Remote and web 2.0 interventions for promoting physical activity

  • Review
  • Intervention

Authors


Abstract

Background

Remote and web 2.0 interventions for promoting physical activity (PA) are becoming increasingly popular but their ability to achieve long term changes are unknown.

Objectives

To compare the effectiveness of remote and web 2.0 interventions for PA promotion in community dwelling adults (aged 16 years and above) with a control group exposed to placebo or no or minimal intervention.

Search methods

We searched CENTRAL, MEDLINE, EMBASE, CINAHL, and some other databases (from earliest dates available to October 2012). Reference lists of relevant articles were checked. No language restrictions were applied.

Selection criteria

Randomised controlled trials (RCTs) that compared remote and web 2.0 PA interventions for community dwelling adults with a placebo or no or minimal intervention control group. We included studies if the principal component of the intervention was delivered using remote or web 2.0 technologies (for example the internet, smart phones) or more traditional methods (for example telephone, mail-outs), or both. To assess behavioural change over time, the included studies had a minimum of 12 months follow-up from the start of the intervention to the final results. We excluded studies that had more than a 20% loss to follow-up if they did not apply an intention-to-treat analysis.

Data collection and analysis

At least two authors independently assessed the quality of each study and extracted the data. Non-English language papers were reviewed with the assistance of an interpreter who was an epidemiologist. Study authors were contacted for additional information where necessary. Standardised mean differences (SMDs) and 95% confidence intervals (CIs) were calculated for the continuous measures of self-reported PA and cardio-respiratory fitness. For studies with dichotomous outcomes, odds ratios and 95% CIs were calculated.

Main results

A total of 11 studies recruiting 5862 apparently healthy adults met the inclusion criteria. All of the studies took place in high-income countries. The effect of the interventions on cardiovascular fitness at one year (two studies; 444 participants) was positive and moderate with significant heterogeneity of the observed effects (SMD 0.40; 95% CI 0.04 to 0.76; high quality evidence). The effect of the interventions on self-reported PA at one year (nine studies; 4547 participants) was positive and moderate (SMD 0.20; 95% CI 0.11 to 0.28; moderate quality evidence) with heterogeneity (I2 = 37%) in the observed effects. One study reported positive results at two years (SMD 0.20; 95% CI 0.08 to 0.32; moderate quality evidence). When studies were stratified by risk of bias, the studies at low risk of bias (eight studies; 3403 participants) had an increased effect (SMD 0.28; 95% CI 0.16 to 0.40; moderate quality evidence). The most effective interventions applied a tailored approach to the type of PA and used telephone contact to provide feedback and to support changes in PA levels. There was no evidence of an increased risk of adverse events (seven studies; 2892 participants). Risk of bias was assessed as low (eight studies; 3060 participants) or moderate (three studies; 2677 participants). There were no differences in effectiveness between studies using different types of professionals delivering the intervention (for example health professional, exercise specialist). There was no difference in pooled estimates between studies that generated the prescribed PA using an automated computer programme versus a human, nor between studies that used pedometers as part of their intervention compared to studies that did not.

Authors' conclusions

We found consistent evidence to support the effectiveness of remote and web 2.0 interventions for promoting PA. These interventions have positive, moderate sized effects on increasing self-reported PA and measured cardio-respiratory fitness, at least at 12 months. The effectiveness of these interventions was supported by moderate and high quality studies. However, there continues to be a paucity of cost effectiveness data and studies that include participants from varying socioeconomic or ethnic groups. To better understand the independent effect of individual programme components, longer term studies, with at least one year follow-up, are required.

Résumé scientifique

Des interventions à distance et web 2.0 visant à promouvoir l'activité physique

Contexte

Des interventions à distance et web 2,0 visant à promouvoir l'activité physique (AP) sont de plus en plus populaires, mais leur capacité à atteindre des changements à long terme est inconnue.

Objectifs

Comparer l'efficacité des interventions à distance et web 2.0 pour la promotion de l'AP chez des adultes (âgés de 16 ans et plus) vivant en institution à un groupe témoin exposé à un placebo ou à l'absence d'intervention ou avec une intervention minime.

Stratégie de recherche documentaire

Nous avons effectué des recherches dans CENTRAL, MEDLINE, EMBASE, CINAHL, et d'autres bases de données (des premières dates disponibles jusqu' en octobre 2012). Les listes de références bibliographiques des articles pertinents ont été examinées. Aucune restriction de langue n'a été appliquée.

Critères de sélection

Des essais contrôlés randomisés (ECR) qui comparaient des interventions d'AP à distance et réseau 2,0 pour des adultes vivant en institution avec un groupe témoin avec un placebo, avec une absence ou une intervention minime. Nous avons inclut les études si le principal composant de l'intervention a été donné à distance ou moyen de technologies réseau 2.0 (par exemple, internet, technologies intelligentes ou des téléphones portables) ou plusieurs méthodes traditionnelles (par exemple, par téléphonique, par la poste), ou les deux. Pour évaluer le changement de comportement au fil du temps, les études incluses présentaient une durée minimale de 12 mois de suivi après le début de l'intervention pour les résultats définitifs. Nous avons exclu les études qui avaient plus de 20% de perte de suivi s' ils n'ont pas appliqué une analyse d'intention de traiter.

Recueil et analyse des données

Au moins deux auteurs ont évalué indépendamment la qualité de chaque étude et extrait les données. Les articles qui n'étaient pas en langue anglaise ont été examinés avec l'aide d'un interprète qui était épidémiologiste. Les auteurs des études ont été contactés pour obtenir des informations supplémentaires lorsque c'était nécessaire. Des différences moyennes standardisées (DMS) et des intervalles de confiance (IC) à 95% ont été calculés pour les mesures continues d'AP et d’entraînement cardiorespiratoire. Pour les études présentant des résultats dichotomiques, les rapports des cotes et les IC à 95% ont été calculés.

Résultats principaux

Un total de 11 études portant sur des 5862 adultes en aparent bon état santé remplissaient les critères d'inclusion. Toutes les études ont été menées dans des pays avec un niveau de vie élevé. L'effet des interventions sur l’entraînement cardio-vasculaire à un an (deux études; 444 participants) a été positif et modéré avec une hétérogénéité significative des effets observés (DMS 0.40; IC à 95%, de 0.04 à 0.76; haute qualité d'évidence). L'effet des interventions sur l'AP fournies par des intéressés à un an (neuf études; 4 547 participants) était positif et modéré (DMS de 0.20; IC à 95%, de 0.11 à 0.28; modéré qualité d'évidence) avec une hétérogénéité (I2 = 37%) dans les effets observés. Une étude rapportait des résultats positifs à deux ans (DMS de 0.20; IC à 95%, de 0.08 à 0.32; modérée qualité d'évidence). Lorsque des études ont été classés par risque de biais, les études à faible risque de biais (huit études; 3403 participants) présentaient une augmentation des effets (DMS de 0.28; IC à 95%, de 0.16 à 0.40; qualité d'évidence modérée). Les interventions les plus efficaces appliquaient une approche sur mesure pour le type d'AP et utilisaient le contact téléphonique pour fournir un retour pour soutenir les changements dans l'AP. Il n'y avait pas de preuve d'un risque accru d'événements indésirables (sept études; 2892 participants). Le risque de biais a été évalué comme faible (huit études; 3060 participants) ou modérée (trois études; 2677 participants). Il n'y avait pas de différence en termes d'efficacité entre les études utilisant différents types de professionnels dans les interventions (par exemple les professionnels de santé ou d'activités physiques adaptées). Il n'y avait pas de différence dans les estimations regroupées entre les études qui généraient la prescription d'AP à l'aide d'un programme informatique automatisé par rapport à un humain, ni entre les études qui utilisaient des pédometres dans le cadre de leur intervention par rapport aux études qui n'avaient pas.

Conclusions des auteurs

Nous avons trouvé des preuves d'évidence pour recommander l'efficacité des interventions à distance et des réseaux 2.0 visant à promouvoir l'AP. Ces interventions avaient un effet positif, modéré, sur l'augmentation de l'AP signalée et sur l'entraînement cardiorespiratoire, au moins à 12 mois. L'efficacité de ces interventions a été corroborée par des études de modérée à haute qualité. Cependant, on continue à avoir une pénurie d'information sur la rentabilité et d'études qui incluent des participants issus de différents groupes ethniques ou socio-économiques. Des études à long terme, avec au moins un an de suivi, sont nécessaires pour mieux comprendre les effets indépendants de programmes individuels.

Plain language summary

Remote and web 2.0 interventions for promoting physical activity

Participating in insufficient amounts of physical activity leads to an increased risk of a number of chronic diseases, and physical and mental health problems. Regular physical activity should be a goal for all adults and it can provide social, emotional and physical health benefits. The majority of adults are not active at recommended levels. We included a total of 11 studies recruiting 5862 apparently healthy adults in this review. The findings of the review indicate that using technologies to support adults' attempts to become more active, achieve the recommended weekly amounts of activity, or become fitter are successful. Changes can be achieved with help from a trained professional and through personal support via telephone, e-mail, or written information. New physical activity can be maintained for at least one year and it does not increase the risk of falls or exercise related injuries. More research is needed to establish which methods of exercise promotion encourage specific groups of people to be more physically active in the long term.

Résumé simplifié

Des interventions à distance et web 2.0 visant à promouvoir l'activité physique

Ne pas pratiquer suffisamment de d'activité physique entraîne un risque accru d'un certain nombre de maladies chroniques, et de problèmes de santé physiques et mentales. Une activité physique régulière devrait être un objectif pour les adultes et elle peut fournir des bénéfices sociaux, émotionnels et physiques. La majorité des adultes n’est pas active aux niveaux recommandés. Nous avons inclut un total de 11 études portant sur 5862 adultes apparemment en bonne santé dans cette revue. Les résultats de cette revue indiquent que l'utilisation de technologies pour soutenir des tentatives d'adultes pour devenir plus actifs, pour atteindre des quantités recommandées hebdomadaire d'activité, ou pour améliorer leur état de santé sont efficaces. Des changements peuvent être obtenus avec l'aide d'un professionnel qualifié et à travers un soutien personnel téléphonique, par mail ou des informations écrites. La nouvelle activité physique peut être maintenue pendant au moins un an et elle n'augmente pas le risque de chutes ou les blessures liées à l'exercice. D'avantage de recherche est nécessaire pour établir quelles méthodes de promotion d'exercice encouragent des groupes spécifiques de personnes à être plus actifs physiquement à long terme.

Notes de traduction

Traduit par: French Cochrane Centre 15th December, 2013
Traduction financée par: Financeurs pour le Canada : Instituts de Recherche en Sant� du Canada, Minist�re de la Sant� et des Services Sociaux du Qu�bec, Fonds de recherche du Qu�bec-Sant� et Institut National d'Excellence en Sant� et en Services Sociaux; pour la France : Minist�re en charge de la Sant�

எளியமொழிச் சுருக்கம்

உடலியல் நடவடிக்கையை மேம்படுத்துவதற்கு நெடுந்தொலைவு மற்றும் இணைய 2.0 சிகிச்சை தலையீடுகள்

பற்றாக்குறையான அளவுகளில் உடலியல் நடவடிக்கையில் பங்குபெறுவது, எண்ணிக்கையிலான நாள்பட்ட வியாதிகள், மற்றும் உடலியல் மற்றும் மன நல பிரச்னைகளின் அதிகரித்த அபாயத்திற்கு வழி நடத்தும். அனைத்து வயது வந்தவர்களுக்கும், ஒழுங்கான உடலியல் நடவடிக்கை ஒரு நோக்கமாக இருக்க வேண்டும், மற்றும் இது சமூக, உணர்வுபூர்வமான, மற்றும் உடலியல் ஆரோக்கிய நன்மைகளை வழங்கக் கூடும். பெரும்பான்மையான வயது வந்தவர்கள் பரிந்துரைக்கப்பட்ட அளவுகளில் உடலியல் இயக்கத்துடன் இல்லை. வெளிப்படையான ஆரோக்கியமான 5862 வயது வந்தவர்களை சேர்த்த மொத்தம் 11 ஆய்வுகளை இந்த திறனாய்வில் நாங்கள் உள்ளடக்கினோம். அதிக இயக்கத்துடன் இருக்க மாறுவதற்கு, பரிந்துரைக்கப்பட்ட நடவடிக்கையின் வார அளவுகளை அடைவதற்கு, அல்லது உடற்திறன் கொண்டவர்களாக மாறுவதற்கான வயது வந்தவர்களின் முயற்சிகளுக்கு ஆதரவளிக்க தொழில்நுட்பங்களை பயன்படுத்துவது வெற்றியளித்தது என்று இந்த திறனாய்வின் கண்டுப்பிடிப்புகள் சுட்டிக்காட்டுகின்றன. ஒரு பயிற்சியளிக்கப்பட்ட தொழில்முறை வல்லுநரின் உதவியாலும் மற்றும் தொலைப்பேசி, மின்னஞ்சல் அல்லது எழுதப்பட்ட தகவல் மூலம் பெறும் தனிப்பட்ட ஆதரவாலும் மாற்றங்களை அடையலாம். புதிய உடலியல் நடவடிக்கை, குறைந்தப்பட்சம் ஒரு வருடத்திற்காவது பராமரிக்கக் கூடும், மற்றும் அது, கீழே விழுதலின் அபாயத்தை அல்லது உடற்பயிற்சி தொடர்பான காயங்களை அதிகரிக்காது. குறிப்பிட்ட மக்கள் குழுக்களை ஒரு நீண்ட காலத்திற்கு அதிக உடலியல் இயக்கத்துடன் இருக்க எந்த உடற்பயிற்சி மேம்பாட்டு முறைகள் ஊக்குவிக்கும் என்பதை நிர்ணயிக்க அதிகமான ஆராய்ச்சி தேவைப்படுகிறது.

மொழிபெயர்ப்பு குறிப்புகள்

மொழிபெயர்ப்பாளர்கள்: சிந்தியா ஸ்வர்ணலதா ஸ்ரீகேசவன், தங்கமணி ராமலிங்கம், ப்ளசிங்டா விஜய், ஸ்ரீகேசவன் சபாபதி.

