Evaluation of a School-Based Intervention Programme to Promote Physical Activity: An Application of the Theory of Planned Behavior

Exercise identity and physical activity behavior during late adolescence: A four wave cross-lagged panel model

Research has shown that physical activity behavior tends to decline across adolescence before stabilizing in adulthood. Identifying salient factors underlying these behavioral changes is therefore imperative for informing intervention development. This study explored the temporal nature of the relationship between exercise identity and physical activity behavior during the transition out of high school. An analysis of data from the Application of integrated Approaches to understanding Physical activity during the Transition to emerging adulthood (ADAPT) prospective cohort study was conducted, involving 1451 Canadian adolescents (Mage = 15.93 ± 0.53 years; 52.4% female). Participants completed the International Physical Activity Questionnaire-Short Form to report weekly moderate-to-vigorous physical activity and an abbreviated version of the Exercise Identity Scale yearly for four years beginning in Grade 11. A four-wave cross-lagged panel model was used to test bi-directional associations between exercise identity and physical activity behavior. Significant auto-regressive effects for exercise identity and physical activity were observed across all four time points. Significant positive cross-lagged paths were observed for exercise identity predicting future physical activity at all time points; however, none of the cross-lagged paths with physical activity predicting future exercise identity were significant. Collectively, these findings support existing theory that emphasizes the role that identity plays in physical activity behavior. Interventions seeking to attenuate the physical activity declines typically observed during the transition to emerging adulthood should therefore consider adopting behavior change techniques that target identity, as it appears to be an important psychological determinant underlying future physical activity engagement.

A Web-Based Physical Activity Promotion Intervention for Inactive Parent-Child Dyads: Protocol for a Randomized Controlled Trial

BACKGROUND

Low levels of physical activity are associated with numerous adverse health outcomes, yet sedentary lifestyles are common among both children and adults. Physical activity levels tend to decline steeply among children aged between 8 and 12 years, even though children's behavioral patterns are largely governed by familial structures. Similarly, parents' activity levels have been generally reported as lower than those of nonparents of comparable age. For this reason, family-based physical activity promotion interventions are a potentially valuable and relatively underresearched method for mitigating physical activity declines as children develop into adolescents and for increasing physical activity in parents.

OBJECTIVE

This study aims to assess the efficacy, feasibility, and acceptability of a novel theory-based web-based physical activity promotion intervention among parent-child dyads in Finland who do not meet physical activity recommendations at baseline.

METHODS

Participants (target N=254) will be recruited from the general population using a panel company and advertisements on social media and randomly assigned to either an immediate intervention group or a waitlist control group. The intervention consists of 4 web-based group workshops over the course of 10 weeks, web-based tasks and resources, and a social support chat group. Data on physical activity behavior and constructs from the integrated behavior change model will be collected through self-report surveys assessing physical activity, autonomy support, autonomous motivation, attitude, subjective norm, perceived behavioral control, intention, self-monitoring, habit, and accelerometer measurements at baseline, post intervention, and 3 months post intervention. Exit interviews with participants will assess the feasibility and acceptability of the intervention procedures.

RESULTS

This study will reveal whether the intervention changes leisure-time physical activity among intervention participants relative to the control group and will examine the intervention's effects on important theoretical predictors of physical activity. It will also yield data that can be used to refine intervention materials and inform further implementation. Trial recruitment commenced in September 2023, and data collection should be completed by December 2024.

CONCLUSIONS

The planned intervention has potential implications for both theory and practice. Practically, the use of an entirely web-based intervention may have scalable future uses for improving physical activity in 2 key populations, while also potentially informing on the value of dyadic, family-based strategies for encouraging an active lifestyle as an alternative to strategies that target either parents or children independently. Further, by assessing change in psychological constructs alongside potential change in behavior, the intervention also allows for important tests of theory regarding which constructs are most linked to favorable behavior change outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06070038; https://clinicaltrials.gov/study/NCT06070038.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/55960.

A Theoretical Perspective on Why Socioeconomic Health Inequalities Are Persistent: Building the Case for an Effective Approach

Despite policy intentions and many interventions aimed at reducing socioeconomic health inequalities in recent decades in the Netherlands and other affluent countries, these inequalities have not been reduced. Based on a narrative literature review, this paper aims to increase insight into why socioeconomic health inequalities are so persistent and build a way forward for improved approaches from a theoretical perspective. Firstly, we present relevant theories focusing on individual determinants of health-related behaviors. Thereafter, we present theories that take into account determinants of the individual level and the environmental level. Lastly, we show the complexity of the system of individual determinants, environmental determinants and behavior change for low socioeconomic position (SEP) groups and describe the next steps in developing and evaluating future effective approaches. These steps include systems thinking, a complex whole-system approach and participation of all stakeholders in system change.

