Preventive Medicine 67 (2014) 46–64
Contents lists available at ScienceDirect
Preventive Medicine journal homepage: www.elsevier.com/locate/ypmed
Review
Systematic review of incidental physical activity community interventions Rebecca Reynolds a,⁎, Stephen McKenzie b, Steven Allender c, Kirsty Brown b, Chad Foulkes b,c a b c
School of Public Health and Community Medicine, UNSW Australia, Sydney, NSW 2052, Australia City of Greater Geelong Council, PO Box 104, Geelong, VIC 3220, Australia WHO Collaborating Centre for Obesity Prevention, Deakin University, Locked Bag 20000, Geelong, VIC 3220, Australia
a r t i c l e
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Available online 25 June 2014 Keywords: Health promotion Health education Motor activity Walking Bicycling Chronic disease Obesity
a b s t r a c t Background. Increasing incidental physical activity (IPA) such as active transport has substantial public health potential. Objective. This systematic review describes community-based and community-wide IPA interventions and assesses their effectiveness. Method. Data sources (Medline, Embase, PsycINFO and CINAHL) were searched along with the reference lists of identified systematic reviews and included articles. Eligibility criteria; 4 + weeks in duration; 20 + participants; community-based or community-wide; stated aim to increase IPA. Results. Forty three studies were identified from 42 original articles; more than half (60%) aimed to increase stair use compared to escalator and/or lift use; a quarter (23%) aimed to increase active transport; and, 16% to increase playground energy expenditure. More than two-thirds of studies reported a significant increase in IPA. Accurate comparisons between studies were not possible due to substantial heterogeneity in study design. Critical appraisal of studies revealed that the level of bias was moderate–high in most of the studies (77%). Conclusion. Due to the heterogeneity and bias of included studies, only limited conclusions can be drawn about the effectiveness of IPA interventions. However, this systematic review provides a timely summary of current evidence that can be used to inform decision-makers in designing IPA interventions in the community. © 2014 Elsevier Inc. All rights reserved.
Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Definition of IPA . . . . . . . . . . . . . . . . . . . . . . . . . . Search strategy . . . . . . . . . . . . . . . . . . . . . . . . . . Study eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . Study selection . . . . . . . . . . . . . . . . . . . . . . . . . . Data collection . . . . . . . . . . . . . . . . . . . . . . . . . . Critical appraisal . . . . . . . . . . . . . . . . . . . . . . . . . . Principal outcome measures . . . . . . . . . . . . . . . . . . . . Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Search results and study selection . . . . . . . . . . . . . . . . . . Critical appraisal . . . . . . . . . . . . . . . . . . . . . . . . . . Narrative synthesis and calculated significant percentage increases in IPA Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Active travel interventions . . . . . . . . . . . . . . . . . . . . . Playground physical activity interventions . . . . . . . . . . . . . .
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Abbreviations: IPA, Incidental Physical Activity; MVPA, Moderate to Vigorous Physical Activity. ⁎ Corresponding author. E-mail addresses: [email protected] (R. Reynolds), [email protected] (S. McKenzie), [email protected] (S. Allender), [email protected] (K. Brown), [email protected] (C. Foulkes).
http://dx.doi.org/10.1016/j.ypmed.2014.06.023 0091-7435/© 2014 Elsevier Inc. All rights reserved.
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Stair use interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Study implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Study limitations and strengths . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conflict of interest statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Acknowledgements and funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Appendix A. Search strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A.1. Medline search strategy 17/01/13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A.2. Embase search strategy 17/01/13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A.3. Psycinfo search strategy 17/01/13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A.4. CINAHL search strategy 17/01/13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Appendix B. Critical appraisal of 43 included studies: 6 critical appraisal criteria for each study (different criteria sets for RCT/CT/CBA vs. ITS — Appendix C. Characteristics of 43 included studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Appendix A. Supplementary data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Introduction Evidence for a positive relationship between physical activity and health, including for the prevention of overweight and obesity, and other non-communicable diseases (Lee et al., 2012), including type 2 diabetes mellitus (Manson et al., 1991) and depression (Mammen and Faulkner, 2013) is strong in both children and adults. The effectiveness of interventions to increase physical activity has been the subject of numerous systematic reviews (Baker et al., 2011; Dobbins et al., 2013; Kahn et al., 2002; Malik et al., 2013; van Sluijs et al., 2007), showing mixed results. A Cochrane review of community-wide physical activity interventions reported that many studies have serious methodological issues and there is insufficient evidence that multi-component community-wide interventions effectively increase population levels of physical activity (Baker et al., 2011). Similarly, Dobbins et al. reviewed school-based physical activity interventions and state, ‘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’ (Dobbins et al., 2013). The evidence appears to be somewhat at its infancy then as to whether it is possible to increase population physical activity levels via a variety of means in different groups — especially sustainably. However, the evidence is strong enough to warrant continued effort into physical activity interventions (Heath et al., 2012), including in school community settings: ‘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’ (VO2 max) (Dobbins et al., 2013). While there have been systematic reviews on specific IPA interventions such as active transport in children (Faulkner et al., 2009) and active transport in adults (Wanner et al., 2012), there have been no systematic reviews to date that focus on community-based or communitywide IPA interventions in combination. One reason for this lack of systematic reviews on IPA interventions in combination may be the difficulty in providing accurate definitions for the term. IPA definitions include, ‘unstructured activity taken during the day, such as walking for transport, housework and the performance of activities of daily living’ (Department of Health and Ageing, A. G. et al., 2006) and conversely the Canadian Society for Exercise Physiology's definition: ‘Activities of daily living’ (Canadian Society for Exercise Physiology, 2011). Increasing incidental energy expenditure via practical day-to-day tasks has substantial public health potential, partly because more adults participate in non-organized physical activity than in organized physical activity (Australian Sports Commission, 2010). In multiple constituencies the concept of creating spaces and opportunities to support IPA on health grounds is gaining traction. The recent US Institute of Medicine report identified environmental and policy strategies as being one of the most promising for accelerating progress in obesity prevention (‘the physical
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53 53 53 54 54 54 54 54 54 54 54 54 54 54 54
activity environment, which includes the built environment as well as norms and processes that increase opportunities for, access to, and social reinforcement of physical activity’) (Institute of Medicine, 2013) and the UK National Institute of Health and Clinical Excellence's scope for systems-level obesity prevention highlights the importance of the built environment and transport systems (National Institute for Health and Care Excellence, 2010). Despite limited evidence governmental recommendations to increase IPA are wide-ranging and include individual and social marketing approaches to policy level change. At the policy level, for example, the Australian Federal Government (Department of Health and Ageing, 2013) recommended that: … the Federal Government work with all levels of government and the private sector to develop nationally consistent urban planning guidelines which focus on creating environments that encourage Australians to be healthy and active. The perceived health benefits of IPA such as walking and cycling appear to contribute approximately 80% of the net benefits of both modes of travel and state that, ‘Incorporating exercise into travel has been identified as a highly effective means to increase daily physical activity, which can help individuals to maintain better health’ (Department of Infrastructure, 2013 (July)). However, the evidence base is often not consistent or clear (Baker et al., 2011; Dobbins et al., 2013). To provide a strong, evidence-based rationale for the development of interventions to increase IPA, a clear understanding of the state of the current literature is required which presents evidence of effectiveness of interventions to increase IPA and efficacy of these interventions in achieving health improvements. This systematic review addresses the effects of community-based and community-wide interventions to increase IPA outcomes – such as self-reported rate of active transport – in 20 or more children and/or adults over 4 or more weeks with the comparison being a control group or baseline data. Interventions were Randomized Controlled Trials (RCT), Controlled Trials (CT), Controlled Before and After (CBA) studies or Interrupted Time Series (ITS) study design.
