthesized across 21,151 subjects in 100 eligible samples. Supervised exercise significantly improved fitness (ES=.571-.584). Interventions designed to motivate minority adults to increase physical activity changed subsequent physical activity behavior (ES=.172-.312) and anthropometric outcomes (ES=.070-.124). Some ES should be interpreted in the context of limited statistical power and heterogeneity. Attempts to match intervention content and delivery with minority populations were inconsistently reported. Healthy minority adults experienced health improvements following supervised exercise. Interventions designed to motivate subjects to increase physical activity have limited magnitude heterogeneous effects.

The effect of community and family interventions on young people's physical activity levels: a review of reviews and updated systematic review

BACKGROUND

Next to the school environment, the family and community environment are key for young people's behaviour and for promoting physical activity (PA).

METHODS

A review of reviews was conducted, after which a literature search was conducted (in PubMed, Scopus and PsychInfo) from August 2007 (search date of the most recent review) to October 2010. Inclusion criteria were study population aged 18 years or younger, controlled trial, no PA control condition, PA promotion intervention and reported analyses of a PA-related outcome. Methodological quality was assessed, and data on intervention details, methods and effects on primary and secondary outcomes (PA, body composition and fitness) were extracted.

RESULTS

Three previous reviews were reviewed, including 13 family-based and three community-based interventions. Study inclusion differed for each review, but all concluded that the evidence was limited, although the potential of family-based interventions delivered in the home and including self-monitoring was highlighted. A further six family-based and four community-based interventions were included in the updated review, with a methodological quality score ranging from 2 to 10 and five studies scoring 6 or higher. Significant positive effects on PA were observed for one community-based and three family-based studies. No distinctive characteristics of the effective interventions compared with those that were ineffective were identified.

CONCLUSIONS

The effect of family- and community-based interventions remains uncertain despite improvements in study quality. Of the little evidence of effectiveness, most comes from those targeted at families and set in the home. Further detailed research is needed to identify key approaches for increasing young people's PA levels in family and community settings.

The integration of a family systems approach for understanding youth obesity, physical activity, and dietary programs

Rates of overweight in youth have reached epidemic proportions and are associated with adverse health outcomes. Family-based programs have been widely used to treat overweight in youth. However, few programs incorporate a theoretical framework for studying a family systems approach in relation to youth health behavior change. Therefore, this review provides a family systems theory framework for evaluating family-level variables in weight loss, physical activity, and dietary approaches in youth. Studies were reviewed and effect sizes were calculated for interventions that manipulated the family system, including components that targeted parenting styles, parenting skills, or family functioning, or which had novel approaches for including the family. Twenty-one weight loss interventions were identified, and 25 interventions related to physical activity and/or diet were identified. Overall, family-based treatment programs that incorporated training for authoritative parenting styles, parenting skills, or child management, and family functioning had positive effects on youth weight loss. Programs to improve physical activity and dietary behaviors that targeted the family system also demonstrated improvements in youth health behaviors; however, direct effects of parent-targeted programming is not clear. Both treatment and prevention programs would benefit from evaluating family functioning and parenting styles as possible mediators of intervention outcomes. Recommendations are provided to guide the development of future family-based obesity prevention and treatment programs for youth.

Effects of strategies to promote children's physical activity on potential mediators

The aim of this paper is to review evidence of the effectiveness of interventions that present physical activity outcomes and potential mediators of behavioural change among 4-12-year-old children. A systematic search of electronic databases for original research articles published in peer-review journals between January 1985 and the end of June 2006 was carried out. A total of 19 studies that reported intervention effects on physical activity and mediators of behavioural change were identified. The most common mediators reported included physical activity knowledge or beliefs (11 studies); self-efficacy (8 studies); and enjoyment or preference for physical activity (6 studies). Less frequently reported mediators included attitudes, behavioural capability, intentions, outcome expectancies, social norms, social support and self-concept. Seven of the 11 interventions that reported intervention effects on knowledge/beliefs stated positive changes in this mediator. Four of the eight studies that reported intervention effects on self-efficacy had significant improvements; however, only two out of six interventions reported significant improvements in physical activity enjoyment or preference. None of the studies reviewed reported whether changes in these constructs mediated changes in children's physical activity behaviours. Although more than half of the studies reviewed reported a positive intervention effect on children's physical activity, no study carried out a mediating analysis to attempt to identify the mechanisms of change. Future research should more clearly identify the mediators of behavioural change that are being targeted and whether this explains intervention effects.

