Methodological challenges in conducting a systematic review of community wide interventions to increase physical activity

Introduction: Evaluating the effectiveness of interventions designed to increase the physical activity in communities is often a difficult and complex task, requiring considerable expertise and investment, and often constrained by methodological limitations. These limitations, in turn, create additional challenges when these studies are used in systematic reviews as they hinder the confidence, precision and interpretation of results. The objective of this paper is to summarise the methodological challenges posed in conducting a systematic review of community-wide physical activity interventions to help inform those conducting future primary research and systematic reviews. Methods: We conducted a Cochrane systematic review of community-wide interventions to increase physical activity. We assessed the methodological quality of the included studies. We will investigate these in greater detail, particularly in relation to the potential impact on measures of effect, confidence in results, generalizability of results and general interpretation. Results: The systematic review was conducted and has been published in the Cochrane Library. A logic model was helpful in defining and interpreting the studies. Many studies of unsuitable study design were excluded; however several important methodological limitations of the primary studies evaluating community-wide physical activity interventions emerged. These included: - the failure to use validated tools to measure physical activity; - issues associated with pre and post test designs; - inadequate sampling of populations; - poor control groups; and - intervention and measurement protocols of inadequate duration. Although it is challenging to undertake rigorous evaluations of complex interventions, these issues result in significant uncertainty over the effectiveness of these interventions, and the possible factors required for a community-wide intervention to be successful. In particular, the combination of several of these limitations (e.g. un-validated tools, inadequate sampling, and short duration) is that studies may lack the sensitivity to detect any meaningful change. Multiple publications of findings for the same study also made interpretation difficult; however, interventions with parallel qualitative publications were helpful. Discussion: Evaluating community wide interventions to increase physical activity in a rigorous way is incredibly challenging. These findings reflect these challenges but have important ramifications for researchers conducting primary studies to determine the efficacy of such interventions, as well as for researchers conducting systematic reviews. This new review shows that the inadequacies of design and evaluation are continuing. It is hoped that the adoption of such suggestions may aid in the development of systematic reviews, but more importantly, in enabling translation of such findings into policy and practice.

Sitting-time, physical activity and depressive symptoms in mid-aged women

Background: Associations between sitting-time and physical activity (PA) with depression are unclear. Purpose: To examine concurrent and prospective associations between both sitting-time and PA with prevalent depressive symptoms in mid-aged Australian women. Methods: Data were from 8,950 women, aged 50-55 years in 2001, who completed mail surveys in 2001, 2004, 2007 and 2010. Depressive symptoms were assessed using the Center for Epidemiological Studies Depression questionnaire. Associations between sitting-time (≤4, >4-7, >7 hrs/day) and PA (none, some, meeting guidelines) with depressive symptoms (symptoms/no symptoms) were examined in 2011 in concurrent and lagged mixed effect logistic modeling. Both main effects and interaction models were developed. Results: In main effects modeling, women who sat >7 hrs/day (OR 1.47, 95%CI 1.29-1.67) and women who did no PA (OR 1.99, 95%CI 1.75-2.27) were more likely to have depressive symptoms than women who sat ≤4 hrs/day and who met PA guidelines, respectively. In interaction modeling, the likelihood of depressive symptoms in women who sat >7 hrs/day and did no PA was triple that of women who sat ≤4 hrs/day and met PA guidelines (OR 2.96, 95%CI 2.37-3.69). In prospective main effects and interaction modeling, sitting-time was not associated with depressive symptoms, but women who did no PA were more likely than those who met PA guidelines to have future depressive symptoms (OR 1.26, 95%CI 1.08-1.47). Conclusions: Increasing PA to a level commensurate with PA guidelines can alleviate current depression symptoms and prevent future symptoms in mid-aged women. Reducing sitting-time may ameliorate current symptoms.

