Physical Activity: Individually-Adapted Health Behavior Change Programs

• In all 18 studies reviewed, individually-adapted health behavior change programs were effective in increasing physical activity as measured by various indicators.
  • Time spent in physical activity: median net increase of 35.4% (interquartile interval: 16.7% to 83.3%; 20 study arms)
  • Aerobic capacity (VO2 max): median increase of 6.3% (interquartile interval: 5.1% to 9.8%; 13 study arms)
  • Energy expenditure: median increase of 64.3% (interquartile interval: 31.2% to 85.5%; 15 study arms)
• Other measures of physical activity, such as the percentage of people starting exercise programs and the frequency of physical activity, also increased as a result of these programs.

• This 2-year study evaluated the cost-effectiveness of two physical activity interventions (lifestyle and structured interventions) provided to adults aged 35 to 60 years.
  • The lifestyle intervention consisted of behavioral skills training to integrate moderate-to-intense physical activity into the lives of participants.
  • The structured exercise intervention consisted of supervised center-based exercise.
• Program costs included personnel, capital equipment, facilities, and general supplies. Research costs, recruitment costs, and value of participants’ time were not included.
• The adjusted cost-effectiveness ratio for each intervention arm ranged between $0.05 to $3.94 and $0.07 to $5.39 per average unit (as defined in the outcomes measured above) of improvement for lifestyle and structured intervention, respectively.

• What characteristics and components are most effective?
• What mode of delivery is most effective?
• Does the effectiveness of behavioral change method vary by type of physical activity?
• Are these interventions effective in increasing physical activity?
• Do these interventions promote positive or negative attitudes toward physical activity?

General Research Issues

The following outlines evidence gaps for reviews of these interventions to increase physical activity: Individually-Adapted Health Behavior Change Programs; Social Support Interventions in Community Settings; Family-Based Social Support; Enhanced School-Based Physical Education (archived); College-Based Physical Education and Health Education; Classroom-Based Health Education to Reduce TV Viewing and Video Game Playing; Community-Wide Campaigns; Mass Media Campaigns (archived); Classroom-Based Health Education Focused on Providing Information; Creation of or Enhanced Access to Places for Physical Activity Combined with Informational Outreach Activities.

Effectiveness

Several crosscutting research issues about the effectiveness of all of the reviewed interventions remain.

• What behavioral changes that do not involve physical activity can be shown to be associated with changes in physical activity?
  • For example, does a decrease in time spent watching television mean an increase in physical activity or will another sedentary activity be substituted?
  • Does an increase in the use of public transportation mean an increase in physical activity or will users drive to the transit stop?
• Physical activity is difficult to measure consistently across studies and populations. Although several good measures have been developed, several issues remain to be addressed.
  • Reliable and valid measures are needed for the spectrum of physical activity. Rationale: Current measures are better for vigorous activity than for moderate or light activity.
  • Sedentary people are more likely to begin activity at a light level; this activity is often not captured by current measurement techniques.
  • Increased consensus about “best measures” for physical activity would help to increase comparability between studies and would facilitate assessment of effectiveness.
• Note: This is not intended to preclude researchers’ latitude in choosing what aspects of physical activity to measure and to decide which measures are most appropriate for a particular study population. Perhaps a useful middle ground position would be the establishment of selected core measures that most researchers should use which could then be supplemented by additional measures. The duration of an intervention’s effect was often difficult to determine.

Applicability

Each recommended and strongly recommended intervention should be applicable in most relevant target populations and settings, assuming that appropriate attention is paid to tailoring. However, possible differences in the effectiveness of each intervention for specific subgroups of the population often could not be determined. Several questions about the applicability of these interventions in settings and populations other than those studied remain.

• Are there significant differences in the effectiveness of these interventions, based on the level or scale of an intervention?
• What are the effects of each intervention in various sociodemographic subgroups, such as age, gender, race, or ethnicity?

Other Positive or Negative Effects

The studies included in this review did not report on other positive and negative effects of these interventions. Research on the following questions would be useful:

• Do informational approaches to increasing physical activity help to increase health knowledge? Is it necessary to increase knowledge or improve attitudes toward physical activity to increase physical activity levels?
• Do these approaches to increasing physical activity increase awareness of opportunities for and benefits of physical activity?
• What are the most effective ways to maintain physical activity levels after the initial behavior change has occurred?
• Are there other benefits from an intervention that might enhance its acceptability? For example, does increasing social support for physical activity carry over into an overall greater sense of community?
• Are there any key harms?
• Is anything known about whether or how approaches to physical activity could reduce potential harms (e.g., injuries or other problems associated with doing too much too fast)?