Creating healthful home food environments: results of a study with participants in the expanded food and nutrition education program

OBJECTIVE

To evaluate a modified curriculum for the 6-session Texas Expanded Food and Nutrition Education Program (EFNEP) promoting healthful home food environments and parenting skills related to obesity prevention.

DESIGN

Two-group randomized control trial; intervention versus usual EFNEP curriculum.

SETTING

Texas EFNEP classes.

PARTICIPANTS

1,104 EFNEP clients in 100 classes.

INTERVENTION

Six short videos, with goal setting, problem solving, guided discussion, and handouts, incorporated into existing EFNEP classes.

MAIN OUTCOME MEASURES

Body mass index (BMI), diet, psychosocial variables with baseline measurements, immediately post, and 4 months later.

ANALYSIS

Mixed-model repeated measures analysis of variance.

RESULTS

100 classes were randomized (54 intervention/46 comparison), with 1,006 participants at baseline (582 intervention, 424 comparison, 97% women, 89% Hispanic). Significant improvements over time were found for both groups' consumption of most food items and nutrients, and nearly all psychosocial variables, regardless of study group. Only the intervention group had a significant BMI decrease at post. Fidelity to the intervention class session structure was high, and comments from intervention staff and clients were positive.

CONCLUSION AND IMPLICATIONS

Existing EFNEP programs in local communities could have a significant impact on family dietary behaviors for populations at risk of obesity. Replication with similar populations is warranted.

Engaging parents to increase youth physical activity a systematic review

BACKGROUND

Parents are often involved in interventions to engage youth in physical activity, but it is not clear which methods for involving parents are effective.

PURPOSE

A systematic review was conducted of interventions with physical activity and parental components among healthy youth to identify how best to involve parents in physical activity interventions for children.

EVIDENCE ACQUISITION

Identified intervention studies were reviewed in 2008 for study design, description of family components, and physical activity outcomes. The quality of reporting was assessed using the CONSORT checklist for reporting on trials of nonpharmacologic treatments.

EVIDENCE SYNTHESIS

The literature search identified 1227 articles, 35 of which met review criteria. Five of the 14 RCTs met > or =70% of CONSORT checklist items. Five general procedures for involving parents were identified: (1) face-to-face educational programs or parent training, (2) family participatory exercise programs, (3) telephone communication, (4) organized activities, and (5) educational materials sent home. Lack of uniformity in reporting trials, multiple pilot studies, and varied measurements of physical activity outcomes prohibited systematic conclusions. Interventions with educational or training programs during family visits or via telephone communication with parents appear to offer some promise.

CONCLUSIONS

There is little evidence for effectiveness of family involvement methods in programs for promoting physical activity in children, because of the heterogeneity of study design, study quality, and outcome measures used. There is a need to build an evidence base of more-predictive models of child physical activity that include parent and child mediating variables and procedures that can effect changes in these variables for future family-based physical activity interventions.

Systematic Review of Interventions to Increase Physical Activity and Physical Fitness in African-Americans

Objective.

To identify characteristics of effective interventions designed to increase physical activity (PA) or fitness among African-Americans.

Data Sources.

Articles published between 1985 and 2006.

Study Inclusion Criteria.

Studies reporting PA or fitness change data in African-American participants were included.

Data Extraction.

Information on study design, intervention, data collection methods, and outcomes was extracted using a standardized form.

Data Synthesis.

Studies were ranked on quality and were summarized separately for adults and children.

Results.

We identified 29 studies in adults and 14 studies in children. Most were randomized controlled trials. All but six specifically targeted African-Americans; comparisons of effectiveness in African-Americans vs. others were not possible. Methodological heterogeneity limited comparisons of findings across studies. In adults, most studies showed significant within-group pre-post improvements in PA, but only 10 studies found differences between intervention and comparison groups. Most studies in children were null.

Conclusions.

Effective programs in adults were from randomized controlled trials and involved structured exercise programs. Studies with explicit cultural adaptations did not necessarily result in better PA outcomes. Additional studies are needed with larger sample sizes, longer follow-up, attention controls, strategies informed by proven behavior change theories, and objective PA assessment.