The effect of educational intervention based on the theory of planned behavior on improving physical and nutrition status of obese and overweight women

Background

Regarding the high rate of obesity and overweight among women, develop a comprehensive and effective program it seems necessary to improve their nutritional behaviors and physical activity. This study aims to survey the effect of educational intervention based on the theory of planned behavior (TPB) on improving physical and nutritional activities of obese and overweight women.

Methods

This experimental study was performed on 400 obese and overweight women over the age of 20. The sampling method was A simple random sampling. The data collection was valid and reliable self-reports measure, questionnaires. This tools was including demographic information, questionnaire based on the constructs of the theory of planned behavior, physical activity performance questionnaire and nutritional performance questionnaire that individuals completed before and 6 months after the educational intervention. The training intervention for the experimental group consisted of 12 sessions of 50–55 min. Data analyzed by SPSS22 and by using chi-square test, independent t-test and paired t-test.

Results

Findings showed that before the educational intervention, was no significant difference between the experimental and control groups in terms of education, household monthly income, occupation, mean age, marital status, awareness, attitude, perceived behavioral control, subjective norms, physical activity and nutritional behavioral intentions, and physical activity and nutritional performance, weight and BMI. However, six months after the training intervention, there was a significant increase in each of the TPB contracts, weight and BMI in the experimental group, while no significant difference was observed in the control group. The meaningful level was considered 0.05.

Conclusion

Our findings partially support of applying theory of planned behavior in reducing the weight, BMI and improved nutritional performance and physical activity of the study subjects. TPB could be an important strategy for effective future educational interventions.

Are Perceptions of Health Dependant on Social Class? Studying Soft Power and Symbolic Violence in a Health Promotion Program among Young Men at Vocational Schools

Health behaviour among young people has a social gradient, and tends to be skewed in terms of gender as well. Young men in vocational educational settings are an example where the inequality in health is apparent. Addressing this problem requires an understanding of health behaviour and its determinants in the target group in order to be able to develop interventions that can address the problem. The aim of the paper is to investigate to what extent a multicomponent intervention based on the Whole School Approach, targeting the risk behaviours, smoking, eating and physical activity that have an impact on health behaviour among male students in a disadvantaged educational setting. The paper uses self-reported longitudinal data on risk behaviours from the “Gearing up the Body” 1-year intervention program that was implemented among students at a Danish vocational school. For the analysis, we created a score model to categorise students and behaviour. Analyses suggest that interventions had only a modest impact and what evidence there is shows that the interventions reduced the health behaviour scores by 0.03 points. More specifically, we find that symbolic violence reduces the health behaviour score of the healthy types by 0.20 points, whereas soft power increases the health behaviour of the unhealthy type by 0.05 points. An explanation for the disappointing results of the “Gearing up the Body” program is tension between different understanding of what is “right” and “wrong” health behaviour. We find that the ideas of soft power and symbolic violence can contribute to a better understanding of why health and health behaviour is understood differently among vocational students. Thus, the finding demonstrates that one needs to apply a participatory approach rather than a normative approach addressing the health behaviour of disadvantaged individuals.

The operationalization of self-identity in reasoned action models: a systematic review of self-identity operationalizations in three decades of research

Background

Self-identity has frequently been proposed as a useful addition to the Theory of Planned Behavior; yet Fishbein and Ajzen decided to not include self-identity when they published that theory's successor, the Reasoned Action Approach. One of their reasons for exclusion is the lack of clear conceptual independence, as manifested in self-identity operationalizations that often conflate the construct with attitudinal or normative measures. Therefore, establishing whether self-identity has added value in the Reasoned Action Approach first requires synthesis of the used operationalisations to develop an operationalization that captures self-identity but not attitude and perceived norm.

Method

In this systematic review we identified 153 articles through the PsycINFO database and descendency approach using Google Scholar. In total, 342 of the operationalisations of self-identity were identified in studies operationalizing it as a potential Reasoned Action Approach extension.

Results and conclusions

After analyzing the full item pool to eliminate duplicates and items that did not measure selfidentity, (also) measured attitudes or norms, did not allow tailoring formulations to target, action, context and time, were not applicable to a wide variety of behaviors, or were ambiguous, seven prototypical items remained. These items lend themselves well for further psychometric study to establish the conceptual independence of self-identity from other Reasoned Action Approach constructs such as attitude and perceived norms.

A longitudinal test of the theory of planned behaviour to explain physical activity level in children: exploration of the role of gender and age

OBJECTIVE

Most previous research based on the Theory of Planned Behaviour (TPB) to explain children's physical activity (PA) remains cross-sectional and the moderating role of demographic variables on the link between TPB variables is rarely explored. This study aims to (1) test a longitudinal cross-lagged panel model based on the TPB to explain PA in children, and (2) examine in what extent this model operates equivalently across age and gender.

DESIGN

Children (N = 363, M = 8.6 years) completed measures of TPB constructs and PA at two measurement times (T1 and T2) within three months.

MAIN OUTCOME MEASURES

Self-reported PA.