The use of SMS messaging for physical activity promotion : preferences of Australian adolescents and their parents

OBJECTIVE: Recent increases in youth mobile phone ownership and usage may provide a unique and innovative opportunity for engagement by health promoters, via a familiar and immediately accessible medium. This study investigated adolescents’ and their parents’ preferences for promoting physical activity via means of SMS messaging. METHODS: Adolescents (36 males and 76 females) and their parents (37 males 75 females) were recruited from two non-denominational same-sex private schools, in Brisbane, Australia. The mean age and standard deviation (SD) for adolescents and parents was 14.03 (0.58) and 47.18 (4.65) respectively. Participants responded to a series of questions regarding mobile phone ownership, and preferences for physical activity, school-based physical activity programs, and programs invovling SMS messaging. Data analysis included descriptive statistics and frequency distributions. T-tests were employed to measure gender effect. RESULTS: Overall, 47 (42%) parents desired their child to be more physically active, and were interested for their child to participate in a school-based physical activity program. Of those parents, 16 (34%) parents were interested in their child participating in an SMS-based physical activity program, with 21 (45%) not interested, and 10 (21%) neutral. One hundred and four (95%) adolescents owned a mobile phone, with 84 (82%) of those adolescents wanting to be more physically active. Of those adolescents, 14 (17%) were interested in participating in an SMS-based physical activity program, with 40 (48%) not interested, and 30 (36%) neutral. There was no significant gender effect. CONCLUSIONS: Although SMS messaging may provide an innovative method for youth physical activity promotion, low levels of interest are concerning. These results differ from other studies utilising SMS messaging for the purpose of health promotion, where more positive feedback from participants were reported. A screening process to gauge interest prior to the implementation of any SMS-based health promotion program may prove invaluable toward the success of the program.

Perception and reality : meeting Australia’s physical activity guidelines for 12-18 year olds

Governments regularly publish empirically derived minimum physical activity (PA) guidelines for youth, in response to the ongoing trend of youth physical inactivity. The purpose of this investigation was to explore parents’ awareness of the national PA guidelines for youth, and adolescents’ and their parents’ perceptions of adolescent PA, and compare these to self-reported adolescent PA. A total of 115 adolescents (aged 12-14) and their parents completed questionnaire assessments. Parents responded to questions concerning their awareness of the national PA guidelines, and whether they believed their child to be sufficiently active. Adolescents completed the International Physical Activity Questionnaire for Adolescents, and questions concerning their perceived level of PA. Adolescents were deemed sufficiently active if they participated in an average of at least 60 minutes of moderate-to-vigorous PA each day. Overall, 104 (90.4%) adolescents and their parents had complete data sets and were included in the analysis. Of the 45 (43.3%) sufficiently and 59 (56.7%) insufficiently active adolescents, 42 (93%) and 41 (69.5%) respectively believed that they were active enough for good general health. Additionally, 41 (91.1%) parents of active and 44 (74.6%) parents of inactive adolescents either agreed or strongly agreed that their child participates in sufficient PA for good general health. Twenty-four (53.3%) parents of active adolescents were unaware of the national PA guidelines, with 10 (22.2%) neither aware or unaware, and 11 (24.4%) aware. Similar results were found for the parents of inactive adolescents with 31 (52.5%) unaware, 17 (28.8%) neither aware or unaware, and 11 (18.6%) aware. These results suggest that the youth PA guidelines are being inadequately received by both adolescents, and their parents. Opportunities to effectively communicate these guidelines such as embedment in curriculum for adolescents, or the dissemination of materials for parents, should be maximised by appropriate authorities.

Sleepless nights : the effect of socioeconomic status, physical activity, and lifestyle factors on sleep quality in a large cohort of Australian women

The aims of this study were to examine: (1) the association between sociodemographic and lifestyle factors and sleep quality in a population-based cohort of Australian women and (2) possible influence of reproductive status and mental and physical health factors on these associations. Data on 3,655 women (mean age046.6 years, range 34.3–67.4) were obtained from the Mater Hospital University of Queensland Study of Pregnancy for this cross-sectional study. Self-rated sleep quality was assessed using the Pittsburgh Sleep Quality Index. For the purpose of this study, two cutoff points (scores 5 and 10) were used to divide women into three categories: normal (65.2 %), moderately poor (26.4 %), and very poor sleep quality (8.5 %). Other covariates were measured at 21-year follow-up as well. After adjusting for reproductive status, mental and physical health, there were significant associations between moderately poor sleep quality and education and between very poor sleep quality and unemployment, both measures of socioeconomic status. In addition, work-related exertion was associated with increased rates of moderately poor sleep quality, whereas those women undertaking moderate exercise were less likely to experience very poor sleep quality. Independent associations between sociodemographic factors and exercise with moderately poor and very poor sleep quality were identified. These findings demonstrate the dynamic nature of the association between exercise/exertion, socioeconomic status, and sleep quality and highlight the importance of taking these into consideration when dealing with issues of poor sleep quality in women.