Identifying barriers that hinder onsite parental involvement in a school-based health promotion program

We investigated whether barriers to onsite parental involvement in the Bienestar Health Program Parent Component could be identified and whether participation rates could be increased by addressing these barriers. All nonparticipating parents of fourth-grade students of San Antonio Independent School District from 4 schools, which were selected randomly from 20 intervention schools in Bienestar, were invited to take part in this study. A total of 47 of 223 (21%) parents engaged in one of four focus groups offered. Parents identified barriers to their involvement in Bienestar that fit into five descriptive categories: (a) low value, (b) high cost, (c) competing family demands, (d) concerns about the program design, and (e) social role norms. The Bienestar Parent Component was then modified according to the focus group findings, which resulted in a marked increase in parental involvement from 17% to 37% overall. These findings suggest that even when parents are involved in the initial design of parent-friendly and culturally sensitive programs, as was the case for Bienestar, maximizing parental involvement may require additional assessment, identification, and remediation of barriers.

School-based physical activity programs for promoting physical activity and fitness in children and adolescents aged 6-18

BACKGROUND

The World Health Organization estimates that 1.9 million deaths worldwide are attributable to physical inactivity. Chronic diseases associated with physical inactivity include cancer, diabetes and coronary heart disease.

OBJECTIVES

The purpose of this systematic review is to summarize the evidence of the effectiveness of school-based interventions in promoting physical activity and fitness in children and adolescents.

SEARCH STRATEGY

The search strategy included searching several databases. In addition, reference lists of included articles and background papers were reviewed for potentially relevant studies, as well as references from relevant Cochrane reviews. Primary authors of included studies were contacted as needed for additional information.

SELECTION CRITERIA

To be included, the intervention had to be relevant to public health practice, implemented, facilitated, or promoted by staff in local public health units, implemented in a school setting and aimed at increasing physical activity, report on outcomes for children and adolescents (aged 6 to 18 years), and use a prospective design with a control group.

DATA COLLECTION AND ANALYSIS

Standardized tools were used by two independent reviewers to rate each study's methodological quality and for data extraction. Where discrepancies existed discussion occurred until consensus was reached. The results were summarized narratively due to wide variations in the populations, interventions evaluated and outcomes measured.

MAIN RESULTS

13,841 titles were identified and screened and 482 articles were retrieved. Multiple publications on the same project were combined and counted as one project, resulting in 395 distinct project accounts (studies). Of the 395 studies 104 were deemed relevant and of those, four were assessed as having strong methodological quality, 22 were of moderate quality and 78 were considered weak. In total 26 studies were included in the review. There is good evidence that school-based physical activity interventions have a positive impact on four of the nine outcome measures. Specifically positive effects were observed for duration of physical activity, television viewing, VO2 max, and blood cholesterol. Generally school-based interventions had no effect on leisure time physical activity rates, systolic and diastolic blood pressure, body mass index, and pulse rate. At a minimum, a combination of printed educational materials and changes to the school curriculum that promote physical activity result in positive effects.

AUTHORS' CONCLUSIONS

Given that there are no harmful effects and that there is some evidence of positive effects on lifestyle behaviours and physical health status measures, ongoing physical activity promotion in schools is recommended at this time.

Moderators of environmental intervention effects on diet and activity in youth

BACKGROUND

The complexity of the relationship between environmental factors on the one hand and dietary behavior and physical activity on the other necessitates the search for moderators of environmental influences. The current evidence base is reviewed regarding potential moderating factors in the effectiveness of environmental interventions aimed at diet and/or physical activity of children and adolescents.

METHODS

The following databases were used: (1) Medline, (2) PubMed, (3) PsychInfo, (4) Web of Science, and (5) ERIC. Additionally, all potentially relevant references in recent reviews were checked.

RESULTS

Of the 41 studies included in the review, only seven studies (17%) were identified that reported tests of potential moderators of intervention effects. Gender proved to be the most frequently studied potential moderator. Additionally, race, age, and site have been studied regarding their potential role in modifying the effect of environmental interventions.

DISCUSSION

The small number of studies identified in this review prohibited us from attempting to formulate a conclusion on differential environment-behavior relationships in distinct subgroups. Rather than being an exception, it is argued that tests of effect modifiers should become common practice in behavioral nutrition and physical activity research to increase our understanding of mechanisms of behavior change and to optimize interventions.