RESULTS

Path analyses revealed that the model tested accounted for 25% of the variance in PA at T2. Subgroups analyses revealed that age significantly moderated the links between subjective norms at T1 and T2, between PA at T1 and T2, and between PA at T1 and subjective norms at T2. Gender significantly moderated the links between intentions at T1 and T2, and between PA at T1 and perceived behavioural control at T2.

CONCLUSION

The temporal stability of the variables of the TPB and the link between initial PA and subsequent TPB variables may vary by children's gender and age.

A Theory of Planned Behavior-Based Program to Increase Physical Activity in Overweight/Obese Military Personnel: A Randomised Controlled Trial

BACKGROUND

Designing a health promotion program to increase physical activity may contribute to weight management. The purpose of this study was to investigate a theory of planned behavior (TPB) program to address this problem in military people.

METHODS

Eighty-four obese/overweight military personnel were randomised into the intervention or control group. A questionnaire assessed demographics, aspects of the TPB program, and physical activity levels. Also assessed were blood glucose and lipid levels. The intervention consisted of seven educational sessions based on TPB. Data were collected at baseline and 3 months after the intervention.

RESULTS

All constructs of the TPB improved between baseline and follow-up in the intervention group (p < .001), while there were no significant changes in the control group (within-group comparisons). Between-group comparisons on TPB measures revealed differences in all domains when results were controlled for baseline covariates. Greater light and moderate physical activity was observed in the intervention group. Body mass index decreased significantly within the intervention group (p < .001). Changes in triglyceride and high-density lipoprotein also favored the intervention over the control group.

CONCLUSION

An intervention based on the TPB may be effective in promoting physical activity and decreasing weight in military personnel who are obese or overweight.

Impact and Moderating Variables of an Intervention Promoting Physical Activity Among Children: Results From a Pilot Study

This pilot study pursued three objectives: to assess the effect of a 1-month multilevel intervention on the PA of children, to assess the impact of the intervention on the theory of planned behavior (TPB) variables, and to evaluate the extent to which the impact of the intervention on PA and TPB variables varied according to personal (i.e., gender and age) and situational (i.e., class and school) moderating variables. Children were aged 7 to 11 years ( n = 306). Analyses revealed a significant increase of PA practice and TPB variables ( ps < .001). Age (i.e., being a younger child) was associated with a higher increase on attitude and perceived control ( ps < .01). The class or the school levels explained a meaningful variance in the evolution of PA or TPB variables (intraclass correlation coefficients > .10). The present study reports the interest and feasibility of a multilevel intervention to increase PA and TPB variables in children.

Predicting Treatment Adherence among Patients Attending Primary Health Care Clinics: The Utility of the Theory of Planned Behaviour

Treatment regimens for conditions such as hypertension and Type II diabetes require strict adherence to medical instructions. Yet, adherence among patients living with chronic medical conditions attending public health clinics is typically low. The present study sought to determine the extent to which the Theory of Planned Behaviour (TPB) was able to significantly explain variance in adherence intentions and behaviour in a sample of 117 formerly disadvantaged South Africans living with diabetes and hypertension in the Western Cape. The results showed that the linear combination of TPB variables — Attitudes, Perceived behavioural control, and Subjective norms — was able to account for 47 per cent of the variance in adherence intentions and 23 per cent of the variance in self-reported adherence behaviour. The addition of the variables Psychological distress and Social support to the two regression models, hypothesised to add predictive power to the TPB, yielded non-significant results. The findings of the study are discussed in the context of applying theoretical models of behaviour developed in the industrially developed world and tested on middle-class subjects to patient samples in developing countries such as South Africa. Our findings suggest that social cognitive models of health behaviour such as the TPB may be useful in predicting treatment adherence but should be used in a critical and cautious manner.

Evaluation of physical activity interventions in youth via the Reach, Efficacy/Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework: A systematic review of randomised and non-randomised trials

CONTEXT

An identified limitation of existing reviews of physical activity interventions in school-aged youth is the lack of reporting on issues related to the translatability of the research into health promotion practice.

OBJECTIVE

This review used the Reach, Efficacy/Effectiveness, Adoption, Implementation and Maintenance framework to determine the extent to which intervention studies promoting physical activity in youth report on factors that inform generalizability across settings and populations.

METHODS AND RESULTS

A systematic search for controlled interventions conducted within the last ten years identified 50 studies that met the selection criteria. Based on Reach, Efficacy/Effectiveness, Adoption, Implementation and Maintenance criteria, most of these studies focused on statistically significant findings and internal validity rather than on issues of external validity. Due to this lack of information, it is difficult to determine whether or not reportedly successful interventions are feasible and sustainable in an uncontrolled, real-world setting.

CONCLUSIONS

Areas requiring further research include costs associated with recruitment and implementation, adoption rate, and representativeness of participants and settings. This review adds data to support recommendations that interventions promoting physical activity in youth should include assessment of adoption and implementation issues.