Anthropometry and body composition of Indonesian adults : an evaluation of body image, eating behaviours, and physical activity

This thesis examines the characteristics of anthropometry and body composition in Indonesian adults and some of the risk factors including body image, eating behaviours, and physical activity. Examination on body image, eating behaviours, and physical activity demonstrates significant correlations with anthropometry and body composition in Indonesian adults. The study also identified body image distortion in some of the participants and provides suggestions for intervention development addressed to the groups of participants which have been identified as having a distorted body image.

Social influences and the physical activity intentions of parents of young-children families: An extended Theory of Planned Behavior Approach

Evidence within Australia and internationally suggests parenthood as a risk factor for inactivity; however, research into understanding parental physical activity is scarce. Given that active parents can create active families and social factors are important for parents’ decision making, the authors investigated a range of social influences on parents’ intentions to be physically active. Parents (N = 580; 288 mothers and 292 fathers) of children younger than 5 years completed an extended Theory of Planned Behavior questionnaire either online or paper based. For both genders, attitude, control factors, group norms, friend general support, and an active parent identity predicted intentions, with social pressure and family support further predicting mothers’ intentions and active others further predicting fathers’ intentions. Attention to these factors and those specific to the genders may improve parents’ intentions to be physically active, thus maximizing the benefits to their own health and the healthy lifestyle practices for other family members.

An observational study of nutrition and physical activity behaviours, knowledge, and advice in pregnancy

Maternal obesity, excess weight gain and lifestyle behaviours during pregnancy have been associated with future overweight and other adverse health outcomes for mothers and babies. This study compared the nutrition and physical activity behaviours of Australian healthy (BMI ≤ 25 k/m2) and overweight (BMI ≥ 25 kg/m2) pregnant women and described their knowledge and receipt of health professional advice early in pregnancy. Methods Pregnant women (n=58) aged 29±5 (mean±s.d.) years were recruited at 16±2 weeks gestation from an Australian metropolitan hospital. Height and weight were measured using standard procedures and women completed a self administered semi-quantitative survey. Results Healthy and overweight women had very similar levels of knowledge, behaviour and levels of advice provided except where specifically mentioned. Only 8% and 36% of participants knew the correct recommended daily number of fruit and vegetable serves respectively. Four percent of participants ate the recommended 5 serves/day of vegetables. Overweight women were less likely than healthy weight women to achieve the recommended fruit intake (4% vs. 8%, p=0.05), and more likely to consume soft drinks or cordial (55% vs 43%, p=0.005) and take away foods (37% vs. 25%, p=0.002) once a week or more. Less than half of all women achieved sufficient physical activity. Despite 80% of women saying they would have liked education about nutrition, physical activity and weight gain, particularly at the beginning of pregnancy, less than 50% were given appropriate advice regarding healthy eating and physical activity. Conclusion Healthy pregnancy behaviour recommendations were not being met, with overweight women less likely to meet some of the recommendations. Knowledge of dietary recommendations was poor and health care professional advice was limited. There are opportunities to improve the health care practices and education pregnant women received to improve knowledge and behaviours. Pregnant women appear to want this.