A church-based physical activity intervention for African American women

This trial evaluated a 6-month, church-based aerobic exercise intervention to increase physical activity among African American women relative to a health lecture and stretching condition. Participants were 196 women from 11 churches. Churches were randomized to an Aerobic Exercise or Health N Stretch intervention. Results indicated that physical activity was not different in Aerobic Exercise and Stretch N Health, although attendance in both interventions was low. Both groups reduced physical inactivity prevalence from baseline (26% and 18% decline, respectively). Higher baseline social support predicted change in physical activity, regardless of treatment assignment. Researchers must continue to work to identify successful intervention strategies to increase physical activity in African American women who are at disproportionate risk of chronic diseases associated with physical inactivity.

Reducing obesity and related chronic disease risk in children and youth: a synthesis of evidence with 'best practice' recommendations

Childhood obesity is a global epidemic and rising trends in overweight and obesity are apparent in both developed and developing countries. Available estimates for the period between the 1980s and 1990s show the prevalence of overweight and obesity in children increased by a magnitude of two to five times in developed countries (e.g. from 11% to over 30% in boys in Canada), and up to almost four times in developing countries (e.g. from 4% to 14% in Brazil). The goal of this synthesis research study was to develop best practice recommendations based on a systematic approach to finding, selecting and critically appraising programmes addressing prevention and treatment of childhood obesity and related risk of chronic diseases. An international panel of experts in areas of relevance to obesity provided guidance for the study. This synthesis research encompassed a comprehensive search of medical/academic and grey literature and the Internet covering the years 1982-2003. The appraisal approach developed to identify best practice was unique, in that it considered not only methodological rigour, but also population health, immigrant health and programme development/evaluation perspectives in the assessment. Scores were generated based on pre-determined criteria with programmes scoring in the top tertile of the scoring range in any one of the four appraisal categories included for further examination. The synthesis process included identification of gaps and an analysis and summary of programme development and programme effectiveness to enable conclusions to be drawn and recommendations to be made. The results from the library database searches (13,158 hits), the Internet search and key informant surveys were reduced to a review of 982 reports of which 500 were selected for critical appraisal. In total 158 articles, representing 147 programmes, were included for further analysis. The majority of reports were included based on high appraisal scores in programme development and evaluation with limited numbers eligible based on scores in other categories of appraisal. While no single programme emerged as a model of best practice, synthesis of included programmes provided rich information on elements that represent innovative rather than best practice under particular circumstances that are dynamic (changing according to population subgroups, age, ethnicity, setting, leadership, etc.). Thus the findings of this synthesis review identifies areas for action, opportunities for programme development and research priorities to inform the development of best practice recommendations that will reduce obesity and chronic disease risk in children and youth. A lack of programming to address the particular needs of subgroups of children and youth emerged in this review. Although immigrants new to developed countries may be more vulnerable to the obesogenic environment, no programmes were identified that specifically targeted their potentially specialized needs (e.g. different food supply in a new country). Children 0-6 years of age and males represented other population subgroups where obesity prevention programmes and evidence of effectiveness were limited. These gaps are of concern because (i) the pre-school years may be a critical period for obesity prevention as indicated by the association of the adiposity rebound and obesity in later years; and (ii) although the growing prevalence of obesity affects males and females equally; males may be more vulnerable to associated health risks such as cardiovascular disease. Other gaps in knowledge identified during synthesis include a limited number of interventions in home and community settings and a lack of upstream population-based interventions. The shortage of programmes in community and home settings limits our understanding of the effectiveness of interventions in these environments, while the lack of upstream investment indicates an opportunity to develop more upstream and population-focused interventions to balance and extend the current emphasis on individual-based programmes. The evidence reviewed indicates that current programmes lead to short-term improvements in outcomes relating to obesity and chronic disease prevention with no adverse effects noted. This supports the continuation and further development of programmes currently directed at children and youth, as further evidence for best practice accumulates. In this synthesis, schools were found to be a critical setting for programming where health status indicators, such as body composition, chronic disease risk factors and fitness, can all be positively impacted. Engagement in physical activity emerged as a critical intervention in obesity prevention and reduction programmes. While many programmes in the review had the potential to integrate chronic disease prevention, few did; therefore efforts could be directed towards better integration of chronic disease prevention programmes to minimize duplication and optimize resources. Programmes require sustained long-term resources to facilitate comprehensive evaluation that will ascertain if long-term impact such as sustained normal weight is maintained. Furthermore, involving stakeholders in programme design, implementation and evaluation could be crucial to the success of interventions, helping to ensure that needs are met. A number of methodological issues related to the assessment of obesity intervention and prevention programmes were identified and offer insight into how research protocols can be enhanced to strengthen evidence for obesity interventions. Further research is required to understand the merits of the various forms in which interventions (singly and in combination) are delivered and in which circumstances they are effective. There is a critical need for the development of consistent indicators to ensure that comparisons of programme outcomes can be made to better inform best practice.