Methods Definition of IPA We use the Australian Institute of Health and Welfare's definition of IPA for this review: IPA includes the forms of physical activity done at work and home, and activity in which people take part as they go about their day-to-day lives, generally using large skeletal muscle groups (Australian Institute of Health and Welfare, 1999). We use the Australian National Public Health Partnership's definition of active transport for this review: ‘travel between destinations by walking,
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cycling or other non-motorized modes’ (National Public Health Partnership, 2001). We used these definitions of IPA and active transport to develop a list of IPAs (Table 1). We added activities to this list by taking terms from six international adult and child questionnaires assessing physical activity (Table 1) (Australian Institute of Health and Welfare, 1999; Centers for Disease Control and Prevention, 2012; Deakin University; Karolinksa Institutet, 2002; Medical Research Council Epidemiology Unit; National Public Health Partnership, 2001; VicHealth). In total, we developed a list of 10 IPAs for purposes of this review (Table 1). Search strategy The search strategy involved the 10 IPA terms listed in Table 1 (Australian Institute of Health and Welfare, 1999; Centers for Disease Control and Prevention, 2012; Deakin University; Karolinksa Institutet, 2002; Medical Research Council Epidemiology Unit; VicHealth) and health promotion terms adapted from a recent Cochrane review on obesity prevention in children (Waters et al., 2011). Search terms were adapted for and run in four databases on 17th January 2013: Medline, Embase, PsycINFO and CINAHL (complete search strategies are provided in Appendix A and the review protocol is not provided elsewhere, but further details can be obtained by contacting the corresponding author, RR). Snowballing was carried out to check that no studies had been missed for inclusion using the reference lists of all relevant systematic reviews (noted during the inclusion and exclusion process) and the reference lists of included studies.
Study selection Search results from the four databases were combined in Endnote reference management software program and duplicates removed. Screening of the remaining articles for eligible studies was completed by SM and RR, who reviewed half each by reviewing title and/or abstract. A 20% sample of studies excluded in this screening stage (10% of studies excluded by SM and 10% of studies excluded by RR) were separately reviewed in a quality control process by CF or KB to check on the likelihood of eligible articles being excluded in the screening process. This methodology has been previously published (Australian Primary Health Care Research Institute and The University of New South Wales, 2006). Studies still potentially eligible after screening were then verified by SM and RR, who reviewed half of the full texts each. Again, 20% sample of studies excluded in this full text verification stage (10% of studies excluded by SM and 10% of studies excluded by RR) were separately reviewed in a quality control process by CF or KB to check on the likelihood of eligible articles being excluded in the verification process (Australian Primary Health Care Research Institute and The University of New South Wales, 2006). Eligible studies that passed the verification stage were included in the systematic review. Snowballing was carried out using the reference lists of eligible studies included in the systematic review from the verification stage. Eligible studies in these reference lists underwent the same review process as studies identified in the database searches, i.e. screening and verification. In all stages, any discrepancies were discussed until consensus was reached. Data collection
Study eligibility Study eligibility criteria are presented in Table 2. Briefly, based on the PRISMA-suggested PICOS criteria (Moher et al., 2009): Participants were 20 or more children and adults in community settings (community-based, i.e. targeting a specific population in the community, e.g. school; or, community-wide, i.e. not targeting a specific population group, e.g. shopping center), e.g. primary schools; Interventions aimed to increase IPA levels over 4 or more weeks, e.g. a multi-component intervention including the education of children and parents about the benefits of active travel by the children to school (Wen et al., 2008); Comparisons were control groups who didn't receive the intervention (or baseline data if participants were acting as their own control); Outcomes were IPA levels, e.g. self-report using questionnaires to both students and parents on how students traveled to and from school (Wen et al., 2008); and Study designs were RCT, CT, CBA and ITS. Studies were eligible if published in a peer-review journal article between January 1970 and December 2012 in the English language.
Table 1 IPAs used in this review. 1. Stair use/taking the stairs 2. Active transport: ‘travel between destinations by walking, cycling or other non-motorized modes’ (National Public Health Partnership, 2001) 3. Walk, cycle or other non-motorized modes to and from places, including: work, school, to do errands, to classes if you are a student, stores, restaurants, movies 4. Stand or walk around during most of the day 5. Gardening or other work around yard/yard work, general maintenance work, including: chopping wood, sweeping patio, heavy lifting, shoveling snow, digging and raking in the garden or yard 6. Household chores, housework, including: carrying light loads, sweeping, washing windows, scrubbing floors 7. Caring for your family 8. Occupational physical activity, including: heavy lifting, digging, heavy construction; climbing up stairs; carrying light loads; repeated lifting, pushing and pulling heavy objects; repeated bending, twisting and reaching; working with hand-held or hand-operated vibrating tools and machinery 9. Walking the dog/working with other animals, e.g. horse 10. Children's play activities, e.g. imaginary play, play indoors with toys, play with pets, bounce on the trampoline, play in the cubby house, play on playground equipment, skipping rope, tag/chasey, down ball/4 square Reference: National Public Health Partnership (2001). PROMOTING ACTIVE TRANSPORT: An intervention portfolio to increase physical activity as a means of transport. from http://www.nphp.gov.au/publications/sigpah/activetransport.pdf.
Data was extracted from studies using full texts by SM and RR into an Excel spreadsheet. Each reviewer inputted half of the eligible studies each into the Excel spreadsheet independently. Data items included: year of publication, study design, study location, intervention details, setting, number of participants or observations, characteristics of participants, duration of intervention, outcomes and significance. Critical appraisal Included studies were critically appraised by RR, CF and KB for their risk of bias using guidelines suggested by the Cochrane Public Health Group, who outlines two sets of criteria for critical assessment of differential study designs: designs that involve a control group; RCT, CT and CBA (baseline data acts as within-group control); vs. ITS (Cochrane Statistical Methods Group and the Cochrane Bias Methods Group, 2011). Authors used their judgment to rate each study as: low risk, high risk, unclear risk or not applicable on six criteria. These six criteria for controlled studies included: “Was the allocation sequence adequately generated?” and “Were baseline outcome measurements similar?”. The six criteria for ITS studies included: “Was knowledge of the allocated interventions adequately prevented during the study?” and “Was incomplete outcome data adequately addressed?”. See Appendix B. Principal outcome measures Primary outcome of this systematic review is narrative synthesis of results due to large heterogeneity in study design, population and outcomes. Secondary outcome of the review is the simplification of selected results (significant IPA increases reported by some studies) into percentage increases from baseline to allow for some generalized between-study comparisons.
Results Search results and study selection The four database searches returned 7227 articles and 43 articles were sourced separately via snowballing. After the removal of duplicates, 5179 articles remained. After screening of title/abstract, 727 full texts were verified and 42 articles included which detail 43 studies (one article detailed two studies (Oja et al., 1998)). See PRISMA flow diagram, Fig. 1 (Moher et al., 2009). Reasons for exclusion included: b4 week study duration, b20 study participants, clinical studies, studies that included a nutrition intervention component and studies that aimed to change fitness via exercise (Table 2).