Summary of findings(Explanation)

Summary of findings for the main comparison. Remote and web 2.0 versus control for promoting physical activity
Remote and web 2.0 versus control for promoting physical activity
Patient or population: patients with promoting physical activity
Settings:
Intervention: Remote and web 2.0 versus control
OutcomesIllustrative comparative risks* (95% CI)Relative effect
(95% CI)
No of Participants
(studies)
Quality of the evidence
(GRADE)
Comments
Assumed riskCorresponding risk
Control Remote and web 2.0 v control
Cardio-respiratory fitness: 12 months The mean cardio-respiratory fitness: 12 months in the intervention groups was
0.4 standard deviations higher
(0.04 to 0.76 higher)
 444
(2 studies)
⊕⊕⊕⊕
high 1
SMD 0.4 (0.04 to 0.76)
Dichotomous outcomes: 12 months
Self-reported physical activity questionnaire
Follow-up: mean 12 months
Study population OR 1.42
(1.21 to 1.66)
1089
(1 study)
⊕⊕⊕⊝
moderate 1
 
301 per 1000 427 per 1000
(364 to 500)
Moderate
301 per 1000 427 per 1000
(364 to 500)
Dichotomous outcomes: 24 months
Self-reported physical activity questionnaire
Follow-up: mean 24 months
Study population OR 1.27
(0.99 to 1.63)
1088
(1 study)
⊕⊕⊕⊝
moderate 1
 
327 per 1000 382 per 1000
(325 to 442)
Moderate
327 per 1000 382 per 1000
(325 to 442)
Self-reported physical activity: 24 months
Self-reported physical activity questionnaire
Follow-up: mean 24 months
 The mean self-reported physical activity: 24 months in the intervention groups was
0.2 standard deviations higher
(0.08 to 0.32 higher)
 1049
(1 study)
⊕⊕⊕⊝
moderate 2
SMD 0.2 (0.08 to 0.32)
Self-reported physical activity: 12 months
Follow-up: mean 12 months
 The mean self-reported physical activity: 12 months in the intervention groups was
0.18 standard deviations higher
(0.1 to 0.27 higher)
 4547
(9 studies)
⊕⊕⊕⊝
moderate 3
SMD 0.18 (0.1 to 0.27)
*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio; OR: Odds ratio
GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

Background

This review focused on remote and web 2.0 interventions that promote physical activity (PA). It is part of a suite of three complementary reviews that provide both an update and a progression for the previously completed Cochrane review titled 'Interventions for promoting physical activity' (Foster 2005a). The titles of the other reviews in this suite are:

  1. 'Face-to-face interventions for promoting physical activity';

  2. 'Face-to-face versus remote and web 2.0 interventions for promoting physical activity'.

The evidence base for both face-to-face PA promotion and remote and web 2.0 interventions is rapidly growing and it is diverging. Consequently, we divided this Cochrane update into two separate reviews that focus on each of these delivery methods compared to true control groups. The third review enabled a head-to-head comparison of these intervention approaches for promoting PA. In all of the reviews we also considered how the effectiveness of PA interventions is influenced by implementing the intervention via a group or individually. The paradigm through which we approached these different methods of PA intervention delivery in this suite of reviews is summarised below (Figure 1).

Figure 1.

Delivery of PA interventions described according to interaction with implementer and other participants.

Description of the condition

The health benefits of adequate levels of PA have been well documented (WHO 2010a). Previous systematic reviews and meta-analyses of observational studies have demonstrated the role of PA in the prevention and treatment of coronary heart disease, hypertension, stroke, type II diabetes, obesity, metabolic syndrome, breast cancer, colon cancer, osteoporosis, falls, depression, anxiety and negative self-concept (Haskell 2007; Janssen 2010; Kesaniemi 2001; Nelson 2007; Strong 2005; Warburton 2006; Williams 2001). It is estimated that in 2008 physical inactivity caused 9% of the premature mortality and 5.3 million deaths worldwide (Lee 2012); this included between 6% and 10% of all deaths from major non-communicable diseases globally. The burden of such diseases is increasing rapidly in low- and middle-income countries (Lee 2012; WHO 2010b). 

The World Health Organization (WHO) recommends that adults should accumulate at least 150 minutes of moderate intensity, or 75 minutes of vigorous intensity, or an equivalent combination of aerobic PA throughout the week (WHO 2010a). This should be achieved in bouts of at least 10 minutes duration (WHO 2010a). Muscle strengthening activities involving the major muscle groups are also recommended on at least two days per week (WHO 2010a). Investigations into the dose-response relationship indicate that PA at levels higher than the minimum recommendations confer greater health benefits (Kesaniemi 2001; WHO 2010a).

The available data suggest that 31.1% of the world's adult population are not meeting the minimum recommendations for PA (Hallal 2012). The direct economic burden of physical inactivity is 1.5% to 3.0% of healthcare system costs and it is an emerging expense in low-and middle-income countries (Oldridge 2008). It has been estimated that increasing by 10% or 25% the number of people that achieve the WHO PA recommendations would prevent more than 553,000 and 1.3 million deaths, respectively, globally each year (Lee 2012). 

Description of the intervention

It has long been accepted that various interventions can promote PA participation and improve health (Dishman 1996). This has prompted growing global interest and investment in PA interventions by different stakeholders using a variety of methods (Heath 2012). It is evident that there are opportunities to influence personal, social and environmental determinants of PA in different contexts and populations (Bauman 2012). A previous Cochrane review found that PA interventions had a moderate effect on participation levels (Foster 2005a). However, conclusions could not be drawn about the effectiveness of isolated components for achieving and maintaining recommended levels of PA in the population.

For the purposes of this review an intervention is any deliberate attempt to increase the PA levels of the participants. It may be delivered using various methods and implemented through a broad range of professions (for example health professional, exercise specialist, PA researchers). This is consistent with the principles of the previous versions of this review (Foster 2005a). The additional critical component of remote and web 2.0 interventions is that the interaction with the implementer does not occur in person. These interventions can be delivered to groups or individually, and several examples are presented below (Table 1).

Table 1. Examples of strategies used in typical remote and web 2.0 physical activity interventions
  Remote and web 2.0 intervention
Individual1) SMS prompts of local places to take physical activity based on personal preferences
2) Computerised tailored feedback via email that provide advice for current physical activity behaviour
3) Telephone reinforcement of public health recommendations for physical activity
Group1) Online advice forums via an interactive website to plan physical activity
2) DVD distributed by post and played in a workplace to provide instruction on optimising physical activity
3) Online networks for comparing physical activity behaviour to other people

How the intervention might work

One of the earliest reviews of the determinants of PA stated that few interventions or adherence studies were based on any theoretical or psychological models (Dishman 1990). However, when the review was repeated four years later the authors noted a marked increase in the use of theories in the studies and interventions (Dishman 1994). It is now accepted that well designed PA interventions are based upon behavioural theories (Bartholomew 2001) but understanding how these are translated into practical strategies needs further evaluation (Foster 2005a). Behavioural theories provide a foundation for an intervention that can explain the drivers of PA behaviour and potential pathways for change (Foster 2005b). They inform the planning, development and implementation of PA interventions, and the majority of studies have also adopted social psychology theories (Biddle 2011).

The use of new media technologies to deliver PA interventions has required implementers to consider the relevance of the existing theories and evidence base. Remote and web 2.0 interventions have emerged from the behavioural theories and strategies that underpin face-to-face interventions, but differ in their delivery. This digital shift has its own brand of science called captology, which is the study of computers as persuasive technologies (Fogg 2002). It includes the design, research and analysis of interactive computing products (for example computers, mobile phones, websites, wireless technologies, mobile applications, video games) created for the purpose of changing people’s attitudes or behaviours. Although captology itself is not a theory, it is the application of different theoretical approaches to deliver the intervention via interactive computing products. Captology has been increasingly observed in trials testing different media delivery systems that take behavioural theories and translate them into cognitive-behavioural strategies (Fogg 2007).

Remote and web 2.0 strategies typically involve 'pushing' tailored information via e-mail or short message service (SMS) from a central source to the participants (Waller 2006). This could include assessment of current behaviour and feedback on current PA levels versus recommendations, motivation and confidence building messages and goal setting prompts (Biddle 2011). Specific examples of remote and web 2.0 interventions targeted at individuals and groups were described previously (Table 1). These types of approaches are dependent on varying the dose of the intervention components. Changing the dose could include altering the frequency of contacts and duration of the participant’s interaction with the intervention, similar to the frequency and contact time found in face-to-face interventions. However, the frequency and duration of the intervention may be different when implemented remotely and may also be augmented by flexibility in the delivery timing (Waller 2006).

Recent systematic reviews consistently describe the effectiveness of internet based PA interventions as short rather than long term, with little data to support what elements of the intervention are related to any changes (Norman 2007; Portnoy 2008; Vandelanotte 2007). The reviews found a range of behavioural theories underpinning these interventions, which are similar to those described for face-to-face interventions. These include the Health Belief Model (HBM) (Becker 1974); the Theory of Reasoned Action/Planned Behaviour (TRA) (Fishbein 1975); Social Cognitive Theory (SCT) (Bandura 1986); and the Transtheoretical Model of behaviour change (TTM) (Prochaska 1982). A recent meta-analysis that tried to determine which internet delivered strategies were particularly effective in producing behaviour change identified the inclusion of educational components as the only factor that contributed significantly to increased intervention effectiveness (Davies 2012).

Why it is important to do this review

Although it is known that the behaviour of individuals can be influenced by PA interventions, the most effective delivery method is not clear (Foster 2005a). In recent times there has been an emergence of remotely delivered interventions that has accelerated with the advent of web 2.0 technology (van den Berg 2007). This impetus has displaced several more traditional face-to-face methods of implementing PA interventions (van den Berg 2007). 

It is intended that this review will provide an up-to-date indication of the effectiveness of remote and web 2.0 PA interventions. Understanding the effectiveness of these newer approaches to implementation should influence PA policy makers and professionals. Completing this update ensures that the most effective implementation methods are identified and is integral to optimising health related outcomes associated with the promotion of PA participation.

Objectives

Primary

To compare the effectiveness of remote and web 2.0 interventions for physical activity (PA) promotion in community dwelling adults (aged 16 years and above) with a control group exposed to placebo or no or minimal intervention.

Secondary

If sufficient data exist, the following secondary objectives were assessed.

  1. Does delivering the intervention to a group versus individually versus mixed (a combination of group and individually) influence the effectiveness in changing PA?

  2. Does the professional delivering the intervention (for example health professional, exercise specialist) influence the effectiveness in changing PA?

  3. Does specifying PA type (for example walking, jogging, aerobics) influence the effectiveness in changing PA?

  4. Does generating the prescribed PA using an automated computer programme influence the effectiveness in changing PA?

  5. Does including pedometers as part of the intervention influence the effectiveness in changing PA?

Methods

Criteria for considering studies for this review

Types of studies

Randomised controlled trials (RCTs) that compared remote and web 2.0 PA interventions for community dwelling adults with a placebo or no or minimal intervention control group. We included studies if the principal component of the intervention was delivered using remote and web 2.0 methods. To assess behavioural change over time the included studies had a minimum of 12 months follow-up from the start of the intervention to the final results. We excluded studies that had more than a 20% loss to follow-up if they did not apply an intention-to-treat analysis.

Types of participants

Community dwelling adults, aged from 16 years to any age, who were free from pre-existing medical conditions or with no more than 10% of participants with pre-existing medical conditions that may have limited participation in PA. 

We excluded interventions on trained athletes or sports students. 

We only included studies that measured PA at an individual level.

Types of interventions

Remote and web 2.0 PA interventions could be delivered using recently developed technologies (for example internet, smart phones) or more traditional methods (for example telephone, mail-outs), or both. Web 2.0 interventions have been categorised as more interactive applications that encourage higher levels of user involvement than web 1.0 Internet programmes (O'Reilly 2005). The interventions could be delivered to groups or individuals. They could involve one-off or ongoing interactions between the implementer and the participants that included:

  • counselling or advice, or both;

  • self-directed or prescribed exercise, or both;

  • home based or facility based exercise, or both;

  • written education or motivational support material, or both.

We excluded mass media and multiple risk factor interventions.

The comparison was with a control group exposed to placebo or no or minimal intervention.

Types of outcome measures

Primary outcomes

The primary outcomes of this review included data that assessed change between baseline and follow-up for:

  • cardio-respiratory fitness (CF), which is often used as a marker for PA and demonstrates similar associations with health related outcomes (Blair 2001). It was either estimated from a submaximal fitness test or recorded directly from a maximal fitness test. CF was typically expressed as a VO2 max score, which is an abbreviation for maximal oxygen uptake (ml/kg/min or ml/min);

  • PA levels, expressed as an estimate of total energy expenditure (kcal/kg/week or kcal/week), total minutes completed at a moderate or vigorous intensity, proportion that reached a predetermined threshold level (for example meeting current public health recommendations), or frequency of participation as a dichotomous or continuous outcome variable. PA could be assessed using objective methods (for example accelerometers, pedometers) or more subjective tools (for example PA diary, survey).

Both 12 and 24 month outcomes were included in the analysis.

Secondary outcomes

The secondary outcomes of this review included data relevant to:

  1. quality of life (for example quality-adjusted life years (QALYs));

  2. cost (for example cost-benefit, cost-utility);

  3. adverse events (for example musculoskeletal injury, cardiovascular event).

Search methods for identification of studies

Electronic searches

We searched the following databases between the 9 October 2012 and 11 October 2012:

  • CENTRAL (Issue 9 of 12, 2012) in The Cochrane Library;

  • MEDLINE (Ovid) (1946 to week 4 September 2012);

  • EMBASE Classic and EMBASE (Ovid) (1947 to week 40 2012);

  • CINAHL Plus with Full Text (EBSCO);

  • PsycINFO (Ovid) (1806 to week 1 October 2012);

  • Web of Science.

We based the search on the previous methods used for the 'Interventions for promoting physical activity' Cochrane review (Foster 2005a) (Appendix 1) and updated them with some amendments (Appendix 2).