Generations Exercising Together to Improve Fitness (GET FIT): a pilot study designed to increase physical activity and improve health-related fitness in three generations of women

A 6-month home-based (HB) physical activity program was compared to a control (CTL) condition in terms of effect on physical activity and health-related fitness in three generations of women (daughter/ mother/maternal grandmother). Volunteers were randomly assigned to a HB or CTL condition. HB participants (n = 28) were asked to participate in lifestyle, aerobic, muscular strength, and flexibility activities at least 3 times per week and they completed 73% of the recommended PA bouts. CTL condition participants (n = 9) were asked to continue their usual pattern of physical activity. Changes in physical activity were measured pre-and post-intervention using the Physical Best questionnaire and pedometer step counts (3-day average). Changes in health-related fitness were assessed using Fitnessgram tests. Group x Time interactions were significant for changes in participation in flexibility activity (d/wk) and steps/day, indicating that the HB group experienced significant positive changes in the expected direction (+305% and +37%, respectively), while the CTL group regressed (-15% and -13%, respectively). The G x T interaction for mile time was significant, although not in the expected direction (CTL group < by 14% and HB group < by 5%). Findings should be interpreted with caution due to several limitations of the study, but several suggestions are made for more effectively studying this topic in the future.

Determinants of physical activity and low-fat diet among low income African American and Hispanic middle school students

African Americans, Hispanics, and those with low income experience disproportionate health problems that can be prevented by physical activity and a lower fat diet. In this descriptive cross-sectional study, antecedents of diet and exercise within the Health Promotion/Transtheoretical Model were examined among low-income African American and Hispanic seventh-grade students (n = 127). Total support was associated with higher physical activity for girls. African Americans perceived greater social support for activity than Hispanics. Family models and support for physical activity and low-fat diet were greater as family income increased. However, higher family role models and lower dietary fat were found among the lowest income Hispanic students' residing ZIP code with a higher concentration of Hispanics and greater availability of Hispanic foods and culture. A school-based approach may be useful to build peer support for physical activity and lower dietary fat. Parish nurse or clinic settings may be most appropriate for building family role models and support. Living in a neighborhood with traditional Hispanic culture and foods appears to have ameliorated the harmful effects of lower income, although further study with larger samples followed over time is needed.

Changing the tide: an Internet/video exercise and low-fat diet intervention with middle-school students

The rising tide of obesity erodes the health of youths and many times results in adult obesity. The purpose of this investigation was to examine the effectiveness of an eight-session health promotion/transtheoretical model Internet/video-delivered intervention to increase physical activity and reduce dietary fat among low-income, culturally diverse, seventh-grade students. Those who completed more than half the sessions increased exercise, t (103) = -1.99, p = .05, and decreased the percentage of dietary fat, t (87) = 2.73, p = .008. Responses to the intervention by stage of change, race, and income are examined.

Interventions for promoting physical activity

BACKGROUND

Little is known about the effectiveness of strategies to enable people to achieve an increase in their physical activity.

OBJECTIVES

To assess the effects of interventions for promoting physical activity in adults aged 16 years and older, not living in an institution.

SEARCH STRATEGY

We searched CENTRAL (Issue 4, 2001), MEDLINE, EMBASE, CINAHL, PsychLIT, BIDS ISI, SPORTDISCUS, SIGLE, SCISEARCH (from earliest date available to December 2001) and reference lists of articles.

SELECTION CRITERIA

Randomised, controlled, trials comparing different interventions to encourage sedentary adults not living in an institution to become physically active. Studies required a minimum of six months follow up from the start of the intervention to the collection of final data and either used an intention to treat analysis or, failing that, had no more than 20% loss to follow up.

DATA COLLECTION AND ANALYSIS

At least two reviewers independently assessed each study quality and extracted data. Study authors were contacted for additional information where necessary. Standardised mean differences and 95% confidence intervals were calculated for continuous measures of self reported physical activity and cardio-respiratory fitness. For studies with dichotomous outcomes, odds ratios and 95% confidence intervals were calculated.