Economic Evidence

The available economic data were limited. Therefore, considerable research is warranted on the following questions:

• What is the cost-effectiveness of each of these interventions?
• How can effectiveness in terms of health outcomes or quality-adjusted health outcomes be better measured, estimated, or modeled?
• How can the cost benefit of these programs be estimated?
• How do specific characteristics of each of these approaches contribute to economic efficiency?
• What combinations of components in multicomponent interventions are most cost-effective?

Barriers

Research questions generated in this review include the following:

• What are the physical or structural (environmental) barriers to implementing these interventions?
• What resource (time and money) constraints prevent or hinder the implementation of these interventions?

• All programs incorporated the following behavioral approaches:
  • Setting goals for physical activity and self-monitoring of progress toward goals
  • Building social support for new behavioral patterns
  • Behavioral reinforcement through self-reward and positive self-talk
  • Structured problem-solving geared to maintenance of the behavior change, and
  • Prevention of relapse into sedentary behaviors.
• Many or most of the included studies used constructs from one or more established health behavior change models.
• All of the interventions evaluated were delivered to people either in group settings or by mail, telephone, or directed media.
• In the typical intervention, volunteers were grouped to provide companionship and support to help each other reach self-selected activity goals. Study participants received phone calls from other participants and from study staff members to monitor progress and encourage them to continue their activities.
• Some studies involved formal discussion groups to address barriers to exercise and negative perceptions about activity.
• Studies were conducted in the United States (17 studies), and Australia (1 study).
• Interventions were offered in community settings (14 studies), worksites (4 studies), schools or universities (2 studies), or a telecommunications company (1 study).
• Studies typically included volunteer samples, which limit generalizing to the entire population.
• Most studies reported results for men and women, though three studies reported results only for women.
• Study populations for most studies were middle-aged; four studies focused on people ages 50 years or older.

Task Force on Community Services. Recommendations to increase physical activity in communities. American Journal of Preventive Medicine 2002;22(4S):67-72.

Centers for Disease Control and Prevention. Increasing physical activity. A report on recommendations of the Task Force on Community Preventive Services. MMWR 2001;50(RR-18):1-16. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5018a1.htm.

Roux L, Pratt M, Tengs TO, et al. Cost effectiveness of community-based physical activity interventions. American Journal of Preventive Medicine 2008;35(6):578-88. Available at: http://www.ajpmonline.org/article/S0749-3797(08)00770-8/abstract.

Dunn AL, Blair SN. Translating evidence-based physical activity interventions into practice. American Journal of Preventive Medicine 2002;22(4S):8-9.

Task Force on Community Services, Zaza S, Briss PA, Harris KW. Physical activity. In: The Guide to Community Preventive Services: What Works to Promote Health? Atlanta (GA): Oxford University Press; 2005:80-113.

Effectiveness Review

Analytic Framework see Figure 1 on page 76

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Effectiveness Review

Summary Evidence Table Economic Review see Table A-3 on page 100

Effectiveness Review

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Cardinal BJ, Sachs ML. Prospective analysis of stage-of-exercise movement following mail-delivered, self-instructional exercise packets. Am J Health Promot 1995;9:430 2.

Chen A. A home-based behavioral intervention to promote walking in sedentary ethnic minority women: project WALK. Womens Health 1998; 4:19 39.

Coleman KJ, Raynor HR, Mueller DM, Cerny FJ, Dorn JM, Epstein LH. Providing sedentary adults with choices for meeting their walking goals. Prev Med 1999;28:510 9.

Dunn AL, Marcus BH, Kampert JB, Garcia ME, Kohl HW 3rd, Blair SN. Comparison of lifestyle and structured interventions to increase physical activity and cardiorespiratory fitness: a randomized trial. JAMA 1999;281:327 34.

Foreyt JP, Goodrick GK, Reeves RS, Raynaud AS. Response of free-living adults to behavioral treatment of obesity: attrition and compliance to exercise. Behav Ther 1993;24:659 69.

Jarvis KL, Friedman RH, Heeren T, Cullinane PM. Older women and physical activity: using the telephone to walk. Womens Health Issues 1997;7:24 9.

Jeffery RW, Wing RR, Thorson C, Burton LR. Use of personal trainers and financial incentives to increase exercise in a behavioral weight-loss program. J Consult Clin Psychol1998;66:777 83.

Jette A, Lachman M, Giorgetti M, et al. Exercise-It’s Never Too Late: The Strong-for-Life Program. Am J Public Health 1999;89:66 72.

Kanders BS, Ullmann-Joy P, Foreyt JP, et al. The black American lifestyle intervention (BALI): the design of a weight loss program for working-class African-American women. J Am Diet Assoc 1994;94:310 2.

King A, Haskell WL, Taylor CB, Kraemer HC, DeBusk RF. Group vs home based exercise training in healthy older men and women. JAMA 1991;266:1535 42.