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Table 2 Study eligibility. Inclusions
Exclusions
Journal article that details an intervention Intervention study (study design: Randomized Controlled Trial, Controlled Trial, Controlled Before and After, Interrupted Time Series) Human English language Beginning January 1970–end December 2012 Preventive Health promotion/education Social media Community-wide (e.g. shopping center, travel station) or community-based (e.g. school, workplace) Incidental Physical Activity (IPA) Active transport Stair use Manual occupation Housework/caring for family Yardwork/gardening Children's play Walking the dog Any age group IPA must be main aim 4+ weeks in duration 20+ participants All measures of physical activity (e.g. subjective and objective)
Reviews/systematic reviews (the reference lists of relevant systematic reviews were checked) Case study, clinical trial, editorial, letter, commentary, report, opinion Clinical study, involving patients or hospitals, pharmacies or GP surgeries, primary care, people with a certain disease, treatments, e.g. weight loss Prevalence or similar study Nutrition intervention part of the intervention Sport Exercise/fitness/exercise for fitness Leisure-time physical activity Pilot Wider physical activity or exercise intervention, of which IPA is only a part Non-intervention, e.g. interview only Population-wide, e.g. policy change, state-wide, mass media Main aim is not to change IPA, e.g. physical activity in general (including sport/exercise), falls prevention Less than 4 weeks in duration Less than 20 participants No baseline/comparison data
Critical appraisal Of the 43 included studies, 9 were judged by the authors to be of low risk of bias, 1 of low-moderate risk of bias, 20 of moderate risk of bias, 1 of moderate-high risk of bias and 12 of high risk of bias. That is, the level of bias was moderate–high in 77% of the studies (33/43) and low or low–moderate in only 23% of the studies (10/43).
Narrative synthesis and calculated significant percentage increases in IPA Appendix C provides details of the 43 included studies. All studies were conducted in high income countries. Twenty studies were conducted in the UK (47%), 11 in North America (US and Canada), (26%), six in other parts of Europe (e.g. Belgium and Finland, (14%), three in Australia (7%), one in Hong Kong (2%), one in Japan (2%) and one in New Zealand (2%). Of the 43 included studies, 14% (n = 6) were RCT, 16% (n = 7) were CT, 53% (n = 23) were CBA, and 16% (n = 7) were ITS (Table 3). Around a quarter (23%) of studies aimed to increase active transport (n = 10), 16% aimed to increase playground energy expenditure (n = 7) and 60% aimed to increase stair use compared to escalator and/or lift use (n = 26), (Table 3). Primary outcomes were active transport (e.g. % of students walking to school (Wen et al., 2008) or distance traveled by walking (McKee et al., 2007)), physical activity (e.g. amount of moderate and/or vigorous physical activity as assessed by short wave telemetry (Stratton and Mullan 2005)) or stair use (e.g. number of escalator/stair-choice observations (Kerr et al., 2001a, 2001b, 2001c)). Ascending and/or descending stair use was measured. Table 4 outlines the basic overall statistics of the 43 included studies, including number of participants, number of observations (e.g. stair use observations) and calculated percentage increase in IPA from baseline in studies that reported significant increases. Most studies (58%) were community-based, conducted in school settings (28%, n = 12), workplaces (21%, n = 9) and higher education campuses (9%, n = 4). The remainder of studies was community-wide, conducted in shopping centers (19%, n = 8), overground or underground train stations (14%, n = 6) and whole-of-community (10%, n = 4). The majority of the studies were between a duration of 4 weeks and 12 weeks (58%, n = 25), followed by N 12 weeks to b 6 months (19%, n = 8), 6 months to b12 months (19%, n = 8) and lastly 12 months
or more (5%, n = 2). 31 studies (72%) reported a significant (p b 0.05) increase in IPA, with 12 (28%) reporting no significant increase in IPA. When simplifying significant increases in IPA reported by 34 of the 43 studies into percentage increases from baseline, the range was from 0% (0.29%) (Eves et al., 2008) to 372% (McKee et al., 2007), with a median of 5% and a mean of 24% (Table 4). The increase of 372% was reported in a UK study that aimed to increase active transport in 60 school children and had a primary outcome of distance traveled by walking (McKee et al., 2007). Post-intervention, the mean distance traveled to school by walking in the intervention children increased significantly from baseline, from 198 to 772 m (389% increase) (McKee et al., 2007). The increase of 372% (McKee et al., 2007) is far greater than the increases reported in the other studies, with the second greatest increase being 105% (Mutrie et al., 2002). Excluding this result produces the same median increase of 5% and a smaller mean increase of 13%. The largest mean percentage increase in IPA as shown in Table 5 is highest for active travel interventions: first in children at school (124.5% increase, or 41.9% if McKee et al (2007) is excluded (McKee et al., 2007)), followed by community-wide in whole-of-population (63.0% increase in n = 1 (Hendricks et al., 2009)) and then in adults in the workplace (38.8% increase). Playground interventions in children in schools have a smaller average increase in IPA than all types of active travel interventions (8.2%), but a larger average increase in IPA than all types of stair use intervention (range 2.3–5.9%). Discussion This systematic review describes community-based and communitywide interventions for increasing IPA. Of 43 included studies from 42 original articles, 34 reported a significant increase in IPA, the mean being 24%, with a range of 0% (0.29%) (Eves et al., 2008) to 372% (McKee et al., 2007). Approximately a quarter of the studies (23%) aimed to increase active transport (e.g. distance traveled by walking to school in meters, number of participants walking or cycling), and these studies reported the largest significant increases in IPA (active transport interventions compared to playground and stair use interventions). However, critical appraisal of studies using Cochrane Public Health Group guidelines (Cochrane Public Health Group) suggests that the level of bias is moderate–high in most studies. This is a similar finding to the recent systematic review update of school physical activity interventions by Dobbins et al (2013), who report that: “…the majority of
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Fig. 1. PRISMA flow diagram.
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” (Dobbins et al., 2013). Similarly, Wanner et al. (2012) systematically reviewed active transport interventions and effects on physical activity and body weight and state: “… study heterogeneity, predominantly cross-sectional designs, and crude measures for active transport and physical activity impede quantitative conclusions” (Wanner et al., 2012). In the current systematic review, we also report substantial heterogeneity in study design, making inter-study comparison difficult.
Active travel interventions The 10 active transport studies captured by this systematic review included a walking school bus program (Heelan et al., 2009), schoolbased education (Hendricks et al., 2009; McKee et al., 2007; McMinn et al., 2012), advice on school travel patterns (Rowland et al., 2003), safe walking routes to school (Staunton et al., 2003), impediments to active transport to school (Wen et al., 2008), work-based education (Oja et al., 1998) and work route and safety information (Mutrie et al., 2002). The studies described the effectiveness of these interventions, their potential health benefits and potential barriers.