MAIN RESULTS

The effect of interventions on self reported physical activity (11 studies; 3940 participants) was positive and moderate, with a pooled standardised mean difference of 0.31 (95% CI 0.12 to 0.50), as was the effect on cardio-respiratory fitness (7 studies; 1406 participants) pooled SMD 0.4 (95% CI 0.09 to 0.70). The effect of interventions in achieving a predetermined threshold of physical activity (6 studies; 2313 participants) was not significant with an odds ratio of 1.30 (95% CI 0.87 to 1.95). There was significant heterogeneity in the reported effects as well as heterogeneity in characteristics of the interventions. The heterogeneity in reported effects was reduced in higher quality studies, when physical activity was self-directed with some professional guidance and when there was on-going professional support.

AUTHORS' CONCLUSIONS

Our review suggests that physical activity interventions have a moderate effect on self reported physical activity and cardio-respiratory fitness, but not on achieving a predetermined level of physical activity. Due to the clinical and statistical heterogeneity of the studies, only limited conclusions can be drawn about the effectiveness of individual components of the interventions. Future studies should provide greater detail of the components of interventions.

Baseline assessment of the health status and health behaviors of African Americans participating in the activities-for-life program: a community-based health intervention program

Obesity is a serious problem in the United States and is associated with hypertension, diabetes, and other health problems such as heart disease and some forms of cancer. There is a higher prevalence of being overweight among African American adults than among their Caucasian counterparts. The objective of this study was to assess baseline health behaviors and health status (hypertension, body mass indices, cholesterol and blood sugar levels) of African Americans participating in a community-based health education and physical fitness program. The sample consisted of 1.34 African American adults (30% males) from a low-income urban area in the Midwest. A health survey was administered to assess their health behaviors and previously diagnosed health problems. Additional data was obtained from health screenings to obtain current information on height, weight, and blood sugar, blood pressure and cholesterol levels. In addition to the sample being markedly overweight and obese (30% and 60% respectively), the results of the health screenings indicated a disproportionate number of participants (62%) with hypertension; 74% of the male participants had high blood pressure. Moreover, the self-reported data suggested that the participants had poor eating habits, sedentary lifestyles, and previously diagnosed health conditions (hypertension, diabetes, and high cholesterol levels) that were comparable to the results of their health screenings. These findings suggest that culturally-relevant, community-based programs that incorporate both nutritionl education and physical fitness are needed in order to educate and motivate participants to decrease behaviors that put them at risk for obesity and other health related problems.

Stage-based interventions for low-fat diet with middle school students

Preventing obesity and cardiovascular disease at early ages is important; however, few effective interventions for early adolescents have been reported. In this study, low-income, culturally diverse students from an urban middle school (n = 60) received four classroom interventions with the use of a combined Health Promotion/Transtheoretical Model to control fat in diet and increase physical activity. A control group (n = 57) received the usual classroom education. Pretest percentage fat in diet was regressed on demographics, access to low-fat foods, perceived self-efficacy, benefits/barriers, and stage of change with results as proposed by the model [F(9,64) = 5.77; p =.000; adjusted R(2) = 0.35]. Posttest percentage fat in food was significantly less for the intervention group as compared with the control group (t = 2.06; df, 115; p =.04).

Daughters and mothers exercising together: effects of home- and community-based programs

PURPOSE

This pilot study compares the effectiveness of home- and community-based physical activity interventions that target mothers and daughters to increase physical activity and improve health-related fitness.

METHODS

Mothers (45.18 +/- 7.49 yr) and daughters (15.41 +/- 1.33 yr) were randomly assigned to a community-based (CB) (N = 20 participants) or home-based (HB) (N = 14 participants) program. CB participants attended three instructor-led sessions per week for 12 wk. HB participants were asked to participate in 3 sessions per week for 12 wk in a program similar to the CB program. The main difference between the programs was that CB activities were completed at a fitness facility within a university and HB activities were completed in or near the home. Before and after the intervention, changes in health-related fitness and physical activity were assessed. A series of 2 (group assignment) x 2 (time) ANOVAs were conducted to assess changes separately for mothers and daughters.