The Cochrane RCT filter (sensitivity maximising) was applied to MEDLINE (Ovid), and search terms as suggested in the Cochrane Handbook for Systematic Reviews of Interventions were used to limit studies to RCTs in EMBASE (Ovid) (Lefebvre 2011). Adaptations of these filters were used in the other databases except for CENTRAL.

We did not apply any language restriction to the searches.

Searching other resources

We conducted handsearching for the International Journal of Behavioural Nutrition and Physical Activity (February 2004 to October 2012). The reference lists of all relevant articles identified during the search were checked by the authors. We also used published systematic reviews of PA interventions as a source for identifying RCTs.

We communicated directly with authors to identify and request unpublished studies and data. A comprehensive list of relevant articles along with the inclusion criteria for the review were sent to the first author of each paper that met the inclusion criteria to ask if they knew of any additional published or unpublished studies which were relevant.

Data collection and analysis

Selection of studies

Two authors (CF, JR) independently manually screened the titles identified in the initial search to exclude those that were obviously outside the scope of the review. The authors were conservative at this stage and where disagreement occurred the citation was included for abstract review. Two authors (CF, JR) independently reviewed the abstracts of all citations that passed the initial title screening. They applied the inclusion criteria in the following way to determine if the full paper was needed for further scrutiny.

Did the study:

  1. aim to examine the effectiveness of a PA or CF promotion strategy to increase PA or cardiovascular fitness (CVF) levels;

  2. use principally remote or web 2.0 methods to promote PA to the intervention group;

  3. allocate participants to the intervention or control group using a method of randomisation;

  4. have a control group that was exposed to placebo, or no or minimal intervention;

  5. include adults aged 16 years and older;

  6. recruit community dwelling adults that were free of chronic disease or with no more than 10% of participants with pre-existing medical conditions that may limit participation in PA;

  7. have a follow-up period of at least 12 months between commencing the intervention and measuring the outcomes;

  8. analyse the results by intention to treat or, failing that, was there less than 20% loss to follow-up.

The authors were conservative at this stage and where disagreement occurred the citation was included for full text review. Two authors (CF, JR) reviewed the full texts of all studies that passed the abstract screening, using the inclusion criteria described above, to identify a final set of eligible studies. The studies included in the previous 'Interventions for promoting physical activity' Cochrane review were also allocated within the new suite of reviews by two authors (CF, JR) (Foster 2005a). When there was persisting disagreement it was resolved by consensus after a third author (MH or MT) reviewed the study in question. Publications and reports that utilised the same data were linked to avoid replication in the analysis.

Data extraction and management

The data extraction form was piloted independently by two authors (CF, JR) and subsequently adjusted to ensure it captured the relevant data. One author (CF or JR) and a Research Fellow from the Warwick Medical School (NF) independently extracted the data from all of the selected studies using the standard form. When there was disagreement a third author reviewed the study and consensus was reached (CF or JR: the author out of these two that did not do the initial data extraction). We extracted data from multiple publications of the same study separately and then combined them to avoid replication. Any missing or ambiguous data were clarified with the study first author via e-mail.

Assessment of risk of bias in included studies

The risk of bias was only assessed and reported for studies that met the inclusion criteria (Higgins 2011).

Two authors (CF, JR) assessed the risk of bias. Where there was disagreement between review authors in the risk of bias assessment, a third author (MH or MT) was asked to independently appraise the study and discrepancies were resolved by consensus between all three authors.

We assessed the studies for the five general domains of bias: selection, performance, attrition, detection, and reporting. Quality scores were allocated for:

  1. allocation sequence generation;

  2. allocation concealment;

  3. incomplete outcome data;

  4. selective outcome reporting;

  5. comparable groups at baseline;

  6. contamination between groups;

  7. validated outcome measures;

  8. outcome measure applied appropriately;

  9. final analysis adjusted for baseline PA levels;

  10. outcome assessment independent and blinded;

  11. intention-to-treat analysis.

When sufficient information was available, we classified each study as at 'high' or 'low' risk of bias for each item. When there was a lack of information or uncertainty over the potential for bias, we described the domain as 'unclear'. We judged the quality of the evidence as 'low', 'medium', or 'high' given the consideration of the study design and size, and the potential impact of the identified weakness noted in the risk of bias table for each study.

Measures of treatment effect

For each study with dichotomous outcomes, we expressed the effect size using an odds ratio (OR). For each study with continuous outcomes, we expressed the effect size using the standardised mean difference (SMD) between the post-intervention values of the randomised groups. We completed a narrative summary of the study results and when there were sufficient data we completed a formal meta-analysis of the included studies.

Unit of analysis issues

When possible, we analysed the studies using the mean and standard deviation (SD) and visualised the results using forest plots. Alternatively, we reported only the point estimate with confidence intervals (CIs) and P values.

When a study had more than one study arm relevant to this review, we examined the overall effects of the intervention versus control by combining the data from the related study arms. We calculated the mean and SD according to the overall numbers within each arm using established approaches (Higgins 2011).

For each study with dichotomous outcomes we calculated an OR and 95% CI. We used the numbers of participants in each arm that were reported as an event (for example active at a predetermined level) or no event (for example not active). Where appropriate, we calculated individual study effects and then the pooled effect sizes as ORs with 95% CIs using a random-effects model. We calculated any missing 95% CIs using established approaches (Higgins 2008).

Dealing with missing data

We excluded studies that had a high degree of incomplete data (that is less than 40% of data) during the risk of bias assessment or when it appeared that missing data were likely to be associated with the reported intervention effect. We contacted the authors of the potentially included studies if missing data were unclear or data had not been fully reported. Missing data were captured in the data extraction form and reported in the risk of bias table.

Assessment of heterogeneity

We quantified and evaluated the amount of heterogeneity to determine whether the observed variation in the study results was compatible with the variation expected by chance alone (Deeks 2011). Heterogeneity was assessed through examination of the forest plots and was quantified using the I2 statistic.

Assessment of reporting biases

We plotted trial effect against standard error and presented it as a funnel plot (Sterne 2011). Asymmetry could be caused by a relationship between effect size and sample size or by publication bias, we also examined any observed effect for clinical heterogeneity (Sterne 2011).

Data synthesis

When possible we reported all continuous outcomes on the original scale. If the outcomes were combined from different scales we standardised them as required for the analysis. We only completed a meta-analysis when the data were clinically homogeneous and we followed established Cochrane methods (Deeks 2011). If data were available, sufficiently similar, and of adequate quality, we used the Cochrane Collaboration's statistical software, Review Manager 2012, to perform the statistical analyses. We used a random-effects model as the default to incorporate heterogeneity between studies. We did not combine evidence from differing study designs and outcome types in the same forest plot (Christinsen 2009).

Subgroup analysis and investigation of heterogeneity

We performed subgroup analyses to compare interventions that were delivered:

  1. to a group versus individually versus mixed (a combination of group and individually);

  2. by a health professional versus a non-health professional;

  3. with a PA type that was specified versus not specified;

  4. with a computer generated prescription versus a human generated prescription;

  5. with a pedometer versus without a pedometer.

Sensitivity analysis

We conducted a sensitivity analysis for studies that definitively met at least 50% of the applicable criteria reported in the 'Risk of bias' tables.

Results

Description of studies

See 'Characteristics of included studies'; 'Characteristics of excluded studies'; 'Characteristics of studies awaiting classification'; 'Characteristics of ongoing studies'

Results of the search

From 27,299 de-duplicated hits, the full texts of 193 papers were retrieved for examination against the inclusion criteria (Figure 2). There were 30 papers describing 11 studies that met the inclusion criteria (Castro 2011; Elley 2003; King 1991; King 2007; Kinmonth 2008; Kolt 2007; Lawton 2008; Marcus 2007; Martinson 2010; Napolitano 2006; van Stralen 2011).

Figure 2.

Study flow diagram.

All searches were completed in October to November 2012. The results of the searches of the electronic databases are detailed in Table 2.

Table 2. Search results for electronic databases
Database searched Number of hits
CINAHL4454
The Cochrane Library6703
EMBASE8930
MEDLINE Ovid11431
PsycINFO Ovid4156
Science Citation Index Expanded6756
Total42430
After de-duplication27299

Included studies

There were 5862 apparently healthy adults who participated in the 11 included studies. The majority of studies recruited both genders with three studies recruiting women only (Elley 2003; Lawton 2008; Napolitano 2006). The stated age range of participants was from 18 to 74 plus years. Details on the ethnic group of participants were reported in seven studies (Castro 2011; King 1991; Kinmonth 2008; Lawton 2008; Marcus 2007; Martinson 2010; Napolitano 2006), with proportions of participants in ethnic minorities ranging from 7% to 33%. Participants were recruited from two settings, primary health care and the community. All of the studies took place in high-income countries.

The interventions were primarily delivered individually and without direct supervision of PA. PA type was specified in one study (King 2007) and delivered by a health professional in two studies (Elley 2003; King 2007). The PA prescription was computer generated in four studies (King 2007; Marcus 2007; Napolitano 2006; van Stralen 2011) and a pedometer was used in three studies (King 2007; Kinmonth 2008; Martinson 2010).

Nine studies included PA self-report at 12 months as an outcome measure (Castro 2011; Elley 2003; King 2007; Kinmonth 2008; Kolt 2007; Marcus 2007; Martinson 2010; Napolitano 2006; van Stralen 2011) and this was sustained for 24 months in one of these studies (Martinson 2010). One study reported a dichotomous outcome variable for PA at both 12 and 24 months (Lawton 2008). There were two studies that reported cardiovascular fitness (CVF) at 12 months (King 2007; Kinmonth 2008).

Two studies were found to be eligible for inclusion from the Foster 2005a review (Elley 2003; King 1991) and nine studies were identified by the updated search (Castro 2011; King 2007; Kinmonth 2008; Kolt 2007; Lawton 2008; Marcus 2007; Martinson 2010; Napolitano 2006; van Stralen 2011).

Excluded studies

The reasons for excluding papers that underwent full text review are outlined in the 'Characteristics of excluded studies' table. Three main reasons contributed to almost 80% of exclusions. The most prevalent was less that 12 months follow-up (n = 78), followed by no appropriate control or intervention group (n = 37) or a face-to-face intervention only (n = 14). There was also one ongoing study (McAuley 2012) and one study awaiting classification (Peels 2012) at the time of this review. The Peels 2012 data were recently published, outside the search period, and will be included in an update of this review.

Risk of bias in included studies

We assessed the risk of bias of the included studies as moderate in three studies (Martinson 2010; Napolitano 2006; van Stralen 2011) and low in the remaining included studies (Castro 2011; Elley 2003; King 1991; King 2007; Kinmonth 2008; Kolt 2007; Lawton 2008; Marcus 2007), see Table 3 and Table 4.

Table 3. Risk of bias and quality scores for included studies
Study Allocation sequence generation Allocation concealment Incomplete outcome data Selective outcome reporting Comparable groups at baseline Contamination between groups
Castro 2011YUYYYU
Elley 2003YUYYYY
King 1991UUNYYNA
King 2007YUYUYNA
Kinmonth 2008UUYYYY
Kolt 2007UUNYNNA
Lawton 2008UYYNUN
Marcus 2007UUYNYY
Martinson 2010UUUYNU
Napolitano 2006UUNUUU
van Stralen 2011UUNYNNA
Table 4. Risk of bias and quality scores for included studies
Study Validated outcome measures Applied appropriately Final analysis adjusted for baseline physical activity levels Outcome assessment independent and blinded Intention-to-treat analysis
Castro 2011YYUYY
Elley 2003YYNNY
King 1991YYYYN
King 2007YYYYY
Kinmonth 2008YYYYY
Kolt 2007YYYYN
Lawton 2008YYYYY
Marcus 2007YYYYY
Martinson 2010YYUYY
Napolitano 2006YYUYN
van Stralen 2011YYUUU

Allocation

All studies used randomised controlled designs. Three studies were assessed to have an adequate approach to allocation sequence generation (Castro 2011; Elley 2003; King 1991), with all other studies classified as having an unclear risk of bias in their allocation concealment approaches with the exception of Lawton 2008. Six studies were assessed as at low risk of selection bias as they reported comparable groups at baseline for important confounders or covariates (Castro 2011; Elley 2003; King 1991; King 2007; Kinmonth 2008; Marcus 2007).

Blinding

We did not rate studies on whether participants were blinded to their group allocation. This would not be appropriate for studies of this type because it is very difficult to blind participants to a PA intervention. We did assess studies on their performance bias, which included whether their outcome assessments were performed independently and by an assessor who was blinded to participant allocation status. Nine studies were assessed to have low risk of performance bias with these criteria (Castro 2011; King 1991; King 2007; Kinmonth 2008; Kolt 2007; Lawton 2008; Marcus 2007; Martinson 2010; Napolitano 2006). Elley 2003 was assessed to have a high risk of bias for blinding and independence of outcome assessment, with van Stralen 2011 assessed as unclear.

All studies were judged to have a low risk of detection bias. This was an assessment of the validity and quality of outcome measures, plus the appropriateness of their application to the participants.

Incomplete outcome data

Six studies were assessed as being at low risk of attrition bias as they reported complete outcome data and presented reasons for any participant dropouts (Castro 2011; Elley 2003; King 2007; Kinmonth 2008; Lawton 2008; Marcus 2007). Four studies were assessed as being at high risk of bias for not reporting attrition data (King 1991; Kolt 2007; Napolitano 2006; van Stralen 2011).

Selective reporting

Two studies had a high risk of reporting bias (Lawton 2008; Marcus 2007), with two additional studies assessed as being unclear (Lawton 2008; Napolitano 2006).

Other potential sources of bias

Other potential sources of bias included two criteria used in our earlier version of this review (Foster 2005a). These were adjusting the final results for the baseline values of PA and adopting an intention-to-treat analysis approach.

Adjusting for baseline values of PA is particularly important in behaviour change studies as there is a likelihood of overestimating effects if baseline adjustment is not performed when using dichotomous outcome measures (for example per cent of adults achieving recommended level of PA). Only six studies had a low risk of bias for this criterion (King 1991; King 2007; Kinmonth 2008; Kolt 2007; Lawton 2008; Marcus 2007) and, from the remaining five studies, four were assessed as being unclear (Castro 2011; Martinson 2010; Napolitano 2006; van Stralen 2011); Elley 2003 was assessed as not adjusting for baseline values.