Physical activity and health-related quality of life among physiotherapists : a cross sectional survey in an Australian hospital and health service

Background Physiotherapists are a professional group with a high rate of attrition and at high risk of musculoskeletal disorders. The purpose of this investigation was to examine the physical activity levels and health-related quality of life of physiotherapists working in metropolitan clinical settings in an Australian hospital and health service. It was hypothesized that practicing physiotherapists would report excellent health-related quality of life and would already be physically active. Such a finding would add weight to a claim that general physical activity conditioning strategies may not be useful for preventing musculoskeletal disorders among active healthy physiotherapists, but rather, future investigations should focus on the development and evaluation of role specific conditioning strategies. Methods A questionnaire was completed by 44 physiotherapists from three inpatient units and three ambulatory clinics (63.7% response rate). Physical activity levels were reported using the Active Australia Survey. Health-related quality of life was examined using the EQ-5D instrument. Physical activity and EQ-5D data were examined using conventional descriptive statistics; with domain responses for the EQ-5D presented in a frequency histogram. Results The majority of physiotherapists in this sample were younger than 30 years of age (n = 25, 56.8%) consistent with the presence of a high attrition rate. Almost all respondents exceeded minimum recommended physical activity guidelines (n = 40, 90.9%). Overall the respondents engaged in more vigorous physical activity (median = 180 minutes) and walking (median = 135 minutes) than moderate exercise (median = 35 minutes) each week. Thirty-seven (84.1%) participants reported no pain or discomfort impacting their health-related quality of life, with most (n = 35,79.5%) being in full health. Conclusions Physical-conditioning based interventions for the prevention of musculoskeletal disorders among practicing physiotherapists may be better targeted to role or task specific conditioning rather than general physical conditioning among this physically active population. It is plausible that an inherent attrition of physiotherapists may occur among those not as active or healthy as therapists who cope with the physical demands of clinical practice. Extrapolation of findings from this study may be limited due to the sample characteristics. However, this investigation addressed the study objectives and has provided a foundation for larger scale longitudinal investigations in this field.

Examining correlates of self-reported and objectively measured physical activity among retirement village residents

Aim Physical activity (PA) patterns of retirement village residents were investigated using self-report and objective measures. Methods Residents (n = 323) from retirement villages in Perth, Australia, were surveyed on PA behaviour and various demographic, residency, health-related and mobility factors. Most participants wore accelerometers for 7 days. Retirement village managers (n = 32) were surveyed on village descriptive characteristics, including the provision of amenities and facilities. Logistic regression models examined village and resident characteristics associated with PA. Results Based on objective measurement, only 27.1% of participants were sufficiently active (n = 288). Walking was one of the most popular PA modes. Few village characteristics were associated with PA; however, villages located in more walkable neighbourhoods increased participants’ odds of transport walking. Travelling outside the village daily also increased PA odds. Conclusions Most residents were insufficiently active to gain health benefits. Considering individual and environmental factors, within the retirement village and neighbourhood settings, and associations with PA, warrants attention.

Age and gender differences in objectively measured physical activity in youth

Purpose The purpose of this study was to evaluate age and gender differences in objectively measured physical activity (PA) in a population-based sample of students in grades 1–12. Methods Participants (185 male, 190 female) wore a CSA 7164 accelerometer for 7 consecutive days. To examine age-related trends, students were grouped as follows: grades 1–3 (N = 90), grades 4–6 (N = 91), grades 7–9 (N = 96), and grades 10–12 (N = 92). Bouts of PA and minutes spent in moderate-to-vigorous PA (MVPA) and vigorous PA (VPA) were examined. Results Daily MVPA and VPA exhibited a significant inverse relationship with grade level, with the largest differences occurring between grades 1–3 and 4–6. Boys were more active than girls; however, for overall PA, the magnitudes of the gender differences were modest. Participation in continuous 20-min bouts of PA was low to nonexistent. Conclusion Our results support the notion that PA declines rapidly during childhood and adolescence and that accelerometers are feasible alternatives to self-report methods in moderately sized population-level surveillance studies.

Correlates of adults' participation in physical activity : review and update

Purpose To review and update the evidence relating to the personal, social, and environmental factors associated with physical activity (PA) in adults. Methods Systematic review of the peer-reviewed literature to identify papers published between 1998 and 2000 with PA (and including exercise and exercise adherence). Qualitative reports or case studies were not included. Results Thirty-eight new studies were located. Most confirmed the existence of factors already known to be correlates of PA. Changes in status were noted in relation to the influence of marital status, obesity, smoking, lack of time, past exercise behavior, and eight environmental variables. New studies were located which focused on previously understudied population groups such as minorities, middle and older aged adults, and the disabled. Conclusion The newly reported studies tend to take a broader “ecological” approach to understanding the correlates of PA and are more focused on environmental factors. There remains a need to better understand environmental influences and the factors that influence different types of PA. As most of the work in this field still relies on cross-sectional studies, longitudinal and intervention studies will be required if causal relationships are to be inferred.