The active transport health benefits described in 8 of the 10 reviewed studies included increased prevalence of walking to school (Heelan et al., 2009; Hendricks et al., 2009), increased distance walked to school (McKee et al., 2007) and increased prevalence of walking to work (Mutrie et al., 2002). The active transport barriers described in the reviewed studies included problems with the walking and cycling environments, such as perceived safety problems, particularly with cycling. A UK study reported that 85% of parents were worried about traffic danger (Rowland et al., 2003), an Australian study (Wen et al., 2008) reported that only 1% of the students that they sampled cycled to school (compared with 32% walking) and a UK study (Mutrie et al., 2002) reported an intervention-related increase in walking, but not in cycling. The active transport studies described in this systematic review collectively suggest that programs which support physically active commuting to and from school and work can be effective ways of increasing physical activity. Our finding is similar to one reported by a recent systematic review by Faulkner et al., (2009) on active school travel interventions, who state: “active school commuters tend to be more physically active overall than passive commuters”, and further state: “…evidence for the impact of (Active School Travel) in promoting healthy body weights for children and youth is not compelling” (Faulkner et al., 2009). Our finding contrasts Wanner et al.'s (2012), who state: “There is limited evidence that active transport is associated
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Increasing public transport also increases IPA by increasing walking time to travel stations. A recent Australian systematic review of how much time is spent in physical activity among adults using public transport reported that, ‘a range of 8–33 additional minutes of walking per day was identified from this systematic search as being attributable to public transport use… if 20% of all inactive adults increased their walking by only 16 min a day for five days a week, we predict there would be a substantial 6.97% increase in the proportion of the adult population considered “sufficiently active”…’ (Rissel et al., 2012). Governments should ensure that promoting active transport is high on their public health agenda (Department of Infrastructure, 2013 (July)). A good example of this comes from Australia, where the Victorian Health Promotion Foundation, VicHealth, and their Action Agenda for Health Promotion 2013–23 highlight active travel as an important focus for the next decade; this is partly illustrated by the statement, ‘We'll be specifically looking at how we encourage people to make walking a part of their everyday life’ (VicHealth, 2013).
Table 3 Summary of study design and IPA intervention of the 43 included studies. Study design and physical activity intervention
n
Randomized controlled trial Active transport Playground Controlled trial Active transport Playground Stair use vs. escalator Controlled before and after study Active transport Playground Stair use vs. escalator Stair use vs. lift Stair use vs. escalator and lift Interrupted time series design Stair use vs. escalator Stair use vs. lift grand total
6 4 2 7 3 3 1 23 3 2 10 7 1 7 4 3 43
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Playground physical activity interventions with more physical activity as well as lower body weight in adults” (Wanner et al., 2012). So, whether active travel interventions consistently increase physical activity in children or adults and whether this is translated to body weight changes is an area of contention and for further research. Additionally, optimal benefits of active travel may be attenuated by barriers such as safety concerns, particularly for cycling. In order to maximize the potential effectiveness of interventions to increase active transport, safety concerns and other issues need to be addressed such as individual family lifestyle needs and links between parent journey to work and student journey to school. Another recent systematic review on active transport to school stated that, ‘More research with higher quality study designs and measures should be conducted to further evaluate interventions and to determine the most successful strategies for increasing active transportation to school’(Chillon et al., 2011). This is of particular importance considering that the prevalence of active transport to school in countries like the US and Australia (van der Ploeg et al., 2008) decreased considerably from 1969/1970 to 2001/2003. Possible reasons for this include, ‘Parental attitudes and safety concerns, the presence of social support from parents and friends, and parent reported neighborhood walkability were all found to be predictors of active commuting, with children receiving peer and family support and living in supportive environments being more likely to walk or cycle’ (Australian National Preventive Health Agency, 2013). ‘Reducing the convenience of the car and improving the convenience of active modes as well as improving the safety of routes to school may promote uptake and maintenance of active commuting and the effectiveness of these interventions should be evaluated’ (Panter et al., 2013). Active transport to work in most high-income countries is low. For example, in July 2013, the Australian Bureau of Statistics reported that, ‘the majority of Australian adults (71%) use a passenger vehicle to get to work or full time study’ (Australian Bureau of Statistics, 2013 (25 July)). The prevalence of prolonged sitting time in cars (≥2 h/day) in a recent Sydney study was higher in full-time workers (men: 21–24%, women: 14–15%) (Mammen and Faulkner, 2013), suggesting that of the workers who drive to work, many of them sit for long periods in their cars — in addition to the likelihood of sitting for most of the day at work.
The seven playground physical activity studies captured by this systematic review included a Learning Landscapes program that included the construction of culturally-tailored schoolyard play spaces (Anthamatten et al., 2011), the provision of play equipment/physical structures and/or markings (e.g. fluorescent (Stratton, 2000) or multicolor markings (Stratton and Mullan 2005)) painted on the playground surface aimed at stimulating physically active play (Cardon et al., 2009; Ridgers et al., 2007; Stratton, 2000; Stratton and Mullan 2005; Verstraete et al., 2006) and a natural experiment upgrade of a community playground (Quigg et al., 2012). The playground physical activity health benefits described in four of the seven reviewed studies included increased physical activity as measured by accelerometer (Quigg et al., 2012; Ridgers et al., 2007) and/or heart rate telemetry (Ridgers et al., 2007; Stratton, 2000) (Stratton and Mullan 2005) and the System for Observing Play and Leisure Activity (SOPLAY, a validated quantitative method for evaluating levels of physical activity of individuals in play and leisure environments) (Anthamatten et al., 2011). The playground physical activity studies described in this systematic review collectively suggest that programs that promote physically active play at school can be effective in increasing physical activity and reducing sedentary time during breaks such as morning recess. Factors other than intervention strategies such as playground markings also influence children's physical activity during play (Stratton, 2000) and activating supervision together with the inclusion of more structured physical activity may be needed in some situations (Cardon et al., 2009). Playground physical activity can be influenced by sex and age, with findings (Stratton and Mullan 2005) that boys and younger children are more physically active. It may therefore be important to target older children and girls in playground interventions (Anthamatten et al., 2011). Several of the playground studies were conducted in areas of deprivation (Anthamatten et al., 2011; Quigg et al., 2012; Ridgers et al., 2007; Stratton and Mullan 2005), and SocioEconomic Status (SES) is an important consideration in study design, particularly due to the interaction of socioeconomics and obesity prevalence (Anthamatten et al., 2011).
Table 4 Basic overall statistics of the 43 included studies.
b
Number of participants Number of observationsb % Absolute significant increase in IPA
n studiesa
Minimum
Maximum
Median
Mean
25 24
47 3369 0% (0.29%)
36,000 158,350
338 32,858
2198 47,154
372%
5%
24%
34 a
The number of studies listed here are selections from the 43 total studies included in this systematic review, e.g. 25 studies reported number of participants, 24 studies reported number of observations and 34 studies reported a significant increase in IPA. b Studies listed number of participants and/or number of observations (e.g. stair use observations).
52
Table 5 Mean percentage increase in IPA stratified by intervention type (active travel, stair use, playground), age of participants, location and duration.
Location Higher education
Shopping centre
Travel station
Workplace
School
Playground
1
N/A
Incidental physical activity intervention and participants
Whole–of– population Active travel
1 63.0
Adults
38.8
Children
2
Whole–of– population Adults Stair use^
5 3
1
3.8
1
2
5.9 2.3
5
1
3.8
2 3
2
1
3.1
4.8
Children Whole–of– population Adults
Playground Children
4
1
* = McKee et al., 2007 result of 372.0% excluded (McKee et al., 2007). #Figures calculated using 34 of the 43 studies that reported a significant increase in IPA. ^Stair use was measured heterogeneously between studies, either by ascending stair use only or by both ascending and descending stair use.