Intention-to-treat analysis underpins the principles of an RCT design to minimise bias. Therefore, we considered failure to include all randomised participants in the final outcome analysis within their allocated group as a critical risk of bias. Seven studies were assessed to have conducted an intention-to-treat analysis (Castro 2011; Elley 2003; King 2007; Kinmonth 2008; Lawton 2008; Marcus 2007; Martinson 2010), with three studies not meeting this criterion (King 1991; Kolt 2007; Napolitano 2006) and van Stralen 2011 assessed as unclear. The proportion of participants in the studies that did not perform an intention-to-treat analysis who were lost to follow-up ranged from 7.1% to 15.9%.

Effects of interventions

See: Summary of findings for the main comparison Remote and web 2.0 versus control for promoting physical activity

Cardio-respiratory fitness (CF)

Two studies (444 participants) reported the effect of their intervention on CF (King 1991; Kinmonth 2008). The pooled effect was positive and moderate with significant heterogeneity in the observed effects (SMD 0.40; 95% CI 0.04 to 0.76), see Analysis 1.1. King 1991 reported a significant difference in VO2 max between the intervention and control groups at 12 months follow-up (SMD 0.59; 95% CI 0.31 to 0.87). Participants in the remote intervention received baseline physiological assessments and then were prescribed home based training at high or low intensity plus written information, with PA logs and phone calls. Telephone calls were made once a week for the first four weeks, twice a week for the next four weeks, and then once a month for 12 months. Kinmonth 2008 reported a non-significant outcome for participants (SMD 0.22; 95% CI -0.05 to 0.48). Participants received a home based one hour counselling visit and two 15 minute follow-up phone calls, and then monthly 30 minute follow-up phone calls. The telephone based group received the home visit plus four 45 minute phone calls and two 15 minute phone calls over 5 months, followed by monthly postal contact for seven months.

Self-reported physical activity - reported as a dichotomous measure

One study (1089 participants) reported PA as a dichotomous measure, which indicated whether a predetermined level of PA was achieved or not (Lawton 2008), see Analysis 1.2, Analysis 1.3. The Women's Lifestyle Study reported significant increases in the proportion of women participants reporting they had achieved the recommended level of 150 minutes of at least moderate intensity PA, as assessed by the NZPAQ-LF at two years (OR 1.33; 95% CI 1.03 to 1.70). This effect was a decline from the levels reported at one year (OR 1.73; 95% CI 1.34 to 2.21). Participants were inactive women aged 40 to 74 years and were recruited via primary care. The participants received written advice from a primary care nurse and a discussion on increasing PA and goal setting, lasting 7 to 13 minutes. The participants received a green prescription card stating their recommended PA. After this meeting a local exercise specialist called all participants (on average five calls each lasting 15 minutes) to encourage PA, using motivational interviewing techniques, over a nine month period. An additional 30 minute visit with a nurse was offered at six months, plus fridge magnets and activity record charts. We noted that although participants were recruited through primary care, their participation was by special invitation and the delivery of the intervention was not part of routine care. The focus on older women, the self-selected nature of participants, and the overall participation rate in this group of 19.5% seemed relatively low in terms of reach.

Self-reported physical activity - reported as a continuous measure

Nine studies (4547 participants) reported their main outcome as one of several continuous measures of PA (Castro 2011; Elley 2003; King 2007; Kinmonth 2008; Kolt 2007; Marcus 2007; Martinson 2010; Napolitano 2006; van Stralen 2011). Measures included estimated energy expenditure (kcals/day, kcals/week of moderate or vigorous PA (MVPA)), total time of PA (mean mins/week of MVPA), and mean number of occasions of PA in past four weeks. The pooled effect of these studies at one year was positive and moderate (SMD 0.20; 95% CI 0.11 to 0.28), see Analysis 1.4. There was no significant heterogeneity in the observed effects (I2 = 37%). One study reported positive results at two years (SMD 0.20; 95% CI 0.08 to 0.32) (Martinson 2010), see Analysis 1.5.

Martinson 2010 was the only study to report outcomes at 24 months, from the Keep Active Minnesota intervention. The outcome measure was minutes of MVPA as assessed by the CHAMPS questionnaire. Inactive adults aged 50 to 70 years were recruited using the health data of members of a health mainenance organisation (HMO). Intervention participants all received a group introduction session, written materials, and an appointment with a phone coach (an exercise sports scientist). This was followed by seven 20 minute phone calls, plus mailed workbooks and pedometers. Then after a review of progress they received monthly phone calls up to 12 months then six calls over the next 12 months. In addition, three motivational challenges were held that included prizes, incentives, DVDs and videos. This study reported a high level of intervention compliance (at six months) with nearly 92% of intervention participants completing at least one phone course session. Nearly 40% of intervention participants completed all seven phone sessions, but these participants were more educated, in better self-reported health, older, had a lower BMI, and were less likely to be in full time employment than participants who did not complete all calls.

Six studies reported positive effects at one year (Castro 2011; Elley 2003; King 2007; Kolt 2007; Marcus 2007; Martinson 2010).

Studies with positive SMDs used a range of different intervention approaches, with varying effect sizes. Castro 2011 recruited inactive adults, aged 50 years and older, and delivered telephone based advice by either trained professional staff or volunteer peer mentors. Telephone calls were delivered twice per month for the first two months and then monthly (up to 14 calls) until 12 months. This followed an initial face-to-face meeting with the staff or peer mentor. Change in MVPA was assessed by using the CHAMPS questionnaire but it was only validated by objective measures at six months. Both peer and professional mentors achieved significant increases in minutes of MVPA compared to the outcome in control participants (SMD 0.47; 95% CI 0.15 to 0.78).

Elley 2003 recruited inactive adults, aged 40 to 79 years, via primary care. Participants received motivation counselling from their general practitioner. This included discussion on increasing PA and goal setting. The participants received a green prescription card stating their recommended PA. After this meeting a local exercise specialist called all participants at least three times to encourage PA using motivational interviewing techniques. Written materials were also sent to participants every three months. These materials included information about local PA opportunities and motivational material. Increases in total energy expenditure assessed by self report were significant (SMD 0.19; 95% CI 0.06 to 0.32).

King 2007 evaluated the effectiveness of PA advice delivered by humans versus advice delivered by computers in the Telephone (CHAT) trial. Sedentary 55 year old adults were recruited to receive either telephone-assisted PA counselling by a health educator or automated computer system generated advice for 30 to 40 minutes plus 15 (10 to 15 minute) phone calls over 12 months. Participants were also sent mail-outs, a pedometer and daily step logs. The computer advice group interacted by touch phone key pads. Both intervention arms achieved nearly 40 minutes per week additional MVPA compared to the control participants with a significant pooled effect (SMD 0.36; 95% CI 0.05 to 0.66).

Kolt 2007 recruited older adults (aged 65 years and older) to the Telewalk intervention. Participants received eight telephone counselling calls over 12 weeks (weekly for the first four weeks and then every two weeks for the remaining eight weeks of the intervention) encouraging them to increase their participation in all forms of PA. The outcome measure was assessed by telephone using the Auckland Heart Study Physical Activity Questionnaire (AHSPAQ) and the mean difference of leisure time PA (mins/week) between the intervention and control groups was approximately 130 minutes at one year (SMD 0.45; 95% CI 0.15 to 0.76).

Marcus 2007 recruited a younger sample compared to other studies of adults. The participants were aged 18 to 65 years and participated in Project STRIDE. All participants received baseline written materials recommending 150 minutes a week of moderate PA and completed PA logs and questionnaires each month. Each participant's response generated tailored feedback containing theory based counselling messages. This feedback was communicated back to each participant, either via mail or by telephone, by a health educator. Contacts were phased at weekly for the first four weeks, biweekly for eight weeks, monthly for three months, and bimonthly for six months. Both intervention groups reported more mins of MVPA per week than controls with the print group nearly 50 minutes more than the phone group (SMD 0.36; 95% CI 0.09 to 0.63).

Martinson 2010 reported slight, significant differences between the intervention and control groups at one year (SMD 0.14; 95% CI 0.02 to 0.26).

No statistically significant effects were observed for the other three studies (Kinmonth 2008; Napolitano 2006; van Stralen 2011). We found no evidence of publication bias, see Figure 3.

Figure 3.

Funnel plot of comparison: 1 Remote and web 2.0 interventions versus control, outcome: 1.4 Self-reported physical activity: 12 months.

Sensitivity analysis by study quality

We examined the pooled effects for the three types of outcome data (self-reported PA, dichotomous and CF outcomes) by an assessment of study risk of bias. We stratified studies on their risk of bias assessments (ROB), see Table 3 and Table 4, by only pooling estimates of effects for studies that had a lower risk of bias (≥ 50% of ROB criteria). Pooled estimates are presented for each outcome type, see Analysis 2.1, Analysis 2.2, Analysis 2.3, Analysis 2.4. Six studies were included (3403 participants) in the sensitivity analysis. A positive and significant pooled estimate was found for self-reported PA effects at 12 months (SMD 0.28; 95% CI 0.16 to 0.40), see Analysis 2.4. This was an increase in the estimated pooled effect compared to the nine studies (SMD 0.20; 95% CI 0.11 to 0.28).

Secondary outcomes

Quality of life

Five studies reported quality of life outcomes, with four of them using the SF-36 measure (Elley 2003; Kinmonth 2008; Kolt 2007; Lawton 2008) and King 2007 using a Vitality Plus Scale of general well-being, see Table 5. From the four studies that reported increases in PA, positive changes in quality of life were reported by King 2007 (human advice arm) and Lawton 2008 in the SF-36 physical functioning and mental health subscales. Elley 2003 reported that the SF-36 scores of self-rated ‘general health’, ‘role physical’, ‘vitality’, and ‘bodily pain’ improved significantly more in the intervention group compared with the control group. Kolt 2007 reported that no differences in SF-36 measures were observed between the groups at 12 months. Although Kinmonth 2008 reported no impact of PA between the intervention and control groups, SF-36 scores for the intervention participants were better than in the control group for six out of eight SF-36 scales. Small effect sizes were reported for physical function, general health and anxiety. Small to moderate effect sizes were reported for social function, energy levels and change in health. Moderate effects were reported for aspects of mental health and impact on daily activities. These effects occurred independently of any change in PA.

Table 5. Quality of life outcomes
Study Quality of life outcomes
Castro 2011Not reported
Elley 2003SF-36 scores of self-rated ‘general health’, ‘role physical’, ‘vitality’, and ‘bodily pain’ improved significantly more in the intervention group compared with the control group.
King 1991Not reported
King 2007Human Advice group had a higher score on the Vitality Plus Scale compared to the control group.
Kinmonth 2008SF-36 scores for intervention participants were better than the control group for six out of eight SF-36 scales. Small effects sizes were reported for physical function, general health and anxiety. Small to moderate effect sizes were reported for social function, energy levels and change in health. Moderate effects were reported for aspects of mental health and impact on daily activities. These effects occurred independently of any change in PA.
Kolt 2007No differences on SF-36 measures were observed between the groups at 12 months.
Lawton 2008SF-36 physical functioning and mental health sub scores were also significantly better in the intervention group at 12 and 24 months, although role physical scores were lower in the intervention group.
Marcus 2007Not reported
Martinson 2010Not reported
Napolitano 2006Not reported
van Stralen 2011Not reported

Cost effectiveness

Three studies reported data for cost effectiveness (Elley 2003; Lawton 2008; Marcus 2007), see Table 6. All three studies reported positive findings for both PA and quality of life measures which appeared to be linked to the calculations of cost effectiveness. Using a different outcome for their intervention Elley 2003 reported that the programme-cost per patient was NZD 170 from a funder’s perspective. The monthly cost effectiveness ratio for total energy expenditure achieved was NZD 11 per kcal/kg/day. The incremental cost of converting one additional ‘sedentary’ adult to an ‘active’ state over a 12 month period was NZD 1756 in programme costs. Lawton 2008 adapted the Green Prescription approach used in the earlier Elley 2003 study but applied a dichotomous measures of PA (% achieving a recommended level). The exercise programme cost was NZD 93.68 (GBP 45.90) per participant. There was no significant difference in indirect costs over the course of the trial between the two groups (rate ratio 0.99; 95% CI 0.81 to 1.2 at 12 months and 1.01; 95% CI 0.83 to 1.23 at 24 months, P = 0.9). Cost effectiveness ratios using programme costs were NZD 687 (EU 331) per person made ‘active’ and sustained at 12 months and NZD 1407 (EU 678) per person made ‘active’ and sustained at 24 months. Finally Marcus 2007 reported that the phone group’s cost effectiveness was $3.53/month/min of improvement, and the print group’s cost effectiveness was $0.35/month/min of improvement in PA recall. At 12 months the cost of moving one person out of sedentary status was $3967 for the phone group and $955 for the print group.

Table 6. Cost effectiveness
Study Cost effectiveness
Castro 2011Not reported
Elley 2003Significant increases in PA were found in the randomised controlled trial. Programme cost per patient was NZ$170 from a funder’s perspective. The monthly cost effectiveness ratio for total energy expenditure achieved was $11 per kcal/kg/day. The incremental cost of converting one additional ‘sedentary’ adult to an ‘active’ state over a 12 month period was NZD 1756 in programme costs.
King 1991Not reported
King 2007Not reported
Kinmonth 2008Not reported
Kolt 2007Not reported
Lawton 2008The exercise programme cost was New Zealand dollars (NZD) 93.68 (EU 45.90) per participant. There was no significant difference in indirect costs over the course of the trial between the two groups (rate ratios 0.99; 95% CI 0.81 to 1.2 at 12 months and 1.01; 95% CI 0.83 to 1.23 at 24 months, P = 0.9). Cost effectiveness ratios using programme costs were NZD 687 (EU 331) per person made ‘active’ and sustained at 12 months and NZD 1407 (EU 678) per person made ‘active’ and sustained at 24 months.
Marcus 2007Phone group’s cost effectiveness was $3.53/month/min of improvement in PA recall, Print group’s cost effectiveness was $0.35/month/min of improvement in PA recall. At 12 months the cost of moving one person out of sedentary status was $3967 for the phone group and $955 for the print group.
Martinson 2010Not reported
Napolitano 2006Not reported
van Stralen 2011Not reported

The remaining studies did not report data on cost effectiveness, despite Castro 2011, King 2007, and Kolt 2007 reporting positive changes in PA at one year.