Marcus B, Emmons KM, Simkin-Silverman LR, et al. Evaluation of motivationally tailored vs standard self-help physical activity interventions at the workplace. Am J Health Promot1998;12:246 53.

Mayer JA, Jermanovich A, Wright BL, Elder JP, Drew JA, Williams SJ. Changes in health behaviors of older adults: the San Diego Medicare Preventive Health Project. Prev Med1994;23:127 33.

McAuley E, Courneya KS, Rudolph DL, Lox CL. Enhancing exercise adherence in middle-aged males and females. Prev Med 1994;23:498 506.

Noland MP. The effects of self-monitoring and reinforcement on exercise adherence. Res Q Exerc Sport 1989;60:216 24.

Owen N, Lee C, Naccarella L, Haag K. Exercise by mail: a mediated behavior-change program for aerobic exercise. J Sport Psychol 1987;9:346 57.

Peterson TR, Aldana SG. Improving exercise behavior: an application of the stages of change model in a worksite setting. Am J Health Promot 1999;13:229 32.

Wing RR, Jeffery RW, Pronk N, Hellerstedt WL. Effects of a personal trainer and financial incentives on exercise adherence in overweight women in a behavioral weight loss program.Obes Res 1996;4:457 62.

Economic Review

Sevick MA, Dunn AL, Morrow MS, Marcus BH, Chen GJ, Blair SN. Cost-effectiveness of lifestyle and structured exercise interventions in sedentary adults. Results of project ACTIVE. Am J Prev Med 2000;19:1 8.

Implementation Resource

Rural Health Information Hub, Obesity Prevention Toolkit
This toolkit compiles information, resources, and best practices to support development and implementation of obesity prevention programs in rural communities. Modules include program models, implementation and evaluation resources, and funding and dissemination strategies.

Effectiveness Review

The search for evidence started with seven computerized databases (MEDLINE, Sportdiscus, Psychlnfo, Transportation Research Information Services [TRIS], Enviroline, Sociological Abstracts, and Social SciSearch) and included reviews of reference lists and consultations with experts in the field. Studies were eligible for inclusion if they:

• Were published in English during 1980-2000
• Were conducted in an Established Market Economy*
• Assessed a behavioral intervention primarily focused on physical activity
• Were primary investigations of interventions selected for evaluation rather than, for example, guidelines or reviews
• Evaluated outcomes selected for review; and
• Compared outcomes among groups of persons exposed to the intervention with outcomes among groups of persons not exposed or less exposed to the intervention (whether the study design included a concurrent or before-and-after comparison)

* Established Market Economies as defined by the World Bank are Andorra, Australia, Austria, Belgium, Bermuda, Canada, Channel Islands, Denmark, Faeroe Islands, Finland, France, Germany, Gibraltar, Greece, Greenland, Holy See, Iceland, Ireland, Isle of Man, Italy, Japan, Liechtenstein, Luxembourg, Monaco, the Netherlands, New Zealand, Norway, Portugal, San Marino, Spain, St. Pierre and Miquelon, Sweden, Switzerland, the United Kingdom, and the United States.

Economic Review

The databases MEDLINE, Transportation Research Information Services (TRIS), Combined Health Information Database (CHID), ECONLIT, PsychInfo, Sociological Abstracts, Sociofile, Social SciSearch, and Enviroline were searched for the period 1980 2000. In addition, the references listed in all retrieved articles were reviewed and experts were consulted. Most of the included studies were either government reports or were published in journals. To be included in the review a study had to:

• Be a primary study rather than, for example, a guideline or review
• Take place in an Established Market Economy
• Be written in English
• Meet the team’s definitions of the recommended and strongly recommended interventions
• Use economic analytical methods such as cost analysis, cost-effectiveness analysis, cost-utility, or cost-benefit analysis; and
• Itemize program costs and costs of illness or injury averted

• Individually-adapted health behavior change programs require careful planning and coordination, well-trained staff members, and resources sufficient to carry out the program as planned.

Evidence-Based Cancer Control Programs (EBCCP)

Find programs from the EBCCP website that align with this systematic review. (What is EBCCP?)

Healthy People 2030

Healthy People 2030 includes the following objectives related to this CPSTF recommendation.

• • Reduce the proportion of adults who do no physical activity in their free time — PA‑01
  • Increase the proportion of adults who do enough aerobic physical activity for substantial health benefits — PA‑02
  • Increase the proportion of adults who do enough aerobic physical activity for extensive health benefits — PA‑03
  • Increase the proportion of adults who do enough muscle-strengthening activity — PA‑04
  • Increase the proportion of adults who do enough aerobic and muscle-strengthening activity — PA‑05