R. Reynolds et al. / Preventive Medicine 67 (2014) 46–64
Mean IPA % increase from baseline
8.2
12mo+
1
6mo to
Contents lists available at ScienceDirect
Preventive Medicine journal homepage: www.elsevier.com/locate/ypmed
Review
Systematic review of incidental physical activity community interventions Rebecca Reynolds a,⁎, Stephen McKenzie b, Steven Allender c, Kirsty Brown b, Chad Foulkes b,c a b c
School of Public Health and Community Medicine, UNSW Australia, Sydney, NSW 2052, Australia City of Greater Geelong Council, PO Box 104, Geelong, VIC 3220, Australia WHO Collaborating Centre for Obesity Prevention, Deakin University, Locked Bag 20000, Geelong, VIC 3220, Australia
a r t i c l e
i n f o
Available online 25 June 2014 Keywords: Health promotion Health education Motor activity Walking Bicycling Chronic disease Obesity
a b s t r a c t Background. Increasing incidental physical activity (IPA) such as active transport has substantial public health potential. Objective. This systematic review describes community-based and community-wide IPA interventions and assesses their effectiveness. Method. Data sources (Medline, Embase, PsycINFO and CINAHL) were searched along with the reference lists of identified systematic reviews and included articles. Eligibility criteria; 4 + weeks in duration; 20 + participants; community-based or community-wide; stated aim to increase IPA. Results. Forty three studies were identified from 42 original articles; more than half (60%) aimed to increase stair use compared to escalator and/or lift use; a quarter (23%) aimed to increase active transport; and, 16% to increase playground energy expenditure. More than two-thirds of studies reported a significant increase in IPA. Accurate comparisons between studies were not possible due to substantial heterogeneity in study design. Critical appraisal of studies revealed that the level of bias was moderate–high in most of the studies (77%). Conclusion. Due to the heterogeneity and bias of included studies, only limited conclusions can be drawn about the effectiveness of IPA interventions. However, this systematic review provides a timely summary of current evidence that can be used to inform decision-makers in designing IPA interventions in the community. © 2014 Elsevier Inc. All rights reserved.
Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Definition of IPA . . . . . . . . . . . . . . . . . . . . . . . . . . Search strategy . . . . . . . . . . . . . . . . . . . . . . . . . . Study eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . Study selection . . . . . . . . . . . . . . . . . . . . . . . . . . Data collection . . . . . . . . . . . . . . . . . . . . . . . . . . Critical appraisal . . . . . . . . . . . . . . . . . . . . . . . . . . Principal outcome measures . . . . . . . . . . . . . . . . . . . . Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Search results and study selection . . . . . . . . . . . . . . . . . . Critical appraisal . . . . . . . . . . . . . . . . . . . . . . . . . . Narrative synthesis and calculated significant percentage increases in IPA Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Active travel interventions . . . . . . . . . . . . . . . . . . . . . Playground physical activity interventions . . . . . . . . . . . . . .
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Abbreviations: IPA, Incidental Physical Activity; MVPA, Moderate to Vigorous Physical Activity. ⁎ Corresponding author. E-mail addresses: [email protected] (R. Reynolds), [email protected] (S. McKenzie), [email protected] (S. Allender), [email protected] (K. Brown), [email protected] (C. Foulkes).
http://dx.doi.org/10.1016/j.ypmed.2014.06.023 0091-7435/© 2014 Elsevier Inc. All rights reserved.
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Stair use interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Study implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Study limitations and strengths . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conflict of interest statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Acknowledgements and funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Appendix A. Search strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A.1. Medline search strategy 17/01/13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A.2. Embase search strategy 17/01/13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A.3. Psycinfo search strategy 17/01/13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A.4. CINAHL search strategy 17/01/13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Appendix B. Critical appraisal of 43 included studies: 6 critical appraisal criteria for each study (different criteria sets for RCT/CT/CBA vs. ITS — Appendix C. Characteristics of 43 included studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Appendix A. Supplementary data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Introduction Evidence for a positive relationship between physical activity and health, including for the prevention of overweight and obesity, and other non-communicable diseases (Lee et al., 2012), including type 2 diabetes mellitus (Manson et al., 1991) and depression (Mammen and Faulkner, 2013) is strong in both children and adults. The effectiveness of interventions to increase physical activity has been the subject of numerous systematic reviews (Baker et al., 2011; Dobbins et al., 2013; Kahn et al., 2002; Malik et al., 2013; van Sluijs et al., 2007), showing mixed results. A Cochrane review of community-wide physical activity interventions reported that many studies have serious methodological issues and there is insufficient evidence that multi-component community-wide interventions effectively increase population levels of physical activity (Baker et al., 2011). Similarly, Dobbins et al. reviewed school-based physical activity interventions and state, ‘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’ (Dobbins et al., 2013). The evidence appears to be somewhat at its infancy then as to whether it is possible to increase population physical activity levels via a variety of means in different groups — especially sustainably. However, the evidence is strong enough to warrant continued effort into physical activity interventions (Heath et al., 2012), including in school community settings: ‘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’ (VO2 max) (Dobbins et al., 2013). While there have been systematic reviews on specific IPA interventions such as active transport in children (Faulkner et al., 2009) and active transport in adults (Wanner et al., 2012), there have been no systematic reviews to date that focus on community-based or communitywide IPA interventions in combination. One reason for this lack of systematic reviews on IPA interventions in combination may be the difficulty in providing accurate definitions for the term. IPA definitions include, ‘unstructured activity taken during the day, such as walking for transport, housework and the performance of activities of daily living’ (Department of Health and Ageing, A. G. et al., 2006) and conversely the Canadian Society for Exercise Physiology's definition: ‘Activities of daily living’ (Canadian Society for Exercise Physiology, 2011). Increasing incidental energy expenditure via practical day-to-day tasks has substantial public health potential, partly because more adults participate in non-organized physical activity than in organized physical activity (Australian Sports Commission, 2010). In multiple constituencies the concept of creating spaces and opportunities to support IPA on health grounds is gaining traction. The recent US Institute of Medicine report identified environmental and policy strategies as being one of the most promising for accelerating progress in obesity prevention (‘the physical
47
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53 53 53 54 54 54 54 54 54 54 54 54 54 54 54
activity environment, which includes the built environment as well as norms and processes that increase opportunities for, access to, and social reinforcement of physical activity’) (Institute of Medicine, 2013) and the UK National Institute of Health and Clinical Excellence's scope for systems-level obesity prevention highlights the importance of the built environment and transport systems (National Institute for Health and Care Excellence, 2010). Despite limited evidence governmental recommendations to increase IPA are wide-ranging and include individual and social marketing approaches to policy level change. At the policy level, for example, the Australian Federal Government (Department of Health and Ageing, 2013) recommended that: … the Federal Government work with all levels of government and the private sector to develop nationally consistent urban planning guidelines which focus on creating environments that encourage Australians to be healthy and active. The perceived health benefits of IPA such as walking and cycling appear to contribute approximately 80% of the net benefits of both modes of travel and state that, ‘Incorporating exercise into travel has been identified as a highly effective means to increase daily physical activity, which can help individuals to maintain better health’ (Department of Infrastructure, 2013 (July)). However, the evidence base is often not consistent or clear (Baker et al., 2011; Dobbins et al., 2013). To provide a strong, evidence-based rationale for the development of interventions to increase IPA, a clear understanding of the state of the current literature is required which presents evidence of effectiveness of interventions to increase IPA and efficacy of these interventions in achieving health improvements. This systematic review addresses the effects of community-based and community-wide interventions to increase IPA outcomes – such as self-reported rate of active transport – in 20 or more children and/or adults over 4 or more weeks with the comparison being a control group or baseline data. Interventions were Randomized Controlled Trials (RCT), Controlled Trials (CT), Controlled Before and After (CBA) studies or Interrupted Time Series (ITS) study design.