Adverse events

Seven studies reported data on adverse events, see Table 7 (Castro 2011; Elley 2003; King 1991; King 2007; Kinmonth 2008; Kolt 2007; Lawton 2008). King 2007 reported that PA related non-cardiac injuries were few and were similar in number across study arms. These included mild muscular fatigue, strain, or soreness during the initial three to four months of the intervention. Kinmonth 2008 provided detailed data on adverse events for 32 participants who within a year of randomisation had visited either a family doctor, emergency department, or hospital outpatients department for pain or injury to muscles, joints, or bones during or after PA. Kolt 2007 reported that there was no evidence of more falls in the intervention group than in the control group over the 12 month trial period. Lawton 2008 reported the number of falls and injuries at 12 and 24 months and the proportions of participants reporting either a fall or injury were significantly higher in the intervention compared to the control group at both time points. Three studies reported no significant difference in adverse events or no major adverse events (fractures and sprains), falls, illness and potential cardiovascular events between groups (Castro 2011; Elley 2003; King 1991).

Table 7. Adverse events
Study Adverse events
Castro 2011No serious adverse events reported occurring during the trial
Elley 2003There were no major adverse events reported as a result of this intervention
King 1991There were several sprains and fractures reported in this study, but there was no difference between the groups and none of the injuries caused any of the participants to withdraw from the study. No cardiac events were reported
King 2007PA-related non-cardiac injuries were few and were similar in number across study arms. These included mild muscular fatigue, strain, or soreness during the initial 3-4 months of intervention
Kinmonth 200832 participants (11 with intervention by telephone, 10 with intervention in person, and 11 in the comparison group) reported that within a year of randomisation they had visited either a family doctor or an emergency department or hospital outpatients’ department for pain or injury to muscles, joints, or bones during or after PA
Kolt 2007There was no evidence of more falls in the intervention group than in the control group over the 12 month trial period
Lawton 2008More falls and injuries were recorded in the intervention group compared with the control group over 24 months
Marcus 2007Not reported
Martinson 2010Not reported
Napolitano 2006Not reported
van Stralen 2011Not reported

Four studies reported no data on adverse events (Marcus 2007; Martinson 2010; Napolitano 2006; van Stralen 2011).

Secondary objectives

See Table 8 and Table 9

Table 8. Who delivers intervention and follow-up, and individual or group approach
Study Who delivered the primary dose of intervention? Intervention individual or group based primary dose Who delivered the follow up dose of intervention? Intervention individual or group based follow up
Castro 2011Trained professional staff member or trained volunteer peer mentorIndividualTrained professional staff member or trained volunteer peer mentorIndividual
Elley 2003General practitioner or practice nurseIndividualLocal exercise specialistIndividual
King 1991Project staff memberIndividualGroup based training provided by community exercise instructors with physical education degrees. Project staff member made follow-up phone callsIndividual or group
King 2007Trained health educator or automated computerIndividualTrained health educator or automated computerIndividual
Kinmonth 2008FacilitatorsIndividualFacilitatorsIndividual
Kolt 2007Exercise counsellorIndividualExercise counsellorIndividual
Lawton 2008Primary care nurseIndividualLocal exercise specialistIndividual
Marcus 2007Phone feedback by educator or print feedbackIndividualPhone feedback by educator or print feedbackIndividual
Martinson 2010Physical activity coachesIndividual or groupPhysical activity coachesIndividual or group
Napolitano 2006Tailored feedback letter from participant’s questionnaire responses and a computer systemIndividualTailored feedback letter from participant’s questionnaire responses and a computer systemIndividual
van Stralen 2011Tailored feedback letterIndividualTailored feedback letter from participant’s questionnaire responsesIndividual
Table 9. Intensity of primary intervention and follow-up, and physical activity choice and supervision
Study Primary dose intensity Physical activity choice Physical activity supervision Follow-up frequency and dose
Castro 2011Telephone based PA advice delivered by either staff or peer mentorParticipants choose own activitiesUnsupervisedPhone calls delivered twice per month for first 2 months and then monthly for the remainder of the year for a total of 14 contacts in 12 months. Plus participants were mailed monthly newsletters and tip sheets
Elley 2003PA counselling using green prescription approach (on average 7 minutes per GP visit and 13 minutes per patient) per practice nurse visitParticipants choose own activitiesUnsupervisedExercise specialist made at least three phone calls (lasting 10-20 minutes) over three months using motivational interviewing techniques. Specific advice about exercise or community groups provided if required. Practice staff also encouraged to give feedback on subsequent GP visits
King 1991

Participants received a baseline physiological assessment and then were prescribed home based training at high or low intensity plus written information

30-40 minutes duration

Home based training programme choose their PA

Group based attended local classes (3 x week)

Unsupervised

Supervised

Four phone calls in first four weeks, then two calls in next four weeks, followed by once a month for 12 months. Phone calls were used to monitor progress, answer questions and provide feedback from activity logs
King 2007All participants received a 30-40 minute instructional session by a trained health educatorPrimarily advised to perform brisk walking but also choice of PA allowedUnsupervisedHuman advice arm and computer advice arm received bi-weekly brief (10 to 15 minute phone calls) for the first month and then 15 contacts across the next 12 months. Participants also received information mail-outs, pedometer, daily PA monitoring and reported this activity during calls
Kinmonth 2008All participants received a home based interview and were then followed up in two different approaches home versus distanceParticipants choose own activitiesUnsupervisedHome groups received four home 1 hour visits and two 15 minute phone calls during 5 months intensive phase, followed by monthly 30 minute phone calls for 7 months. Pedometers were available for those who wanted them. The distance group received four 45 minute phone calls and two 15 minute support calls during the intensive 5 month period followed by monthly postal contact for remaining 7 months
Kolt 2007Phone call from exercise counsellor using stage of change approach and motivational techniques (mean call length was 10.2 to 16.5 minutes)Participants choose own activitiesUnsupervisedParticipants received 8 phone calls over the first 12 weeks: weekly for the first four weeks then bi-weekly for the next eight weeks. Plus supplementary materials including walking logs and pamphlets
Lawton 2008PA counselling using green prescription approachParticipants choose own activitiesUnsupervisedParticipants received on average 5 phone calls, each lasting 15 minutes, plus a 30 minute interview at six months
Marcus 2007All participants received individually tailored messages via print or telephone, generated by a computer system. Included were stage of change targeted booklets, and PA related tip sheets. Phone calls lasted 13 minutes on averageParticipants choose own activitiesUnsupervisedParticipants received a total of 14 contacts over 12 months, weekly for the first month. All participants were asked to complete a PA log and a brief questionnaire each month. Follow up measures taken at 6 and 12 months
Martinson 2010All participants received a group based or individual phone sessionParticipants choose own activitiesUnsupervisedAll participants received a seven session core coaching for PA course delivered bi-weekly by phone. Then monthly check in calls for the remainder of the first 12 months and bimonthly calls during the next 12 months of the study. Plus motivational challenges, 4 optional group speaking events and resources
Napolitano 2006All participants received individually tailored messages via print, generated by a computer systemParticipants choose own activitiesUnsupervisedAll participants received repeat feedback letters (post questionnaire assessments) at 1, 3 and 6 months. Plus all participants attended in-person assessments at 3 and 12 months
van Stralen 2011All participants received individually tailored messages via print, generated by a computer system (3-11 pages)Participants choose own activitiesUnsupervisedSecond letter sent two months after baseline. Third letter sent two weeks after 3 month questionnaire assessment. Intervention plus arm received tailored information and a map about local PA opportunities

Does delivering the intervention to a group versus individually versus mixed (combined group and individually) influence the effectiveness in changing PA?

No studies adopted a consistent group based approach as part of their intervention, see Analysis 3.1. Although Martinson 2010 did offer a group approach to orientate participants to their intervention, we found few group based approaches, which may reflect the individual nature of the communication mechanisms (telephone or computer) used in remote and web 2.0 interventions.

Does the professional delivering the intervention (for example health professional, exercise specialist) influence the effectiveness in changing PA?

Two studies delivered their interventions via a health professional (Elley 2003; King 2007) while the remaining seven did not (Castro 2011; Kinmonth 2008; Kolt 2007; Marcus 2007; Martinson 2010; Napolitano 2006; van Stralen 2011), see Analysis 3.2, Analysis 3.3. The pooled estimate effect for non-health professionals (SMD 0.19; 95% CI 0.09 to 0.30) was very simlar to health professionals (SMD 0.21; 95% CI 0.09 to 0.34).

Does specifying physical activity type (for example walking, jogging, aerobics) influence the effectiveness in changing PA?

Only one study specified the type of PA for its participants (King 2007), with the majority allowing participants a choice (Castro 2011; Elley 2003; Kinmonth 2008; Kolt 2007; Marcus 2007; Martinson 2010; Napolitano 2006; van Stralen 2011), see Analysis 3.4, Analysis 3.5. King 2007 did report a large increase in PA between the intervention and control groups (SMD 0.36; 95% CI 0.05 to 0.66), but more studies are needed to assess if this can be replicated.

Does generating the prescribed physical activity using an automated computer programme influence the effectiveness in changing PA?

We found no difference in pooled estimates between studies that generated the prescribed PA using an automated computer programme versus a human approach. Four studies generated their PA prescriptions by computer (King 2007; Marcus 2007; Napolitano 2006; van Stralen 2011), with a pooled positive estimate (SMD 0.18; 95% CI 0.04 to 0.33) that was similar to the remaining studies that generated and delivered their prescriptions via humans (SMD 0.22; 95% CI 0.10 to 0.34). However, the similarity of the pooled estimates of effect raised the issue that one approach may be more cost effective than the other. This observation was supported by the results of Marcus 2007 and warrants further investigation.

Does including pedometers as part of the intervention influence the effectiveness in changing PA?

We found no difference between studies that included pedometers as part of their intervention and those that did not. Three studies included pedometers as part of their intervention (King 2007; Kinmonth 2008; Martinson 2010) (SMD 0.16; 95% CI 0.05 to 0.27). However, both King 2007 and Martinson 2010 placed emphasis on encouraging participants to use the pedometers as a behavioural tool to self-monitor walking levels whereas Kinmonth 2008 let participants use pedometers if appropriate. The pooled estimate for the non-pedometer studies was positive and significant (SMD 0.23; 95% CI 0.11 to 0.35).

Discussion

Summary of main results

We were able to find consistent evidence to support the effectiveness of remote and web 2.0 interventions for promoting PA. These interventions have positive, moderate sized effects on increasing self-reported PA and measured cardio-respiratory fitness (CF), at least at 12 months. The effectiveness of these interventions was supported by moderate and high quality studies. We were not able to assess the longer term effectiveness of remote and web 2.0 interventions to promote PA beyond 12 months.

The most effective interventions applied a tailored approach to the type of PA and used telephone contact to provide feedback and to support changes in PA levels. We were not able to identify if the person who initiates (health professional or exercise counsellor) or who implements the intervention (human versus machine) has any positive or negative differential impact on outcomes. We were unable to determine the effectiveness of interventions with any specific groups beyond older and well educated adults. The participants in the studies that were reviewed were generally white, well educated and middle aged, and it is possible that the observed effects may be different in the wider population. There were no studies in this review that examined the effectiveness of interventions in minority groups of any kind.

We did not find any randomised controlled studies (RCTs) with at least 12 months follow-up that assessed web or computer based interventions. This reflected that our excluded studies either did not have sufficient follow-up (at least 12 months) or had inadequate study designs that commonly lacked true control groups.

We were not able to assess if the most effective interventions could be easily translated into existing practice. This is an important step as some interventions included components that would be difficult to deliver in usual practice due to resource demand, necessary follow-up, and extensive contact time. Our findings indicate that further investigation is needed to examine the cost effectiveness of automated systems to generate PA prescriptions and to deliver feedback remotely. Such systems may be attractive to practice, particularly if effectiveness is comparable to more expensive approaches. This is a priority as only three studies presented data on the long term cost effectiveness of their intervention.

Overall completeness and applicability of evidence

Our conclusions are limited because studies were all delivered in high-income countries, but this may be due to the technology focus of this review. Our review demonstrates that there is high quality evidence to support the effectiveness of remote and web 2.0 interventions for promoting PA, but we note that the majority of studies targeted older adults (50 plus years) rather than younger adults.

The participants in the studies that were reviewed were generally white, well educated and middle or older aged, and it is possible that the observed effects may be different in the wider population. There were no studies in this review that examined the effectiveness of interventions that targeted minority groups of any kind.

The potential applicability of this evidence is potentially high as interventions were initiated either by phone calls or face-to-face contacts and sustained by phone calls or web based technologies. There is clearly a need to replicate these effective interventions across different communities in high-, middle- and low-income countries. We did not find any evidence of publication bias in this review.

Quality of the evidence

The overall quality of studies was higher than our previous review of interventions to promote PA to adults (Foster 2005a). Studies were all consistently using validated outcome measures applied appropriately. This is particularly important given the small differences in changing levels of PA between the intervention and control groups, as intervention effects wane. We recognise that most studies used self-report measures of PA, which are subject to recall bias and may lack precision, but any misclassification is non-differential (as both the intervention and control groups complete the measure) and will attenuate the effect of the intervention. This problem did not apply to measures of cardio-respiratory fitness. The majority of studies adopted sound designs in addressing blinding, independence of outcome assessment and data analysis. It is important to recognise that none of the studies were able to blind participants to their group allocation and we felt this criterion was not appropriate to our studies because it is very difficult to be blinded to PA intervention. We assessed that the risk of bias of included studies was moderate in three studies (Martinson 2010; Napolitano 2006; van Stralen 2011) or low across all the remaining included studies (Castro 2011; Elley 2003; King 1991; King 2007; Kinmonth 2008; Kolt 2007; Lawton 2008; Marcus 2007).