Community wide interventions for increasing physical activity

BACKGROUND

Multi-strategic community wide interventions for physical activity are increasingly popular but their ability to achieve population level improvements is unknown.

OBJECTIVES

To evaluate the effects of community wide, multi-strategic interventions upon population levels of physical activity.

SEARCH METHODS

We searched the Cochrane Public Health Group Segment of the Cochrane Register of Studies,The Cochrane Library, MEDLINE, MEDLINE in Process, EMBASE, CINAHL, LILACS, PsycINFO, ASSIA, the British Nursing Index, Chinese CNKI databases, EPPI Centre (DoPHER, TRoPHI), ERIC, HMIC, Sociological Abstracts, SPORT Discus, Transport Database and Web of Science (Science Citation Index, Social Sciences Citation Index, Conference Proceedings Citation Index). We also scanned websites of the EU Platform on Diet, Physical Activity and Health; Health-Evidence.org; the International Union for Health Promotion and Education; the NIHR Coordinating Centre for Health Technology (NCCHTA); the US Centre for Disease Control and Prevention (CDC) and NICE and SIGN guidelines. Reference lists of all relevant systematic reviews, guidelines and primary studies were searched and we contacted experts in the field. The searches were updated to 16 January 2014, unrestricted by language or publication status.

SELECTION CRITERIA

Cluster randomised controlled trials, randomised controlled trials, quasi-experimental designs which used a control population for comparison, interrupted time-series studies, and prospective controlled cohort studies were included. Only studies with a minimum six-month follow up from the start of the intervention to measurement of outcomes were included. Community wide interventions had to comprise at least two broad strategies aimed at physical activity for the whole population. Studies which randomised individuals from the same community were excluded.

DATA COLLECTION AND ANALYSIS

At least two review authors independently extracted the data and assessed the risk of bias. Each study was assessed for the setting, the number of included components and their intensity. The primary outcome measures were grouped according to whether they were dichotomous (per cent physically active, per cent physically active during leisure time, and per cent physically inactive) or continuous (leisure time physical activity time (time spent)), walking (time spent), energy expenditure (as metabolic equivalents or METS)). For dichotomous measures we calculated the unadjusted and adjusted risk difference, and the unadjusted and adjusted relative risk. For continuous measures we calculated percentage change from baseline, unadjusted and adjusted.

MAIN RESULTS

After the selection process had been completed, 33 studies were included. A total of 267 communities were included in the review (populations between 500 and 1.9 million). Of the included studies, 25 were set in high income countries and eight were in low income countries. The interventions varied by the number of strategies included and their intensity. Almost all of the interventions included a component of building partnerships with local governments or non-governmental organisations (NGOs) (29 studies). None of the studies provided results by socio-economic disadvantage or other markers of equity. However, of those included studies undertaken in high income countries, 14 studies were described as being provided to deprived, disadvantaged or low socio-economic communities. Nineteen studies were identified as having a high risk of bias, 10 studies were unclear, and four studies had a low risk of bias. Selection bias was a major concern with these studies, with only five studies using randomisation to allocate communities. Four studies were judged as being at low risk of selection bias although 19 studies were considered to have an unclear risk of bias. Twelve studies had a high risk of detection bias, 13 an unclear risk and four a low risk of bias. Generally, the better designed studies showed no improvement in the primary outcome measure of physical activity at a population level.All four of the newly included, and judged to be at low risk of bias, studies (conducted in Japan, United Kingdom and USA) used randomisation to allocate the intervention to the communities. Three studies used a cluster randomised design and one study used a stepped wedge design. The approach to measuring the primary outcome of physical activity was better in these four studies than in many of the earlier studies. One study obtained objective population representative measurements of physical activity by accelerometers, while the remaining three low-risk studies used validated self-reported measures. The study using accelerometry, conducted in low income, high crime communities of USA, emphasised social marketing, partnership with police and environmental improvements. No change in the seven-day average daily minutes of moderate to vigorous physical activity was observed during the two years of operation. Some program level effect was observed with more people walking in the intervention community, however this result was not evident in the whole community. Similarly, the two studies conducted in the United Kingdom (one in rural villages and the other in urban London; both using communication, partnership and environmental strategies) found no improvement in the mean levels of energy expenditure per person per week, measured from one to four years from baseline. None of the three low risk studies reporting a dichotomous outcome of physical activity found improvements associated with the intervention.Overall, there was a noticeable absence of reporting of benefit in physical activity for community wide interventions in the included studies. However, as a group, the interventions undertaken in China appeared to have the greatest possibility of success with high participation rates reported. Reporting bias was evident with two studies failing to report physical activity measured at follow up. No adverse events were reported.The data pertaining to cost and sustainability of the interventions were limited and varied.