Methods Definition of IPA We use the Australian Institute of Health and Welfare's definition of IPA for this review: IPA includes the forms of physical activity done at work and home, and activity in which people take part as they go about their day-to-day lives, generally using large skeletal muscle groups (Australian Institute of Health and Welfare, 1999). We use the Australian National Public Health Partnership's definition of active transport for this review: ‘travel between destinations by walking,
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R. Reynolds et al. / Preventive Medicine 67 (2014) 46–64
cycling or other non-motorized modes’ (National Public Health Partnership, 2001). We used these definitions of IPA and active transport to develop a list of IPAs (Table 1). We added activities to this list by taking terms from six international adult and child questionnaires assessing physical activity (Table 1) (Australian Institute of Health and Welfare, 1999; Centers for Disease Control and Prevention, 2012; Deakin University; Karolinksa Institutet, 2002; Medical Research Council Epidemiology Unit; National Public Health Partnership, 2001; VicHealth). In total, we developed a list of 10 IPAs for purposes of this review (Table 1). Search strategy The search strategy involved the 10 IPA terms listed in Table 1 (Australian Institute of Health and Welfare, 1999; Centers for Disease Control and Prevention, 2012; Deakin University; Karolinksa Institutet, 2002; Medical Research Council Epidemiology Unit; VicHealth) and health promotion terms adapted from a recent Cochrane review on obesity prevention in children (Waters et al., 2011). Search terms were adapted for and run in four databases on 17th January 2013: Medline, Embase, PsycINFO and CINAHL (complete search strategies are provided in Appendix A and the review protocol is not provided elsewhere, but further details can be obtained by contacting the corresponding author, RR). Snowballing was carried out to check that no studies had been missed for inclusion using the reference lists of all relevant systematic reviews (noted during the inclusion and exclusion process) and the reference lists of included studies.
Study selection Search results from the four databases were combined in Endnote reference management software program and duplicates removed. Screening of the remaining articles for eligible studies was completed by SM and RR, who reviewed half each by reviewing title and/or abstract. A 20% sample of studies excluded in this screening stage (10% of studies excluded by SM and 10% of studies excluded by RR) were separately reviewed in a quality control process by CF or KB to check on the likelihood of eligible articles being excluded in the screening process. This methodology has been previously published (Australian Primary Health Care Research Institute and The University of New South Wales, 2006). Studies still potentially eligible after screening were then verified by SM and RR, who reviewed half of the full texts each. Again, 20% sample of studies excluded in this full text verification stage (10% of studies excluded by SM and 10% of studies excluded by RR) were separately reviewed in a quality control process by CF or KB to check on the likelihood of eligible articles being excluded in the verification process (Australian Primary Health Care Research Institute and The University of New South Wales, 2006). Eligible studies that passed the verification stage were included in the systematic review. Snowballing was carried out using the reference lists of eligible studies included in the systematic review from the verification stage. Eligible studies in these reference lists underwent the same review process as studies identified in the database searches, i.e. screening and verification. In all stages, any discrepancies were discussed until consensus was reached. Data collection
Study eligibility Study eligibility criteria are presented in Table 2. Briefly, based on the PRISMA-suggested PICOS criteria (Moher et al., 2009): Participants were 20 or more children and adults in community settings (community-based, i.e. targeting a specific population in the community, e.g. school; or, community-wide, i.e. not targeting a specific population group, e.g. shopping center), e.g. primary schools; Interventions aimed to increase IPA levels over 4 or more weeks, e.g. a multi-component intervention including the education of children and parents about the benefits of active travel by the children to school (Wen et al., 2008); Comparisons were control groups who didn't receive the intervention (or baseline data if participants were acting as their own control); Outcomes were IPA levels, e.g. self-report using questionnaires to both students and parents on how students traveled to and from school (Wen et al., 2008); and Study designs were RCT, CT, CBA and ITS. Studies were eligible if published in a peer-review journal article between January 1970 and December 2012 in the English language.
Table 1 IPAs used in this review. 1. Stair use/taking the stairs 2. Active transport: ‘travel between destinations by walking, cycling or other non-motorized modes’ (National Public Health Partnership, 2001) 3. Walk, cycle or other non-motorized modes to and from places, including: work, school, to do errands, to classes if you are a student, stores, restaurants, movies 4. Stand or walk around during most of the day 5. Gardening or other work around yard/yard work, general maintenance work, including: chopping wood, sweeping patio, heavy lifting, shoveling snow, digging and raking in the garden or yard 6. Household chores, housework, including: carrying light loads, sweeping, washing windows, scrubbing floors 7. Caring for your family 8. Occupational physical activity, including: heavy lifting, digging, heavy construction; climbing up stairs; carrying light loads; repeated lifting, pushing and pulling heavy objects; repeated bending, twisting and reaching; working with hand-held or hand-operated vibrating tools and machinery 9. Walking the dog/working with other animals, e.g. horse 10. Children's play activities, e.g. imaginary play, play indoors with toys, play with pets, bounce on the trampoline, play in the cubby house, play on playground equipment, skipping rope, tag/chasey, down ball/4 square Reference: National Public Health Partnership (2001). PROMOTING ACTIVE TRANSPORT: An intervention portfolio to increase physical activity as a means of transport. from http://www.nphp.gov.au/publications/sigpah/activetransport.pdf.
Data was extracted from studies using full texts by SM and RR into an Excel spreadsheet. Each reviewer inputted half of the eligible studies each into the Excel spreadsheet independently. Data items included: year of publication, study design, study location, intervention details, setting, number of participants or observations, characteristics of participants, duration of intervention, outcomes and significance. Critical appraisal Included studies were critically appraised by RR, CF and KB for their risk of bias using guidelines suggested by the Cochrane Public Health Group, who outlines two sets of criteria for critical assessment of differential study designs: designs that involve a control group; RCT, CT and CBA (baseline data acts as within-group control); vs. ITS (Cochrane Statistical Methods Group and the Cochrane Bias Methods Group, 2011). Authors used their judgment to rate each study as: low risk, high risk, unclear risk or not applicable on six criteria. These six criteria for controlled studies included: “Was the allocation sequence adequately generated?” and “Were baseline outcome measurements similar?”. The six criteria for ITS studies included: “Was knowledge of the allocated interventions adequately prevented during the study?” and “Was incomplete outcome data adequately addressed?”. See Appendix B. Principal outcome measures Primary outcome of this systematic review is narrative synthesis of results due to large heterogeneity in study design, population and outcomes. Secondary outcome of the review is the simplification of selected results (significant IPA increases reported by some studies) into percentage increases from baseline to allow for some generalized between-study comparisons.
Results Search results and study selection The four database searches returned 7227 articles and 43 articles were sourced separately via snowballing. After the removal of duplicates, 5179 articles remained. After screening of title/abstract, 727 full texts were verified and 42 articles included which detail 43 studies (one article detailed two studies (Oja et al., 1998)). See PRISMA flow diagram, Fig. 1 (Moher et al., 2009). Reasons for exclusion included: b4 week study duration, b20 study participants, clinical studies, studies that included a nutrition intervention component and studies that aimed to change fitness via exercise (Table 2).