Potential biases in the review process

One limitation of this review is potential publication bias. Other types of interventions may exist but have not been submitted or accepted for publication, or only those with positive results have been published. We did not see any indication of publication bias from our funnel plots.

Agreements and disagreements with other studies or reviews

Our results appear consistent with previous systematic reviews of technology based intervention and PA interventions focusing on middle aged or older adults. What is novel about our review, compared to these other reviews, is our more robust criteria regarding duration of follow-up (12 months) and comparison of remote intervention to a true control group.

Our pooled effect estimate is consistent with other recent meta-analyses or systematic reviews of PA interventions, particularly our pooled estimate of effects for self-reported PA outcomes at 12 months (SMD 0.20; 95% CI 0.11 to 0.28). Our previous review of interventions to promote PA to adults (Foster 2005a) found small to moderate effects of interventions at six months (SMD 0.28; 95% CI 0.15 to 0.41). Our new results have extended the duration of pooled effects to 12 months, from a high quality group of studies. When studies were stratified by low risk of bias studies (8 studies; 3403 participants) the effects were increased (SMD 0.28; 95% CI 0.16 to 0.40).

Conn 2011 (99,011 participants) reported that the overall mean effect size for comparisons of intervention groups versus control groups was 0.19 (95% CI –0.14 to 0.53) (higher mean for intervention participants than for control participants). This review included many non-randomised studies. Hobbs 2013 reported a similar effect size for self-reported PA duration 12 months after randomisation for interventions targeting older adults (SMD 0.19; 95% CI 0.10 to 0.28). They reported that effective interventions involved individual tailoring with personalized activity goals or provision of information about local opportunities in the environment. Only LaPlante 2011 conducted a systematic literature review of e-health interventions targeting PA and reported that only seven studies used pure control groups, and of those four demonstrated support for e-health but the others showed no significant differences. This review echoed our own and Conn 2011 concerns with the heterogeneity of intervention approaches, and poor research design, outcome measures and power analyses.

Our results reflect the outcomes from studies with optimal study design and 12 month duration. They are consistent with other reviews that included interventions with shorter follow-up periods. We are unaware of similar reviews with such strict inclusion criteria but recognise that this has resulted in exclusion of many shorter term studies of internet based interventions. Davies 2012 conducted a recent meta-analysis of internet-delivered PA behaviour change programs (n = 34 studies) and concluded that effect sizes were small and studies were short term in duration. The authors advocated evaluating intervention fidelity by comparing the participation of the intervention group with the actual web based materials and activities. This focus on compliance was not well reported among our studies. Assessing the dose and response relationship between intervention and outcome is important, particularly where the interaction may be virtual and machine not human based. Short 2011 reviewed the effectiveness of of the tailored print literature to identify key factors relating to efficacy in tailored print PA interventions. Using a narrative synthesis of 12 interventions, Short 2011 reached a similar conclusion to our own that tailored print based interventions with multiple intervention follow-up contacts had moderate positive effects on PA. However, they were unable to tease out the key factors relating to efficacy and to determine if this approach was cost effective (only two included studies reported cost effectiveness data) or sustainable in the long term.

We found very few web based or Smart phone interventions that met our inclusion criteria. We suspect that short term efficacy studies have been performed with such technologies but to date these types of interventions have not been fully evaluated by long term RCTs. Future studies should consider including common commercial web based and sensor systems, that could integrate push and pull technologies, plus incentives.

Authors' conclusions

Implications for practice

There is high quality evidence to suggest that interventions designed to increase PA using remote and web 2.0 technologies can lead to longer term increases in PA, certainly for older adults. Due to the clinical and statistical heterogeneity of the studies, only limited conclusions can be drawn about the effectiveness of individual components of such interventions (that is which strategies were most effective). Nevertheless, interventions which deliver by phone or mail and provide people with professional and tailored guidance about starting an exercise programme and then provide ongoing support are more effective in encouraging the uptake of PA. Initiation of PA must be supported by frequent and focused follow-up. There is no evidence that such interventions will reduce PA or cause other harm. There is also limited evidence of the long term effectiveness of interventions.

Implications for research

There is high quality evidence to support the effectiveness of PA interventions for sedentary adults in the general populations. Effects are maintained at one year but there remain gaps in the quality and breadth of the evidence base for PA promotion using remote and web 2.0 approaches. There is a very clear need for studies using appropriate control groups rather than running comparison studies between different variants of technological interventions. Furthermore, there continues to be a paucity of cost effectiveness data and studies that include participants from varying socioeconomic or ethnic groups. In order to better understand the independent effect of individual programme components, longer studies with at least one year follow-up and greater power are required. In this review we have been able to describe what was done within interventions but were unable to unpick what elements were most effective.

Acknowledgements

The authors wish to acknowledge Karen Rees, Nadine Flowers and the Cochrane Heart Group for their contributions and support during the planning of this suite of reviews.

Data and analyses

Download statistical data

Comparison 1. Remote and web 2.0 interventions versus control
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Cardiorespiratory fitness: 12 months2444Std. Mean Difference (IV, Random, 95% CI)0.40 [0.04, 0.76]
2 Dichotomous outcomes: 12 months11089Odds Ratio (IV, Random, 95% CI)1.73 [1.34, 2.21]
3 Dichotomous outcomes: 24 months11089Odds Ratio (IV, Random, 95% CI)1.33 [1.03, 1.70]
4 Self reported physical activity: 12 months94547Std. Mean Difference (IV, Random, 95% CI)0.20 [0.11, 0.28]
5 Self reported physical activity: 24 months11049Std. Mean Difference (IV, Random, 95% CI)0.20 [0.08, 0.32]
Analysis 1.1.

Comparison 1 Remote and web 2.0 interventions versus control, Outcome 1 Cardiorespiratory fitness: 12 months.

Analysis 1.2.

Comparison 1 Remote and web 2.0 interventions versus control, Outcome 2 Dichotomous outcomes: 12 months.

Analysis 1.3.

Comparison 1 Remote and web 2.0 interventions versus control, Outcome 3 Dichotomous outcomes: 24 months.

Analysis 1.4.

Comparison 1 Remote and web 2.0 interventions versus control, Outcome 4 Self reported physical activity: 12 months.

Analysis 1.5.

Comparison 1 Remote and web 2.0 interventions versus control, Outcome 5 Self reported physical activity: 24 months.

Comparison 2. Remote and web 2.0 interventions versus control with low risk of bias (risk of bias score ≥ 50%)
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Cardiorespiratory fitness: 12 months2444Std. Mean Difference (IV, Random, 95% CI)0.40 [0.04, 0.76]
2 Dichotomous outcomes: 12 months11089Odds Ratio (IV, Random, 95% CI)1.73 [1.34, 2.21]
3 Dichotomous outcomes: 24 months11089Odds Ratio (IV, Random, 95% CI)1.33 [1.03, 1.70]
4 Self reported physical activity: 12 months61870Std. Mean Difference (IV, Random, 95% CI)0.28 [0.16, 0.40]
Analysis 2.1.

Comparison 2 Remote and web 2.0 interventions versus control with low risk of bias (risk of bias score ≥ 50%), Outcome 1 Cardiorespiratory fitness: 12 months.

Analysis 2.2.

Comparison 2 Remote and web 2.0 interventions versus control with low risk of bias (risk of bias score ≥ 50%), Outcome 2 Dichotomous outcomes: 12 months.

Analysis 2.3.

Comparison 2 Remote and web 2.0 interventions versus control with low risk of bias (risk of bias score ≥ 50%), Outcome 3 Dichotomous outcomes: 24 months.

Analysis 2.4.

Comparison 2 Remote and web 2.0 interventions versus control with low risk of bias (risk of bias score ≥ 50%), Outcome 4 Self reported physical activity: 12 months.

Comparison 3. Remote and web 2.0 interventions versus control (subgroup analysis - self-reported physical activity: 12 months)
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Delivery: individual94547Std. Mean Difference (IV, Random, 95% CI)0.20 [0.11, 0.28]
2 Implementer: health professional21067Std. Mean Difference (IV, Random, 95% CI)0.21 [0.09, 0.34]
3 Implementer: non-health professional73480Std. Mean Difference (IV, Random, 95% CI)0.19 [0.09, 0.30]
4 Physical activity type: specified1189Std. Mean Difference (IV, Random, 95% CI)0.36 [0.05, 0.66]
5 Physical activity type: not specified84358Std. Mean Difference (IV, Random, 95% CI)0.19 [0.10, 0.27]
6 Prescribed physical activity: human generated52491Std. Mean Difference (IV, Random, 95% CI)0.22 [0.10, 0.34]
7 Prescribed physical activity: computer generated42056Std. Mean Difference (IV, Random, 95% CI)0.18 [0.04, 0.33]
8 Intervention: includes pedometer31456Std. Mean Difference (IV, Random, 95% CI)0.16 [0.05, 0.27]
9 Intervention: does not include pedometer63091Std. Mean Difference (IV, Random, 95% CI)0.23 [0.11, 0.35]
Analysis 3.1.

Comparison 3 Remote and web 2.0 interventions versus control (subgroup analysis - self-reported physical activity: 12 months), Outcome 1 Delivery: individual.

Analysis 3.2.

Comparison 3 Remote and web 2.0 interventions versus control (subgroup analysis - self-reported physical activity: 12 months), Outcome 2 Implementer: health professional.

Analysis 3.3.

Comparison 3 Remote and web 2.0 interventions versus control (subgroup analysis - self-reported physical activity: 12 months), Outcome 3 Implementer: non-health professional.

Analysis 3.4.

Comparison 3 Remote and web 2.0 interventions versus control (subgroup analysis - self-reported physical activity: 12 months), Outcome 4 Physical activity type: specified.

Analysis 3.5.

Comparison 3 Remote and web 2.0 interventions versus control (subgroup analysis - self-reported physical activity: 12 months), Outcome 5 Physical activity type: not specified.

Analysis 3.6.

Comparison 3 Remote and web 2.0 interventions versus control (subgroup analysis - self-reported physical activity: 12 months), Outcome 6 Prescribed physical activity: human generated.

Analysis 3.7.

Comparison 3 Remote and web 2.0 interventions versus control (subgroup analysis - self-reported physical activity: 12 months), Outcome 7 Prescribed physical activity: computer generated.

Analysis 3.8.

Comparison 3 Remote and web 2.0 interventions versus control (subgroup analysis - self-reported physical activity: 12 months), Outcome 8 Intervention: includes pedometer.

Analysis 3.9.

Comparison 3 Remote and web 2.0 interventions versus control (subgroup analysis - self-reported physical activity: 12 months), Outcome 9 Intervention: does not include pedometer.

Appendices

Appendix 1. Search strategies 2005

MEDLINE (Ovid)

1 exp Exertion/
2 Physical fitness/
3 exp "Physical education and training"/
4 exp Sports/
5 exp Dancing/
6 exp Exercise therapy/
7 (physical$ adj5 (fit$ or train$ or activ$ or endur$)).tw.
8 (exercis$ adj5 (train$ or physical$ or activ$)).tw.
9 sport$.tw.
10 walk$.tw.
11 bicycle$.tw.
12 (exercise$ adj aerobic$).tw.
13 (("lifestyle" or life-style) adj5 activ$).tw.
14 (("lifestyle" or life-style) adj5 physical$).tw.
15 or/1-14
16 Health education/
17 Patient education/
18 Primary prevention/
19 Health promotion/
20 Behaviour therapy
21 Cognitive therapy
22 Primary health care
23 Workplace/
24 promot$.tw.
25 educat$.tw.
26 program$.tw.
27 or/16-26
28 15 and 27

RCT filter (Dickersin 1995)

EMBASE

1.((((health-education) or (health-education-research)) or ((patient-education) or (patient-education-and-counseling)) or ((health-promotion) or (health-promotion-international)) or (primary-health-care) or ((workplace) or (workplace-)) or (promot*) or ((promot*) or ((educat*) or ((program*) and ((((exertion) or (fitness) or (fitness-) or ((fitness) or (fitness-)) or (exercise) or ((exercise) or (sport) or (walk*)))

2.((research) or (((((random-controlled) or (random-sample) or (randomisation) or (randomised) or (randomised-controlled) or (randomization) or (randomization-) or (randomizd) or (randomize) or (randomized) or (randomized-block) or (randomized-controlled) or (randomized-controlled-trial) or (randomized-control)) or ((double-blind) or (double-blind-procedure)) or ((single-blind) or (single-blind-procedure))) and (ec=human)) or (clinical) or (clin*) or (trial*) or (((clin* near trial*) in ti) and (ec=human)) or (clin*) or (trial*) or (((clin* near trial*) in ab) and (ec=human)) or (sing*) or (doubl*) or (trebl*) or (tripl*) or (blind*) or (mask*) or (((sing* or doubl* or trebl* or tripl*) near (blind* or mask*)) and (ec=human)) or ((placebos) or (placebo-controlled)) or ((placebo* in ti) and (ec=human)) or ((placebo* in ab) and (ec=human)) or ((random* in ti) and (ec=human)) or ((random in ab) and (ec=human)) or (research)) ec=human)

3.((((studies) or (prospective-study) or (follow-up) or (comparative) or (evaluation)) and (ec=human))