AUTHORS' CONCLUSIONS

Although numerous studies have been undertaken, there is a noticeable inconsistency of the findings in the available studies and this is confounded by serious methodological issues within the included studies. The body of evidence in this review does not support the hypothesis that the multi-component community wide interventions studied effectively increased physical activity for the population, although some studies with environmental components observed more people walking.

Views on human papillomavirus vaccination: a mixed-methods study of urban youth

While the human papillomavirus (HPV) vaccine has potential to protect against the majority of HPV-associated cancers, vaccination rates in the United States remain low. Racial/ethnic and economic disparities exist for HPV vaccination completion rates. We conducted a mixed-methods study using the theory of planned behavior framework to explore attitudes and beliefs about HPV vaccination among urban, economically disadvantaged adolescents. Fifty adolescents aged 14-18 years were recruited from community-based organizations to complete a written survey and participate in a focus group. The mean age was 15.5 ± 1.3 years; 98 % were African American or mixed race; 64 % were female; 52 % reported previous sexual intercourse; 40 % reported receipt of ≥1 HPV vaccine dose. The knowledge deficit about the HPV vaccine was profound and seemed slightly greater among males. Mothers, fathers and grandmothers were mentioned as important referents for HPV vaccination, but peers and romantic partners were not. Common barriers to vaccination were lack of awareness, anticipated side effects (i.e., pain), and concerns about vaccine safety. Characteristics associated with ≥1 vaccine dose were: having heard of the HPV vaccine versus not (65 vs. 20 %, p = 0.002) and agreeing with the statement "Most people I know would think HPV vaccine is good for your health" versus not (67 vs. 27 %, p = 0.007). Our work indicates a profound lack of awareness about HPV vaccination as well as the important influence of parents among urban, economically-disadvantaged youth. Awareness of these attitudes and beliefs can assist providers and health officials by informing specific interventions to increase vaccine uptake.

Accessing General and Sexual Healthcare: Experiences of Urban Youth

Urban adolescents face many barriers to health care that contribute to health disparities in rates of sexually transmitted infections (STIs) and unintended pregnancy. Designing interventions to increase access to health care is a complex process that requires understanding the perspectives of adolescents. We conducted six focus groups to explore the attitudes and beliefs about general and sexual health care access as well as barriers to care among urban, economically disadvantaged adolescents. Participants first completed a written survey assessing health behaviors, health care utilization, and demographics. The discussion guide was based on the Theory of Planned Behavior and its constructs: attitudes, subjective norms, and perceived behavioral control. Transcripts of group discussions were analyzed using directed content analysis with triangulation and consensus to resolve differences. Fifty youth participated (mean age 15.5 years; 64% female; 90% African American). Many (23%) reported missed health care in the previous year. About half (53%) reported previous sexual intercourse; of these, 35% reported no previous sexual health care. Youth valued adults as important referents for accessing care as well as multiple factors that increased comfort such as good communication skills, and an established relationship. However, many reported mistrust of physicians and identified barriers to accessing care including fear and lack of time. Most felt that accessing sexual health care was more difficult than general care. These findings could inform future interventions to improve access to care and care-seeking behaviors among disadvantaged youth.

Long-term effects of 4-year longitudinal school-based physical activity intervention on the physical fitness of children and youth during 7-year followup assessment

Many school-based physical activity (PA) interventions have been developed, but only a few have assessed their long-term effects. A PA intervention taking place in the first four years of some Slovenian primary schools entails an enhanced physical education (PE) curriculum, including two extra lessons of PE per week, a wider selection of PE content, and additional outdoor education delivered by both a specialist PE teacher and a general teacher. The effects of the intervention on children's physical fitness (motor tasks and anthropometry) were evaluated within a quasi-experimental study. In total, 324 children from nine Slovenian primary schools either received the enhanced curriculum (intervention (n=160)) or standard PE (control (n=164)), and were followed for a four-year intervention period and seven years post intervention. Data from the SLOFIT database were used to compare differences in the physical fitness of children each year. Linear Mixed Models were used to test the influence of the PA intervention. Over an 11-year period, the PA intervention group significantly differed in all motor tasks, but not in anthropometric measures or body mass index, after controlling for year of measurement and sex. Differences between the control and intervention groups decreased with time. This study highlights the importance of tracking the long term effects of PA interventions. PA intervention in the first four years of Slovenian primary school offers the possibility of improving physical performance in children; initiatives aiming to increase their performance (physical fitness, physical activity) and health outcomes are warranted.

Knowledge, attitudes, and beliefs about emergency contraception: a survey of female adolescents seeking care in the emergency department

OBJECTIVES

This study aimed to assess urban adolescents' knowledge of and attitudes about emergency contraception (EC) and to assess the intention to use EC in particular hypothetical situations. We hypothesized that knowledge about EC would be limited, but that adolescents would support using EC in certain situations.

METHODS

A cross-sectional survey of English-speaking, 14- to 19-year-old adolescent girls presenting for care at 2 urban pediatric emergency departments. The survey was based on previous research with this target population and the constructs of the theory of planned behavior.