RESULTS

CB participants attended 77% of the sessions, and none of the pairs dropped out. HB participants completed 70% of the recommended sessions, and three pairs dropped out. Mothers and daughters in both groups significantly increased their participation in aerobic, muscular strength, and flexibility activities (P = 0.02 to 0.000). Daughters in both groups significantly improved their muscular endurance (sit-ups,P = 0.000). Mothers in both groups improved their muscular strength (push-ups, P = 0.003), muscular endurance (sit-ups, P = 0.000), flexibility (sit-and-reach, P = 0.008), and aerobic capacity (1-mile walk, P = 0.002). Positive changes in diastolic blood pressure also occurred (P = 0.008).

CONCLUSION

Mothers and daughters responded positively to CB and HB physical activity programs. Home-based physical activity programming is a cost-effective means to increase physical activity and improve health-related fitness in these groups.

Evaluation of a community-based intervention to promote physical activity in youth: lessons from Active Winners

PURPOSE

To test the effects of a community-based physical activity intervention designed to increase physical activity and to conduct an extensive process evaluation of the intervention.

DESIGN

Quasi-experimental.

SETTING

Two rural communities in South Carolina. One community received the intervention, and the other served as the comparison.

SUBJECTS

Public school students who were in fifth grade at the start of the study (558 at baseline) were eligible to participate. A total of 436 students participated over the course of the study.

INTERVENTION

The intervention included after-school and summer physical activity programs and home, school, and community components designed to increase physical activity in youth. The intervention took place over an 18-month period.

MEASURES

Students reported after-school physical activity at three data collection points (prior to, during, and following the intervention) using the Previous Day Physical Activity Recall (PDPAR). They also completed a questionnaire designed to measure hypothesized psychosocial and environmental determinants of physical activity behavior. The process evaluation used meeting records, documentation of program activities, interviews, focus groups, and heart rate monitoring to evaluate the planning and implementation of the intervention.

RESULTS

There were no significant differences in the physical activity variables and few significant differences in the psychosocial variables between the intervention and comparison groups. The process evaluation indicated that the after-school and summer physical activity component of the intervention was implemented as planned, but because of resource and time limitations, the home, school, and community components were not implemented as planned.

CONCLUSIONS

The intervention did not have a significant effect on physical activity in the target population of children in the intervention community. This outcome is similar to that reported in other studies of community-based physical activity intervention.

Correlates of exercise adherence in an African American church community

This study identified correlates of attendance to a community-based exercise program in an African American church congregation. After medical clearance, 48 participants completed measures of social support, health-related quality of life, depression, exercise self-efficacy, and exercise motivation and then participated in an exercise program for 6 months (attendance rate = 27%). Age, a sense of affiliation as a motivator to exercise, and weekly caloric expenditure derived from yard work were positively associated with program attendance, and full- or part-time employment was negatively associated with attendance. The authors concluded that exercise adherence is a complicated phenomenon that is influenced by a variety of environmental, personal, and social factors. Social factors, in particular, may be important in promoting adherence to an exercise program in African Americans.

Exercise training for African Americans with disabilities residing in difficult social environments

OBJECTIVE

To examine the feasibility, efficacy, and safety of a structured 12-week exercise training program for a predominantly African-American group of adults with multiple health conditions who reside in difficult social environments.

METHODS

A total of 37 females and 7 males (mean age, 54.1 years) participated in an exercise training regimen 3 days per week for 60 minutes per day (cardiovascular, 30 minutes; strength, 20 minutes; and flexibility, 10 minutes). Outcome measures included peak VO(2) (mL min(-1), mL kg(-1) min(-1)); upper and lower body strength (strength); hand-grip strength (GS); body weight (BW); total skin folds (TS); waist-to-hip ratio (WHR); hamstring/low-back flexibility (HLBF); and shoulder flexibility (SF).

RESULTS

Compared to the control group, the exercise group showed significant gains in peak VO(2) (p < 0.01); strength (p < 0.01); and body composition (TS, p < 0.01). There was no significant difference between the exercise and control groups on BW, WHR, HLBF, and GS. Of a total 1116 exercise sessions (31 experimental participants x 36 sessions), 87% of the sessions were attended.

CONCLUSIONS

A structured exercise-training program can provide substantial improvement in strength and cardiovascular fitness in low-income, sedentary adults with multiple chronic conditions and/or risk factors for chronic conditions. Future research should explore simple home-based and community-based physical activity interventions that provide ongoing support for increasing and maintaining physical activity participation in this cohort.