CINAHL

1.exact{controlled}
2.exact{randomized}
3.exact{random-assignment}
4.exact{double-blind}
5.exact{single-blind}
6.#1 or #2 or #3 or #4 or #5
7.exact{animal}
8.exact{human}
9.#6 not #7
10.exact{clinical}
11.(clin* near trial*) in ti
12.(clin* near trial*) in ab
13.(singl* or doubl* or trebl* or tripl*) near (blind* or mask*)
14.(#13 in ti) or (#13 in ab)
15.placebos
16.placebo* in ti
17.placebo* in ab
18.random* in ti
19.random* in ab
20.exact{research-methodology}
21.#10 or #11 or #12 or #13 or #14 or #15 or #16 or #17
22.#18 or #19 or #20
23.#21 or #22
24.animal
25.human
26.#23 not #24
27.#26 or #9 or #8 or #25
28.exact{comparative}
29.study
30.#28 and #29
31.exact{evaluation}
32.studies
33.#31 and #32
34.exact{follow-up}
35.exact{propsective}
36.#35 and #32
37.control* or prosepctiv* or volunteer*
38.(#37 in ti) or (#37 in ab)
39.#38 or #36 or #33 or #30
40.#39 not #24
41.#39 or #27 or #9
42.explode "exertion/"/ all subheadings
43."physical fitness"
44.explode "physical education and training"/ all subheadings
45.explode "sports"/ all subheadings
46.explode "dancing"/ all subheadings
47.explode "exercise therapy"/ all subheadings
48.(physical$ adj5 (fit$ or train$ or activ$ or endur$)).tw.
49.(exercis$ adj5 (train$ or physical$ or activ$)).tw.
50.sport$.tw.
51.walk$.tw.
52.bicycle$.tw
53.(exercise$ adj aerobic$).tw.
54.(("lifestyle" or life-style) adj5 activ$).tw.
55.(("lifestyle" or life-style) adj5 physical$).tw.
56.#42 or #43 or #44 or #45 or #46 or #47 or #48 or #49 or (exercise$) or (aerobic$) or ("lifestyle") or (activ$) or ("lifestyle") or (life-style) or (physical$)
57.health education
58.patient education
59.primary prevention
60.health promotion
61.behaviour therapy
62.cognitive therapy
63.primary health care
64.workplace
65.promot$.tw.
66.educat$.tw.
67.program$.tw.
68.#57 or #58 or #59 or #60 or #61 or #62 or #63 or #64 or #65 or #66 or #67
69.#68 and #56
70.#69 and #41

PsycLIT

1.exertion
2.physical-fitness
3.exercise
4.explode exercise
5.sport
6.walk*
7.cycle
8.#1 or #2 or #3 or #4 or #5 or #6 or #7
9.health education
10.patient education
11.primary prevention
12.health promotion
13.behaviour therapy
14.cognitive therapy
15.primary health care
16.workplace
17.promot$.tw.
18.educat$.tw.
19.program$.tw.
20.#9 or #10 or #11 or #12 or #13 or #14 or #15 or #16 or #17 or #18 or #19
21.#8 and #20
22.controlle
23.randomized
24.random-assignment
25.double-blind
26.single-blind
27.#22 or #23 or #24 or #25 or #26
28.animal
29.human
30.#27 not #28
31.clinical
32.(clin* near trial*) in ti
33.clin* near trial*) in ab
34.(singl* or doubl* or trebl* or tripl*) near (blind* or mask*)
35.(#34 in ti) or (#34 in ab)
36.placebos
37.placebo* in ti
38.placebo* in ab
39.random* in ti
40.random* in ab
41.research-methodology}
42.#31 or #32 or #33 or #34 or #35 or #36 or #37 or #38
43.#39 or #40 or #41
44.#42 or #43
45.animal
46.human
47.#44 not #45
48.#47 or #30 or #29 or #46
49.comparative
50.study
51.#49 and #50
52.evaluation
53.studies
54.#52 and #53
55.follow-up
56.propsective
57.#56 and #53
58.control* or prosepctiv* or volunteer*
59.(#58 in ti) or (#58 in ab)
60.#59 or #57 or #54 or #51
61.#60 not #45
62.#60 or #48 or #30
63.#62 and #21

SPORTDISCUS

1.'physical activity'
2.exercise
3.fitness
4.sedentary
5.housebound
6.aerobics or circuits or swimming or aqua or jogging or running or cycling or fitness or yoga or walking or sport
7.patient education
8.primary prevention
9.health promotion
10.behaviour therapy
11.cognitive therapy
12.primary health care
13.workplace
14.controlled
15.randomized
16.random-assignment
17.double-blind
18.single-blind
19.clinical
20.placebos
21.comparative
22.evaluation
23.study

SIGLE

1.explode "Exertion/"/ all subheadings
2."Physical fitness"
3.explode "Physical education and training"/ all subheadings
4.explode "Sports"/ all subheadings
5.explode "Dancing"/ all subheadings
6.explode "Exercise therapy"/ all subheadings
7.(physical$ adj5 (fit$ or train$ or activ$ or endur$)).tw.
8.(exercis$ adj5 (train$ or physical$ or activ$)).tw.
9.sport$.tw.
10.walk$.tw.
11.bicycle$.tw
12.(exercise$ adj aerobic$).tw.
13.(("lifestyle" or life-style) adj5 activ$).tw.
14.(("lifestyle" or life-style) adj5 physical$).tw.
15.#1 or #2 or #3 or #4 or #5 or #6 or #7 or #8 or (exercise$) or (aerobic$) or ("lifestyle") or (activ$) or ("lifestyle") or (life-style) or (physical$)
16.Health Education
17.Patient education
18.Primary prevention
19.Health promotion
20.Behaviour therapy
21.Cognitive therapy
22.Primary health care
23.Workplace
24.promot$.tw.
25.educat$.tw.
26.program$.tw.
27.#16 or #17 or #18 or #19 or #20 or #21 or #22 or #23 or #24 or #25 or #26
28.#15 and #27

SCISEARCH

1.((promot$ or uptake or encourag$ or increas$ or start) near (physical adj activity))
2.(promot$ or uptake or encourag$ or increas$ or start) near exercise
3.(promot$ or uptake or encourag$ or increas$ or start) near (aerobics or circuits or swimming or aqua$)
4.(promot$ or uptake or encourag$ or increas$ or start) near (jogging or running or cycling)
5.(promot$ or uptake or encourag$ or increas$ or start) near ((keep adj fit) or (fitness adj class$) or yoga)
6.(promot$ or uptake or encourag$ or increas$ or start) near walking
7.(promot$ or uptake or encourag$ or increas$ or start) near sport$

Appendix 2. Search strategies 2012

CENTRAL

#1MeSH descriptor: [Physical Fitness] this term only
#2MeSH descriptor: [Physical Exertion] this term only
#3MeSH descriptor: [Physical Education and Training] explode all trees
#4MeSH descriptor: [Sports] explode all trees
#5MeSH descriptor: [Dancing] this term only
#6MeSH descriptor: [Exercise Therapy] explode all trees
#7physical* near activ*
#8physical* near train*
#9physical* near fit*
#10exercise* near train*
#11exercise* near activ*
#12exercise* near physical*
#13sport*
#14walk*
#15bicycle*
#16exercise* near aerobic*
#17((life next style*) near activ*)
#18life-style* near activ*
#19lifestyle* near activ*
#20((life next style*) near physical*)
#21life-style* near physical*
#22lifestyle* near physical*
#23#1 or #2 or #3 or #4 or #5 or #6 or #7 or #8 or #9 or #10 or #11
#24#12 or #13 or #14 or #15 or #16 or #17 or #18 or #19 or #20 or #21 or #22
#25#23 or #24
#26MeSH descriptor: [Health Education] this term only
#27MeSH descriptor: [Patient Education as Topic] this term only
#28MeSH descriptor: [Primary Prevention] this term only
#29MeSH descriptor: [Health Promotion] explode all trees
#30MeSH descriptor: [Behavior Therapy] this term only
#31MeSH descriptor: [Cognitive Therapy] this term only
#32MeSH descriptor: [Primary Health Care] this term only
#33MeSH descriptor: [Workplace] this term only
#34promot*
#35educat*
#36program*
#37#26 or #27 or #28 or #29 or #30 or #31 or #32 or #33 or #34 or #35 or #36
#38#25 and #37

MEDLINE Ovid

1. Physical Exertion/
2. Physical Fitness/
3. exp "Physical Education and Training"/
4. exp Sports/
5. Dancing/
6. exp Exercise Therapy/
7. exp Exercise/
8. (physical$ adj5 (fit$ or train$ or activ$ or endur$ or exertion$)).tw.
9. (exercis$ adj5 (train$ or physical$ or activ$)).tw.
10. sport$.tw.
11. walk$.tw.
12. bicycle$.tw.
13. ((exercise$ adj3 aerobic$) or aerobics).tw.
14. ((lifestyle or life-style) adj5 activ$).tw.
15. ((lifestyle or life-style) adj5 physical$).tw.
16. or/1-15
17. Health Education/
18. Patient Education as Topic/
19. Primary Prevention/
20. exp Health Promotion/
21. Behavior Therapy/
22. Cognitive Therapy/
23. Primary Health Care/
24. Workplace/
25. promot$.tw.
26. educat$.tw.
27. program$.tw.
28. or/17-27
29. 16 and 28
30. randomized controlled trial.pt.
31. controlled clinical trial.pt.
32. randomized.ab.
33. placebo.ab.
34. drug therapy.fs.
35. randomly.ab.
36. trial.ab.
37. groups.ab.
38. 30 or 31 or 32 or 33 or 34 or 35 or 36 or 37
39. exp animals/ not humans.sh.
40. 38 not 39
41. 29 and 40
42. (200412$ or 2005$ or 2006$ or 2007$ or 2008$ or 2009$ or 2010$ or 2011$ or 2012$).ed.
43. 41 and 42

EMBASE Ovid

1. exp exercise/
2. fitness/
3. physical education/
4. exp sport/
5. dancing/
6. exp kinesiotherapy/
7. (physical* adj5 (fit* or train* or activ* or endur* or exert*)).tw.
8. (exercis* adj5 (train* or physical* or activ*)).tw.
9. sport*.tw.
10. walk*.tw.
11. ((exercise* adj aerobic*) or aerobic*).tw.
12. ((lifestyle or life-style) adj5 activ*).tw.
13. bicycle*.tw.
14. ((lifestyle or life-style) adj5 physical*).tw.
15. or/1-14
16. health education/
17. patient education/
18. primary prevention/
19. health promotion/
20. behavior therapy/
21. cognitive therapy/
22. primary health care/
23. workplace/
24. promot*.tw.
25. educat*.tw.
26. program*.tw.
27. or/16-26
28. 15 and 27
29. random$.tw.
30. factorial$.tw.
31. crossover$.tw.
32. cross over$.tw.
33. cross-over$.tw.
34. placebo$.tw.
35. (doubl$ adj blind$).tw.
36. (singl$ adj blind$).tw.
37. assign$.tw.
38. allocat$.tw.
39. volunteer$.tw.
40. crossover procedure/
41. double blind procedure/
42. randomized controlled trial/
43. single blind procedure/
44. 29 or 30 or 31 or 32 or 33 or 34 or 35 or 36 or 37 or 38 or 39 or 40 or 41 or 42 or 43
45. (animal/ or nonhuman/) not human/
46. 44 not 45
47. 28 and 46
48. (200412* or 2005* or 2006* or 2007* or 2008* or 2009* or 2010* or 2011* or 2012*).dd.
49. 47 and 48
50. limit 49 to embase

CINAHL Plus with Full Text EBSCO

S34 S33 Limiters - Exclude MEDLINE records
S33 S31 and S32
S32 EM 20041201-20121010
S31 S20 and S30
S30 S21 or S22 or S23 or S24 or S25 or S26 or S27 or S28 or S29
S29 TX allocat*
S28 TX control*
S27 TX assign*
S26 TX placebo*
S25 (MH "Placebos")
S24 TX random*
S23 TX (clinic* N1 trial?)
S22 PT clinical trial
S21 (MH "Clinical Trials+")
S20 S10 and S19
S19 S11 or S12 or S13 or S14 or S15 or S16 or S17 or S18
S18 (TI promot* or educat* or program*) or (AB promot* or educat* or program*)
S17 (MH "Work Environment")
S16 (MH "Primary Health Care")
S15 (MH "Behavior Therapy+")
S14 (MH "Health Promotion")
S13 (MH "Preventive Health Care")
S12 (MH "Patient Education")
S11 (MH "Health Education")
S10 S1 or S2 or S3 or S4 or S5 or S6 or S7 or S8 or S9
S9 (TI sport* or walk* or bicycle* or exercis* or aerobic*) or (AB sport* or walk* or bicycle* or exercis* or aerobic*)
S8 (TI physical N5 (fit* or train* or activ* or endur* or exert*)) or (AB physcial* N5 (fit* or train* or activ* or endur* or exert*))
S7 (TI exercis* N5 (train* or physical* or activ*)) or (AB exercis* N5 (train* or physical* or activ*))
S6 (MH "Exercise+") or (MH "Therapeutic Exercise+")
S5 (TI (lifestyle* or life-style*) N5 (activ* or physical*)) or (AB (lifestyle* or life-style*) N5 (activ* or physical*))
S4 (MH "Sports+") or (MH "Dancing+")
S3 (MH "Physical Education and Training")
S2 (MH "Physical Fitness")
S1 (MH "Exertion")

PsycINFO

1. exp exercise/
2. physical fitness/
3. physical activity/
4. exp sports/
5. physical education/
6. (physical$ adj5 (fit$ or train$ or activ$ or endur$ or exertion$)).tw.
7. (exercis$ adj5 (train$ or physical$ or activ$)).tw.
8. sport$.tw.
9. walk$.tw.
10. bicycle$.tw.
11. ((exercise$ adj3 aerobic$) or aerobics).tw.
12. ((lifestyle or life-style) adj5 activ$).tw.
13. ((lifestyle or life-style) adj5 physical$).tw.
14. or/1-13
15. health education/
16. client education/
17. health promotion/
18. prevention/
19. primary health care/
20. behavior therapy/
21. cognitive therapy/
22. cognitive behavior therapy/
23. workplace*.tw.
24. promot$.tw.
25. educat$.tw.
26. program$.tw.
27. or/15-26
28. 14 and 27
29. random*.tw.
30. trial.ab.
31. groups.ab.
32. factorial$.tw.
33. crossover$.tw.
34. cross over$.tw.
35. cross-over$.tw.
36. placebo$.tw.
37. assign$.tw.
38. allocat$.tw.
39. volunteer$.tw.
40. clinical trials/
41. (doubl$ adj blind$).tw.
42. (singl$ adj blind$).tw.
43. or/29-42
44. 28 and 43
45. (200412* or 2005* or 2006* or 2007* or 2008* or 2009* or 2010* or 2011* or 2012*).up.
46. 44 and 45

Web of Science

# 20 #19 AND #18
# 19 TS=(random* or blind* or allocat* or assign* or trial* or placebo* or crossover* or cross-over*)
# 18 #17 AND #8
# 17 #16 OR #15 OR #14 OR #13 OR #12 OR #11 OR #10 OR #9
# 16 TI=(promot* or educat* or program*)
# 15 TS=(workplace)
# 14 TS=(primary health care)
# 13 TS=(cognitive therap*)
# 12 TS=((behaviour or behavior) NEAR/2 therap*)
# 11 TS=(health NEAR/2 promot*)
# 10 TS=(primary prevent*)
# 9 TS=((health educat*) or (patient* educat*))
# 8 #7 OR #6 OR #5 OR #4 OR #3 OR #2 OR #1
# 7 TS=((lifestyle* or life-style*) NEAR/5 (activ* or physcial*))
# 6 TS=((exercis* NEAR/2 aerobic*) or aerobic*)
# 5 TS=(sport* or danc* or walk* or bicycle*)
# 4 TS=(physical* educat*)
# 3 TS=(exercis* NEAR/5 (train* or physical* or activ*))
# 2 TS=(physical NEAR/5 (fit* or train* or activ* or endur* or exert*))
# 1 TS=(exercis* therap*)

Contributions of authors

All named authors contributed to the conceptual planning of this suite of reviews to update the previously completed Cochrane review assessing 'Interventions for promoting physical activity' (Foster 2005a). This manuscript was initially drafted by Charlie Foster and Justin Richards. Editorial contributions were received from Margaret Thorogood and Melvyn Hillsdon.