RESULTS

We enrolled 223 adolescents; 56% reported a history of sexual activity. Sixty-four percent stated that they had heard of EC. Participants with a history of sexual activity were more likely to have heard of EC compared with those without (odds ratio, 2.6; 95% confidence interval, 1.4-4.7), as were those 17 years and older (odds ratio, 2.3; 95% confidence interval, 1.2-4.3). The majority of participants were concerned about potential short-term and long-term adverse effects (86% and 78%, respectively); many participants were concerned about the cost of EC (45%) and about being able to get to a doctor for a prescription (45%). Participants supported using EC in the following situations: rape (88%), the condom breaks (82%), or no birth control was used (76%). Fewer supported using EC in the following situations: missed 1 oral contraceptive pill (51%) or first sexual experience (57%).

CONCLUSIONS

Participants indicated that although they would support EC use in several situations, they have concerns about EC use and access. Awareness of these factors and potential influences of EC use can guide providers toward effective counseling and interventions aimed to increase adolescents' use of EC in appropriate settings.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Community wide interventions for increasing physical activity

BACKGROUND

Multi-strategic community wide interventions for physical activity are increasingly popular but their ability to achieve population level improvements is unknown.

OBJECTIVES

To evaluate the effects of community wide, multi-strategic interventions upon population levels of physical activity.

SEARCH STRATEGY

We searched the Cochrane Public Health Group Specialised Register, The Cochrane Library, MEDLINE, MEDLINE in Process, EMBASE, CINAHL, LILACS, PsycINFO, ASSIA, The British Nursing Index, Chinese CNKI databases, EPPI Centre (DoPHER, TRoPHI), ERIC, HMIC, Sociological Abstracts, SPORTDiscus, Transport Database and Web of Science (Science Citation Index, Social Sciences Citation Index, Conference Proceedings Citation Index). We also scanned websites of the EU Platform on Diet, Physical Activity and Health; Health-Evidence.ca; the International Union for Health Promotion and Education; the NIHR Coordinating Centre for Health Technology (NCCHTA) and NICE and SIGN guidelines. Reference lists of all relevant systematic reviews, guidelines and primary studies were followed up. We contacted experts in the field from the National Obesity Observatory Oxford, Oxford University; Queensland Health, Queensland University of Technology, the University of Central Queensland; the University of Tennessee and Washington University; and handsearched six relevant journals. The searches were last updated to the end of November 2009 and were not restricted by language or publication status.

SELECTION CRITERIA

Cluster randomised controlled trials, randomised controlled trials (RCT), quasi-experimental designs which used a control population for comparison, interrupted time-series (ITS) studies, and prospective controlled cohort studies (PCCS) were included. Only studies with a minimum six-month follow up from the start of the intervention to measurement of outcomes were included. Community wide interventions had to comprise at least two broad strategies aimed at physical activity for the whole population. Studies which randomised individuals from the same community were excluded.

DATA COLLECTION AND ANALYSIS

At least two review authors independently extracted the data and assessed the risk of bias of each included study. Non-English language papers were reviewed with the assistance of an epidemiologist interpreter. Each study was assessed for the setting, the number of included components and their intensity. Outcome measures were grouped according to whether they were dichotomous (physically active, physically active during leisure time and sedentary or physically inactive) or continuous (leisure time physical activity, walking, energy expenditure). For dichotomous measures we calculated the unadjusted and adjusted risk difference, and the unadjusted and adjusted relative risk. For continuous measures we calculated net percentage change from baseline, unadjusted and adjusted risk difference, and the unadjusted and adjusted relative risk.

MAIN RESULTS

After the selection process had been completed 25 studies were included in the review. Of the included studies, 19 were set in high income countries, using the World Bank economic classification, and the remaining six were in low income countries. The interventions varied by the number of strategies included and their intensity. Almost all of the interventions included a component of building partnerships with local governments or non-governmental organisations (NGOs) (22 studies). None of the studies provided results by socio-economic disadvantage or other markers of equity consideration. However of those included studies undertaken in high income countries, 11 studies were described by the authors as being provided to deprived, disadvantaged, or low socio-economic communities.Fifteen studies were identified as having a high risk of bias, 10 studies were unclear, and no studies had a low risk of bias. Selection bias was a major concern with these studies, with only one study using randomisation to allocate communities (Simon 2008). No studies were judged as being at low risk of selection bias although 16 studies were considered to have an unclear risk of bias. Eleven studies had a high risk of detection bias, 10 with an unclear risk and four with no risk. Assessment of detection bias included an assessment of the validity of the measurement tools and quality of outcome measures. The effects reported were inconsistent across the studies and the measures. Some of the better designed studies showed no improvement in measures of physical activity. Publication bias was evident.