R. Reynolds et al. / Preventive Medicine 67 (2014) 46–64
49
Table 2 Study eligibility. Inclusions
Exclusions
Journal article that details an intervention Intervention study (study design: Randomized Controlled Trial, Controlled Trial, Controlled Before and After, Interrupted Time Series) Human English language Beginning January 1970–end December 2012 Preventive Health promotion/education Social media Community-wide (e.g. shopping center, travel station) or community-based (e.g. school, workplace) Incidental Physical Activity (IPA) Active transport Stair use Manual occupation Housework/caring for family Yardwork/gardening Children's play Walking the dog Any age group IPA must be main aim 4+ weeks in duration 20+ participants All measures of physical activity (e.g. subjective and objective)
Reviews/systematic reviews (the reference lists of relevant systematic reviews were checked) Case study, clinical trial, editorial, letter, commentary, report, opinion Clinical study, involving patients or hospitals, pharmacies or GP surgeries, primary care, people with a certain disease, treatments, e.g. weight loss Prevalence or similar study Nutrition intervention part of the intervention Sport Exercise/fitness/exercise for fitness Leisure-time physical activity Pilot Wider physical activity or exercise intervention, of which IPA is only a part Non-intervention, e.g. interview only Population-wide, e.g. policy change, state-wide, mass media Main aim is not to change IPA, e.g. physical activity in general (including sport/exercise), falls prevention Less than 4 weeks in duration Less than 20 participants No baseline/comparison data
Critical appraisal Of the 43 included studies, 9 were judged by the authors to be of low risk of bias, 1 of low-moderate risk of bias, 20 of moderate risk of bias, 1 of moderate-high risk of bias and 12 of high risk of bias. That is, the level of bias was moderate–high in 77% of the studies (33/43) and low or low–moderate in only 23% of the studies (10/43).
Narrative synthesis and calculated significant percentage increases in IPA Appendix C provides details of the 43 included studies. All studies were conducted in high income countries. Twenty studies were conducted in the UK (47%), 11 in North America (US and Canada), (26%), six in other parts of Europe (e.g. Belgium and Finland, (14%), three in Australia (7%), one in Hong Kong (2%), one in Japan (2%) and one in New Zealand (2%). Of the 43 included studies, 14% (n = 6) were RCT, 16% (n = 7) were CT, 53% (n = 23) were CBA, and 16% (n = 7) were ITS (Table 3). Around a quarter (23%) of studies aimed to increase active transport (n = 10), 16% aimed to increase playground energy expenditure (n = 7) and 60% aimed to increase stair use compared to escalator and/or lift use (n = 26), (Table 3). Primary outcomes were active transport (e.g. % of students walking to school (Wen et al., 2008) or distance traveled by walking (McKee et al., 2007)), physical activity (e.g. amount of moderate and/or vigorous physical activity as assessed by short wave telemetry (Stratton and Mullan 2005)) or stair use (e.g. number of escalator/stair-choice observations (Kerr et al., 2001a, 2001b, 2001c)). Ascending and/or descending stair use was measured. Table 4 outlines the basic overall statistics of the 43 included studies, including number of participants, number of observations (e.g. stair use observations) and calculated percentage increase in IPA from baseline in studies that reported significant increases. Most studies (58%) were community-based, conducted in school settings (28%, n = 12), workplaces (21%, n = 9) and higher education campuses (9%, n = 4). The remainder of studies was community-wide, conducted in shopping centers (19%, n = 8), overground or underground train stations (14%, n = 6) and whole-of-community (10%, n = 4). The majority of the studies were between a duration of 4 weeks and 12 weeks (58%, n = 25), followed by N 12 weeks to b 6 months (19%, n = 8), 6 months to b12 months (19%, n = 8) and lastly 12 months
or more (5%, n = 2). 31 studies (72%) reported a significant (p b 0.05) increase in IPA, with 12 (28%) reporting no significant increase in IPA. When simplifying significant increases in IPA reported by 34 of the 43 studies into percentage increases from baseline, the range was from 0% (0.29%) (Eves et al., 2008) to 372% (McKee et al., 2007), with a median of 5% and a mean of 24% (Table 4). The increase of 372% was reported in a UK study that aimed to increase active transport in 60 school children and had a primary outcome of distance traveled by walking (McKee et al., 2007). Post-intervention, the mean distance traveled to school by walking in the intervention children increased significantly from baseline, from 198 to 772 m (389% increase) (McKee et al., 2007). The increase of 372% (McKee et al., 2007) is far greater than the increases reported in the other studies, with the second greatest increase being 105% (Mutrie et al., 2002). Excluding this result produces the same median increase of 5% and a smaller mean increase of 13%. The largest mean percentage increase in IPA as shown in Table 5 is highest for active travel interventions: first in children at school (124.5% increase, or 41.9% if McKee et al (2007) is excluded (McKee et al., 2007)), followed by community-wide in whole-of-population (63.0% increase in n = 1 (Hendricks et al., 2009)) and then in adults in the workplace (38.8% increase). Playground interventions in children in schools have a smaller average increase in IPA than all types of active travel interventions (8.2%), but a larger average increase in IPA than all types of stair use intervention (range 2.3–5.9%). Discussion This systematic review describes community-based and communitywide interventions for increasing IPA. Of 43 included studies from 42 original articles, 34 reported a significant increase in IPA, the mean being 24%, with a range of 0% (0.29%) (Eves et al., 2008) to 372% (McKee et al., 2007). Approximately a quarter of the studies (23%) aimed to increase active transport (e.g. distance traveled by walking to school in meters, number of participants walking or cycling), and these studies reported the largest significant increases in IPA (active transport interventions compared to playground and stair use interventions). However, critical appraisal of studies using Cochrane Public Health Group guidelines (Cochrane Public Health Group) suggests that the level of bias is moderate–high in most studies. This is a similar finding to the recent systematic review update of school physical activity interventions by Dobbins et al (2013), who report that: “…the majority of
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R. Reynolds et al. / Preventive Medicine 67 (2014) 46–64
Fig. 1. PRISMA flow diagram.
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” (Dobbins et al., 2013). Similarly, Wanner et al. (2012) systematically reviewed active transport interventions and effects on physical activity and body weight and state: “… study heterogeneity, predominantly cross-sectional designs, and crude measures for active transport and physical activity impede quantitative conclusions” (Wanner et al., 2012). In the current systematic review, we also report substantial heterogeneity in study design, making inter-study comparison difficult.
Active travel interventions The 10 active transport studies captured by this systematic review included a walking school bus program (Heelan et al., 2009), schoolbased education (Hendricks et al., 2009; McKee et al., 2007; McMinn et al., 2012), advice on school travel patterns (Rowland et al., 2003), safe walking routes to school (Staunton et al., 2003), impediments to active transport to school (Wen et al., 2008), work-based education (Oja et al., 1998) and work route and safety information (Mutrie et al., 2002). The studies described the effectiveness of these interventions, their potential health benefits and potential barriers.