Measurement of general and specific approaches to physical activity parenting : a systematic review

Background Parents play a significant role in shaping youth physical activity (PA). However, interventions targeting PA parenting have been ineffective. Methodological inconsistencies related to the measurement of parental influences may be a contributing factor. The purpose of this article is to review the extant peer-reviewed literature related to the measurement of general and specific parental influences on youth PA. Methods A systematic review of studies measuring constructs of PA parenting was conducted. Computerized searches were completed using PubMed, MEDLINE, Academic Search Premier, SPORTDiscus, and PsycINFO. Reference lists of the identified articles were manually reviewed as well as the authors' personal collections. Articles were selected on the basis of strict inclusion criteria and details regarding the measurement protocols were extracted. A total of 117 articles met the inclusionary criteria. Methodological articles that evaluated the validity and reliability of PA parenting measures (n=10) were reviewed separately from parental influence articles (n=107). Results A significant percentage of studies used measures with indeterminate validity and reliability. A significant percentage of articles did not provide sample items, describe the response format, or report the possible range of scores. No studies were located that evaluated sensitivity to change. Conclusion The reporting of measurement properties and the use of valid and reliable measurement scales need to be improved considerably.

Validity of family child care providers' proxy reports on children's physical activity

Background Interventions to promote physical activity (PA) in children attending family child care homes (FCCHs) require valid, yet practical, measurement tools. The aim of this study was to assess the validity of two proxy report instruments designed to measure PA in children attending FCCHs. Methods A sample of 37 FCCH providers completed the Burdette parent proxy report, modified for the family child care setting for 107 children 3.4±1.2 years of age. A second sample of 42 FCCH providers completed the Harro parent and teacher proxy report, modified for the family child care setting, for 131 children 3.8±1.3 years of age. Both proxy reports were assessed for validity using accelerometry as a criterion measure. Results Significant positive correlations were observed between provider-reported PA scores from the modified Burdette proxy report and objectively measured total PA (r=0.30; p<0.01) and moderate-to-vigorous PA (MVPA; r=0.34; p<0.01). Across levels of provider-reported PA, both total PA and MVPA increased significantly in a linear dose-response fashion. The modified Harro proxy report was not associated with objectively measured PA. Conclusion Proxy PA reports completed by family child care providers may be a valid assessment option in studies where more burdensome objective measures are not feasible.

Psychometric properties of the modified RESIDE physical activity questionnaire among low-income overweight women

Objectives This study explored the criterion-related validity and test-retest reliability of the modified RESIDential Environment physical activity questionnaire and whether the instrument's validity varied by body mass index, education, race/ethnicity, or employment status. Design Validation study using baseline data collected for randomized trial of a weight loss intervention. Methods Participants recruited from health departments wore an ActiGraph accelerometer and self-reported non-occupational walking, moderate and vigorous physical activity on the modified RESIDential Environment questionnaire. We assessed validity (n = 152) using Spearman correlation coefficients, and reliability (n = 57) using intraclass correlation coefficients. Results When compared to steps, moderate physical activity, and bouts of moderate/vigorous physical activity measured by accelerometer, these questionnaire measures showed fair evidence for validity: recreational walking (Spearman correlation coefficients 0.23–0.36), total walking (Spearman correlation coefficients 0.24–0.37), and total moderate physical activity (Spearman correlation coefficients 0.18–0.36). Correlations for self-reported walking and moderate physical activity were higher among unemployed participants and women with lower body mass indices. Generally no other variability in the validity of the instrument was found. Evidence for reliability of RESIDential Environment measures of recreational walking, total walking, and total moderate physical activity was substantial (intraclass correlation coefficients 0.56–0.68). Conclusions Evidence for questionnaire validity and reliability varied by activity domain and was strongest for walking measures. The questionnaire may capture physical activity less accurately among women with higher body mass indices and employed participants. Capturing occupational activity, specifically walking at work, may improve questionnaire validity.