AUTHORS' CONCLUSIONS

Although numerous studies have been undertaken, there is a noticeable inconsistency of the findings of the available studies and this is confounded by serious methodological issues within the included studies. The body of evidence in this review does not support the hypothesis that multi-component community wide interventions effectively increase population levels of physical activity. There is a clear need for well-designed intervention studies and such studies should focus on the quality of the measurement of physical activity, the frequency of measurement and the allocation to intervention and control communities.

Key beliefs for targeted interventions to increase physical activity in children: analyzing data from an extended version of the theory of planned behaviour

Given the high prevalence of overweight and low levels of physical activity among children, a better understanding of physical activity behaviour is an important step in intervention planning. This study, based on the theory of planned behaviour, was conducted among 313 fifth graders and their parents. Children completed a computer-based questionnaire to evaluate theoretical constructs and behaviour. Additional information was obtained from parents by means of a questionnaire. Correlates of children's physical activity were intention and self-identity. Determinants of intention were self-efficacy, self-identity, and attitude. Parental variables were mediated through cognitions. Among girls, practicing sedentary activities was an additional negative determinant of intention. Key beliefs of boys and girls were related to time management and difficulties associated with physical activity. For girls, social identification as an active girl was another important belief related to positive intention. This study provides theory-based information for the development of more effective interventions aimed at promoting physical activity among children.

Adding effect sizes to a systematic review on interventions for promoting physical activity among European teenagers

This commentary adds effect sizes to the recently published systematic review by De Meester and colleagues and provides a more detailed insight into the effectiveness of interventions to promote physical activity among European teenagers. The main findings based on this evidence were: (1) school-based interventions generally lead to short term improvement in physical activity levels, but there were large differences between interventions with regard to effect sizes; (2) a multi-component approach (including environmental components) generally resulted in larger effect sizes, thereby providing evidence for the assumption that a multi-component approach should produce synergistic results; and (3) if an intervention aimed to affect more health behaviours besides physical activity, then the intervention appeared to be less effective in favour of physical activity.

Interventions for promoting physical activity among European teenagers: a systematic review

Background

Although physical activity is considered to yield substantial health benefits, the level of physical activity among European teenagers is not sufficient. Adolescence is characterized by a decline in physical activity level. Many studies investigated the effectiveness of interventions promoting physical activity among young people, but none dealt with the available evidence specific for Europe. This review was conducted to summarize the effectiveness of interventions to promote physical activity among European teenagers.

Methods

A systematic review was conducted to identify European intervention studies published in the scientific literature since 1995. Four databases were searched, reference lists were scanned and the publication lists of the authors of the retrieved articles were checked. The ANGELO framework was used to categorise the included studies by setting and by intervention components.

Results

The literature search identified 20 relevant studies. Fifteen interventions were delivered through the school setting, of which three included a family component and another three a family and community component. One intervention was conducted within a community setting, three were delivered in primary care and one was delivered through the internet. Ten interventions included only an individual component, whereas the other ten used a multi-component approach. None of the interventions included only an environmental component.

Main findings of the review were: (1) school-based interventions generally lead to short term improvements in physical activity levels; (2) improvements in physical activity levels by school-based interventions were limited to school related physical activity with no conclusive transfer to leisure time physical activity; (3) including parents appeared to enhance school-based interventions; (4) the support of peers and the influence of direct environmental changes increased the physical activity level of secondary school children; (5) the assumption that a multi-component approach should produce synergistic results can not be confirmed; (6) when interventions aimed to affect more than one health behaviour the intervention appeared to be less effective in favour of physical activity.

Conclusion

Overall, the current European literature supports the short-term effectiveness of school-based physical activity promotion programmes. The available evidence for the effectiveness in other settings is rather limited and underscores the need for further research.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Association of multiple behavioral risk factors with adolescents' willingness to engage in eHealth promotion

OBJECTIVE

This study examines adolescents' willingness to use the internet and other forms of technology for health promotion purposes (i.e., "eHealth promotion" willingness) and determines if a relationship exists between adolescents' behavioral risks and their eHealth promotion willingness.

METHODS

A total of 332 adolescents provided data at a routine medical check-up, including assessments of technology access, eHealth promotion willingness, and multiple behavioral risk factors for child- and adult-onset disease (body mass index, physical activity, smoking, sun protection, depression).

RESULTS

The level of access to technology among the sample was high, with moderate willingness to engage in eHealth promotion. After adjusting for adolescents' access to technology, the presence of multiple behavioral risk factors was positively associated with willingness to use technology for health promotion purposes (beta =.12, p =.03).

CONCLUSIONS

Adolescents with both single and multiple behavioral risk factors are in need of health promotion to prevent the onset of disease later in life. eHealth appears to be an acceptable and promising intervention approach with this population.

Assessing attitudes about emergency contraception among urban, minority adolescent girls: an in-depth interview study

OBJECTIVE

The purpose of this work was to explore the knowledge, attitudes, and beliefs of urban, minority adolescent girls about intention to use emergency contraception pills and to identify barriers to emergency contraception pill use.