The active transport health benefits described in 8 of the 10 reviewed studies included increased prevalence of walking to school (Heelan et al., 2009; Hendricks et al., 2009), increased distance walked to school (McKee et al., 2007) and increased prevalence of walking to work (Mutrie et al., 2002). The active transport barriers described in the reviewed studies included problems with the walking and cycling environments, such as perceived safety problems, particularly with cycling. A UK study reported that 85% of parents were worried about traffic danger (Rowland et al., 2003), an Australian study (Wen et al., 2008) reported that only 1% of the students that they sampled cycled to school (compared with 32% walking) and a UK study (Mutrie et al., 2002) reported an intervention-related increase in walking, but not in cycling. The active transport studies described in this systematic review collectively suggest that programs which support physically active commuting to and from school and work can be effective ways of increasing physical activity. Our finding is similar to one reported by a recent systematic review by Faulkner et al., (2009) on active school travel interventions, who state: “active school commuters tend to be more physically active overall than passive commuters”, and further state: “…evidence for the impact of (Active School Travel) in promoting healthy body weights for children and youth is not compelling” (Faulkner et al., 2009). Our finding contrasts Wanner et al.'s (2012), who state: “There is limited evidence that active transport is associated
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Increasing public transport also increases IPA by increasing walking time to travel stations. A recent Australian systematic review of how much time is spent in physical activity among adults using public transport reported that, ‘a range of 8–33 additional minutes of walking per day was identified from this systematic search as being attributable to public transport use… if 20% of all inactive adults increased their walking by only 16 min a day for five days a week, we predict there would be a substantial 6.97% increase in the proportion of the adult population considered “sufficiently active”…’ (Rissel et al., 2012). Governments should ensure that promoting active transport is high on their public health agenda (Department of Infrastructure, 2013 (July)). A good example of this comes from Australia, where the Victorian Health Promotion Foundation, VicHealth, and their Action Agenda for Health Promotion 2013–23 highlight active travel as an important focus for the next decade; this is partly illustrated by the statement, ‘We'll be specifically looking at how we encourage people to make walking a part of their everyday life’ (VicHealth, 2013).
Table 3 Summary of study design and IPA intervention of the 43 included studies. Study design and physical activity intervention
n
Randomized controlled trial Active transport Playground Controlled trial Active transport Playground Stair use vs. escalator Controlled before and after study Active transport Playground Stair use vs. escalator Stair use vs. lift Stair use vs. escalator and lift Interrupted time series design Stair use vs. escalator Stair use vs. lift grand total
6 4 2 7 3 3 1 23 3 2 10 7 1 7 4 3 43
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Playground physical activity interventions with more physical activity as well as lower body weight in adults” (Wanner et al., 2012). So, whether active travel interventions consistently increase physical activity in children or adults and whether this is translated to body weight changes is an area of contention and for further research. Additionally, optimal benefits of active travel may be attenuated by barriers such as safety concerns, particularly for cycling. In order to maximize the potential effectiveness of interventions to increase active transport, safety concerns and other issues need to be addressed such as individual family lifestyle needs and links between parent journey to work and student journey to school. Another recent systematic review on active transport to school stated that, ‘More research with higher quality study designs and measures should be conducted to further evaluate interventions and to determine the most successful strategies for increasing active transportation to school’(Chillon et al., 2011). This is of particular importance considering that the prevalence of active transport to school in countries like the US and Australia (van der Ploeg et al., 2008) decreased considerably from 1969/1970 to 2001/2003. Possible reasons for this include, ‘Parental attitudes and safety concerns, the presence of social support from parents and friends, and parent reported neighborhood walkability were all found to be predictors of active commuting, with children receiving peer and family support and living in supportive environments being more likely to walk or cycle’ (Australian National Preventive Health Agency, 2013). ‘Reducing the convenience of the car and improving the convenience of active modes as well as improving the safety of routes to school may promote uptake and maintenance of active commuting and the effectiveness of these interventions should be evaluated’ (Panter et al., 2013). Active transport to work in most high-income countries is low. For example, in July 2013, the Australian Bureau of Statistics reported that, ‘the majority of Australian adults (71%) use a passenger vehicle to get to work or full time study’ (Australian Bureau of Statistics, 2013 (25 July)). The prevalence of prolonged sitting time in cars (≥2 h/day) in a recent Sydney study was higher in full-time workers (men: 21–24%, women: 14–15%) (Mammen and Faulkner, 2013), suggesting that of the workers who drive to work, many of them sit for long periods in their cars — in addition to the likelihood of sitting for most of the day at work.
The seven playground physical activity studies captured by this systematic review included a Learning Landscapes program that included the construction of culturally-tailored schoolyard play spaces (Anthamatten et al., 2011), the provision of play equipment/physical structures and/or markings (e.g. fluorescent (Stratton, 2000) or multicolor markings (Stratton and Mullan 2005)) painted on the playground surface aimed at stimulating physically active play (Cardon et al., 2009; Ridgers et al., 2007; Stratton, 2000; Stratton and Mullan 2005; Verstraete et al., 2006) and a natural experiment upgrade of a community playground (Quigg et al., 2012). The playground physical activity health benefits described in four of the seven reviewed studies included increased physical activity as measured by accelerometer (Quigg et al., 2012; Ridgers et al., 2007) and/or heart rate telemetry (Ridgers et al., 2007; Stratton, 2000) (Stratton and Mullan 2005) and the System for Observing Play and Leisure Activity (SOPLAY, a validated quantitative method for evaluating levels of physical activity of individuals in play and leisure environments) (Anthamatten et al., 2011). The playground physical activity studies described in this systematic review collectively suggest that programs that promote physically active play at school can be effective in increasing physical activity and reducing sedentary time during breaks such as morning recess. Factors other than intervention strategies such as playground markings also influence children's physical activity during play (Stratton, 2000) and activating supervision together with the inclusion of more structured physical activity may be needed in some situations (Cardon et al., 2009). Playground physical activity can be influenced by sex and age, with findings (Stratton and Mullan 2005) that boys and younger children are more physically active. It may therefore be important to target older children and girls in playground interventions (Anthamatten et al., 2011). Several of the playground studies were conducted in areas of deprivation (Anthamatten et al., 2011; Quigg et al., 2012; Ridgers et al., 2007; Stratton and Mullan 2005), and SocioEconomic Status (SES) is an important consideration in study design, particularly due to the interaction of socioeconomics and obesity prevalence (Anthamatten et al., 2011).
Table 4 Basic overall statistics of the 43 included studies.
b
Number of participants Number of observationsb % Absolute significant increase in IPA
n studiesa
Minimum
Maximum
Median
Mean
25 24
47 3369 0% (0.29%)
36,000 158,350
338 32,858
2198 47,154
372%
5%
24%
34 a
The number of studies listed here are selections from the 43 total studies included in this systematic review, e.g. 25 studies reported number of participants, 24 studies reported number of observations and 34 studies reported a significant increase in IPA. b Studies listed number of participants and/or number of observations (e.g. stair use observations).
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Table 5 Mean percentage increase in IPA stratified by intervention type (active travel, stair use, playground), age of participants, location and duration.
Location Higher education
Shopping centre
Travel station
Workplace
School
Playground
1
N/A
Incidental physical activity intervention and participants
Whole–of– population Active travel
1 63.0
Adults
38.8
Children
2
Whole–of– population Adults Stair use^
5 3
1
3.8
1
2
5.9 2.3
5
1
3.8
2 3
2
1
3.1
4.8
Children Whole–of– population Adults
Playground Children
4
1
* = McKee et al., 2007 result of 372.0% excluded (McKee et al., 2007). #Figures calculated using 34 of the 43 studies that reported a significant increase in IPA. ^Stair use was measured heterogeneously between studies, either by ascending stair use only or by both ascending and descending stair use.
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Mean IPA % increase from baseline
8.2
12mo+
1
6mo to