PATIENTS AND METHODS

We conducted an in-depth, semistructured interview study of healthy, urban-dwelling, English-speaking 15- to 19-year-old black adolescents seeking care in a children's hospital emergency department. Purposive sampling was used to recruit sexually active and nonsexually active adolescents and those with and without a history of pregnancy. Enrollment continued until saturation of key themes was achieved. Participants returned after their emergency department visit for a 1-hour interview. The interview consisted of semistructured questions based on the theory of planned behavior constructs: attitudes (including knowledge), subjective norms, and perceived behavioral control, as well as demographic data collection. Interviews were recorded and transcribed. Transcripts were coded by 2 members of the study team by using a modified grounded-theory method.

RESULTS

Thirty interviews were required for saturation. Mean participant age was 16.4 years; 53% reported being sexually active, and 17% reported a history of pregnancy. Specific knowledge gaps exist about emergency contraception pills, including misconceptions about the recommended time frame for taking the medication. Several major themes were noted for each of the constructs. Intention to use emergency contraception pills is affected by the conflicting attitudes that the emergency contraception pill works faster than birth control pills and that those who use emergency contraception pills are irresponsible; family and friends are important influences and have uninformed but generally supportive opinions; and adolescents have a perception of limited behavioral control because of their young age and concerns about confidentiality.

CONCLUSIONS

Urban, minority adolescent girls have misconceptions about emergency contraception pills, are affected by the opinions of those close to them, and express concern about specific barriers. These findings can inform specific interventions aimed at addressing the barriers to emergency contraception pill use that are of most importance to this population of young women.

Adherence to Antiretroviral Therapy in the Context of the National Roll-Out in South Africa: Defining a Research Agenda for Psychology

Since 2004, antiretroviral therapy (ART) has been provided by the South African Department of Health to patients who need it as part of the national ART roll-out. Despite the initial success of a trial ART programme in Khayelitsha near Cape Town, it is unclear that adherence to ART is optimal among the patients receiving treatment in the context of the national roll-out. In this article I call attention to the psychosocial barriers to adherence that may potentially be faced by patients receiving ART. These barriers include poverty, health literacy, perceived social support, mental health, substance abuse, and stigma. Three social cognitive theories are briefly reviewed to conceptualise the phenomenon of ART adherence, namely, the Health Belief Model, the Theory of Planned Behaviour, and the Informational—Behavioural—Motivational Model. Constructs such as health motivation, perceived threats, perceived barriers, attitudes towards ART, perceived subjective norms, and perceived behavioural control are examined for their potential role in developing a theoretical understanding of adherence to ART. Finally, the role of culture is considered in response to concerns that social cognitive models developed in industrially developed countries are limited in their application in a developing country such as South Africa. As the question of adherence to ART in South Africa has received little attention from social science researchers, I set a tentative agenda for psychosocial research with a view to enhancing the likelihood of optimal adherence among AIDS patients.

Associação entre prevalência de inatividade física e indicadores de condição socioeconômica em adolescentes

OBJETIVO: A redução nos níveis de atividade física na população jovem tem sido amplamente descrita em vários países, sobretudo em alguns subgrupos dessa população. O objetivo deste estudo foi determinar a prevalência de inatividade física em adolescentes escolares do ensino médio do município de João Pessoa - PB, e analisar sua associação com indicadores de condição socioeconômica. METODOLOGIA: Participaram do estudo 2.566 adolescentes (1.132 rapazes e 1.434 moças), de 14 a 18 anos de idade (16,5±1,17). Foram levantadas informações demográficas (sexo e idade), socioeconômicas (trabalho, tipo de escola, classe econômica, escolaridade dos pais), e mediu-se o nível de atividade física (kcal/kg/dia), mediante utilização de um diário de atividade física. Foram classificados como fisicamente inativos os adolescentes com demanda energética diária <37kcal/kg/dia. Na análise multivariável recorreu-se à regressão de Poisson, tendo a razão de prevalência como medida de associação. RESULTADOS: Cerca de seis em cada dez adolescentes foram classificados como fisicamente inativos (55,9%, n=1.435), com prevalência estatisticamente mais elevada nas moças (64,2%) do que nos rapazes (45,5%; p<0,001). A prevalência de inatividade física se associou positivamente com a condição socioeconômica, indicando maior prevalência de inatividade física nos adolescentes que não trabalhavam (rapazes RP=2,22; IC95%=1,62-3,04 e moças RP=1,52; IC95%=1,19-1,93), e nas moças cujos pais apresentavam maior nível de escolaridade (RP=1,20; IC95%=1,05-1,35), comparados, respectivamente, aos que trabalham e cujos pais tinham menor nível de escolaridade. CONCLUSÃO: A prevalência de inatividade física foi alta, principalmente nas moças. Adolescentes que pertenciam aos estratos socioeconômicos mais privilegiados se mostraram mais expostos à inatividade física, sobretudo as moças.