Declarations of interest

Melvyn Hillsdon has received a research council grant to investigate the feasibility of a primary care PA intervention. This was not a study of outcomes and therefore had no bearing on this review. He has been a member of a NICE programme development group on walking and cycling and was paid for travel expenses.

No other authors have any known conflict of interest.

Sources of support

Internal sources

  • British Heart Foundation Core Grant (021/P&C/Core/2010/HPRG), UK.

External sources

  • NIHR Cochrane Incentive Scheme 2012, UK.

Differences between protocol and review

Study selection

The six month follow-up period was extended to 12 months in response to the recommendations from the previous versions of this review that called for better study quality with longer follow-up periods (Foster 2005a).

Data extraction

The identified authors undertaking this task were modified.

Assessing the risk of bias

The identified authors undertaking this task were modified and the criteria for completing this task were explicitly identified.

Unit of analysis

The method for dealing with multiple intervention arms in a study was changed and these were not compared to a split control group. Instead, the relevant intervention arms were combined for comparison against the existing control group using established approaches (Higgins 2011).

Subgroup analysis

The following refinements were made to the subgroup analysis based on the data that were available in the identified studies.

  1. The inclusion of a comparison of group versus individual versus mixed (group and individual) was removed from the primary outcome measures section and more appropriately included as a subgroup analysis. This comparison also became a secondary rather than a primary objective.

  2. The prescription of the intervention was changed to focus on whether the type of PA was specified and if it was human or computer generated.

  3. The intensity of the intervention delivery was changed to focus on whether the PA was continuously monitored using a pedometer.

Sensitivity analysis

The threshold for 'low' risk was specified as meeting at least 50% of the applicable risk of bias criteria

Characteristics of studies

Characteristics of included studies [ordered by study ID]

Castro 2011

Methods 
ParticipantsInactive adults aged 50 years and older
InterventionsTelephone based advice to exercise delivered by trained professional staff or volunteer peer mentors. Telephone calls were delivered twice per month for the first 2 months and then monthly (up to 14 calls) until 12 months. This followed an initial face-to-face meeting with their staff or peer mentor.
OutcomesSelf-reported PA
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low riskA computerised Efron procedure with gender stratification was used to randomly allocate participants to one of the three study arms. There were no statistically significant differences between study arms in age, education level, gender distribution, race or ethnicity, marital status, or employment status (P values > 0.05)
Allocation concealment (selection bias)Unclear riskNot reported/appropriate
Blinding of participants and personnel (performance bias)
All outcomes
Low riskClear presentation of participant numbers at each stage of trial
Blinding of outcome assessment (detection bias)
All outcomes
Low riskMeasurement staff members were blinded to study arm assignment
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskAnalyses were conducted using both raw data with case-wise deletion of missing values, and intention-to-treat analyses ˜ 19% (n = 34) were lost at 12 months
Selective reporting (reporting bias)Unclear riskAll outcomes stated were analysed
Other biasLow riskValidated outcome measures

Elley 2003

Methods 
ParticipantsLess active adults aged 40-79 years
InterventionsParticipants received motivation counselling from their general practitioner. This included discussion on increasing PA and goal setting. The participants received a green prescription card stating their recommended PA. After this meeting a local exercise specialist called all participants at least 3 times to encourage PA using motivational interviewing techniques. Written materials were also sent to participants every 3 months. These materials included information about local PA opportunities and motivational material.
OutcomesSelf-reported PA
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low risk23 practices were randomised to provide the intervention and 23 were randomised to provide usual care. 4 of the control practices withdrew before patient recruitment (4 were going overseas, 2 had staffing problems and 1 had another reason although this is not specified
Allocation concealment (selection bias)Low riskAppropriate as the trial was clustered by practice to reduce the risk of the intervention being contaminated. This technique also meant that study participants were less aware of differences between intervention and control arms, but both were aware that they were part of a study that asked about exercise
Blinding of participants and personnel (performance bias)
All outcomes
Low riskClear presentation of participant numbers at each stage of trial
Blinding of outcome assessment (detection bias)
All outcomes
High riskAuthors stated they used a systematic screening process, few exclusion criteria, self-administered questionnaires, objective and electronic health measures, and signed witness statements of results to minimise the risk of recruitment and assessor bias resulting from the lack of blinding.
Incomplete outcome data (attrition bias)
All outcomes
Low riskAll outcomes reported
Selective reporting (reporting bias)Unclear riskAll outcomes stated were analysed
Other biasLow riskValidated outcome measures

King 1991

Methods 
ParticipantsInactive community older volunteers aged 50-65 years
InterventionsParticipants received baseline physiological assessments and then were prescribed either home or group based training at high or low intensity plus written information, PA logs and phone calls. Telephone phone calls were made once a week for the first four weeks, twice a week for the next four weeks and then once a month for 12 months.
OutcomesCardio-respiratory fitness
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskParticipants were randomly assigned to one of the four exercise training conditions using a computerised version of the Efron procedure
Allocation concealment (selection bias)High riskNot stated
Blinding of participants and personnel (performance bias)
All outcomes
Low riskClear presentation of participant numbers at each stage of trial
Blinding of outcome assessment (detection bias)
All outcomes
Low riskAssessment staff were blind to the results of the subjects' previous visits
Incomplete outcome data (attrition bias)
All outcomes
High riskAll outcomes reported
Selective reporting (reporting bias)Low riskAll outcomes stated were analysed
Other biasLow riskValidated outcome measures

King 2007

Methods 
ParticipantsInactive adults aged 55 years and older
InterventionsTelephone-assisted PA counselling by a health educator or automated computer system generated advice for 30-40 minutes plus 15 (10-15 minute) phone calls over 12 months. Also participants were sent mail-outs, a pedometer and daily step logs. The computer advice group interacted by touch phone key pads.
OutcomesSelf-reported PA
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low riskA computerised version of the Efron procedure was used to assign participants to the 3 arms. Participants were similar across the 3 study arms on the major baseline variables of interest (all P values > 0.20)
Allocation concealment (selection bias)Unclear riskNot stated
Blinding of participants and personnel (performance bias)
All outcomes
Low riskClear presentation of participant numbers at each stage of trial
Blinding of outcome assessment (detection bias)
All outcomes
Low riskAll study assessment staff were blinded to participant study arm assignment
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskAll outcomes reported
Selective reporting (reporting bias)Low riskAll outcomes stated were analysed
Other biasLow riskValidated outcome measures, ITT analysis adopted

Kinmonth 2008

Methods 
ParticipantsInactive adults aged 30 to 50 years from families with a history of type 2 diabetes
InterventionsParticipants received a home based 1 hour counselling visit and two 15 minute follow-up phone calls and then monthly 30 minute follow-up phone calls. The telephone based group received the home visit plus four 45 minute phone calls and two 15 minute phone calls over 5 months, followed by monthly postal contact for 7 months.
Outcomes

Self-reported PA

Cardio-respiratory fitness

Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskNot stated but baseline characteristics, including stratifying variables, in the three trial groups were similar
Allocation concealment (selection bias)Unclear riskNot stated
Blinding of participants and personnel (performance bias)
All outcomes
Low riskClear presentation of participant numbers at each stage of trial
Blinding of outcome assessment (detection bias)
All outcomes
Low riskTrial staff who did measurement and data entry were unaware of the groups to which participants had been assigned
Incomplete outcome data (attrition bias)
All outcomes
Low riskAll outcomes reported
Selective reporting (reporting bias)Low riskAll outcomes stated were analysed
Other biasLow riskValidated outcome measures, ITT analysis adopted

Kolt 2007

Methods 
ParticipantsInactive adults aged 65 years and older
InterventionsThe participants received 8 telephone counselling calls over 12 weeks, weekly for the first 4 weeks and then every 2 weeks for the remaining 8 weeks of the intervention.
OutcomesSelf-reported PA
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskAuthors state another researcher generated the allocation sequence
Allocation concealment (selection bias)Unclear riskNot stated
Blinding of participants and personnel (performance bias)
All outcomes
Low riskClear presentation of participant numbers at each stage of trial
Blinding of outcome assessment (detection bias)
All outcomes
Low riskAssessor blinded to allocation group
Incomplete outcome data (attrition bias)
All outcomes
Low riskAll outcomes reported
Selective reporting (reporting bias)Low riskAll outcomes stated were analysed
Other biasLow riskValidated outcome measures

Lawton 2008

Methods 
ParticipantsInactive women aged 40-74 years
InterventionsParticipants received written advice from a primary care nurse that included discussion on increasing PA and goal setting, lasting 7-13 minutes. The participants received a green prescription card stating their recommended PA. After this meeting a local exercise specialist called all participants, (on average 5 calls each lasting 15 minutes), to encourage PA using motivational interviewing techniques, over a nine month period. An additional 30 minute visit with a nurse was offered at 6 months, plus fridge magnets and activity record charts.
OutcomesSelf-reported PA
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskNot stated - After baseline measures the nurse opened sequentially numbered opaque envelopes containing the allocated treatment group (intervention or control)
Allocation concealment (selection bias)Unclear riskNot stated
Blinding of participants and personnel (performance bias)
All outcomes
Low riskClear presentation of participant numbers at each stage of trial
Blinding of outcome assessment (detection bias)
All outcomes
Low riskNurses assessing participants at 12 and 24 month follow-up visits were blind to group allocation, and participants were asked not to discuss group allocation with the assessing nurse
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskAll outcomes reported
Selective reporting (reporting bias)Low riskAuthors reported they deviated from planned analyses in the omission of data relating to physical fitness (a secondary outcome) as the potential for inaccuracies in the recording of pulse rate meant the quality of the data was questionable and not analysed here
Other biasLow riskValidated outcome measures, ITT analysis adopted

Marcus 2007

Methods 
ParticipantsInactive adults aged 18 to 65 years
InterventionsAll participants received baseline written materials recommending 150 minutes a week of moderate PA and completed PA logs and questionnaires each month. Each participants response generated tailored feedback containing theory based counselling messages. This feedback was communicated back to each participant either via mail or by telephone by a health educator. Contacts were phased at weekly for the first four weeks, biweekly for 8 weeks, monthly for 3 months and bimonthly for 6 months.
OutcomesSelf-reported PA
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskNot stated but randomisation was described as successful as none of the baseline variables of interest showed significant differences at the α=0.05 level
Allocation concealment (selection bias)Unclear riskNot stated
Blinding of participants and personnel (performance bias)
All outcomes
Low riskClear presentation of participant numbers at each stage of trial. To avoid intervention contamination effects, explicit training of the research assistants and health educator by a different Ph.D. level investigator (MN) and ongoing monitoring of intervention protocols occurred throughout the study
Blinding of outcome assessment (detection bias)
All outcomes
Low riskAuthors reported that In order to reduce bias in the measurement of MVPA, study staff participated in either assessment or intervention delivery, but not both. Study staff who conducted assessments, including our main outcome measure (that is 7 day PAR), were blinded to treatment condition
Incomplete outcome data (attrition bias)
All outcomes
Low riskAll outcomes reported
Selective reporting (reporting bias)Low riskAll outcomes stated were analysed
Other biasLow riskValidated outcome measures, ITT analysis adopted

Martinson 2010

Methods 
ParticipantsInactive adults aged 50 to 70 years
InterventionsFollowing a group introduction session, participants received written materials and an appointment with a phone coach (an exercise sports scientist). This was followed by seven 20 minute phone calls, plus mailed workbooks and pedometers. Then after a review of progress they received monthly phone calls up to 12 months then 6 calls over the next 12 months. In addition three motivational challenges were held including prizes, incentives, DVDs and videos.
OutcomesSelf-reported PA
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskSubjects were allocated equally in blocks of 20 according to a schedule prepared by the study statistician using a random numbers table and unobservable to the study co-ordinator. Randomisation was successful in creating groups that were similar on numerous demographic characteristics
Allocation concealment (selection bias)Unclear riskSubjects were allocated equally in blocks of 20 according to a schedule prepared by the study statistician using a random numbers table and unobservable to the study co-ordinator
Blinding of participants and personnel (performance bias)
All outcomes
Unclear riskClear presentation of participant numbers at each stage of trial
Blinding of outcome assessment (detection bias)
All outcomes
Low riskAuthors reported that outcome analyses were conducted after study recruitment was completed and intervention staff were blinded to results during the intervention delivery period so that neither the sample size, group assignment, nor intervention delivery could be influenced by knowledge of the impact of the intervention on PA
Incomplete outcome data (attrition bias)
All outcomes
Low riskAll outcomes reported
Selective reporting (reporting bias)Low riskAll outcomes stated were analysed
Other biasLow riskValidated outcome measures

Napolitano 2006

Methods 
ParticipantsInactive women
InterventionsParticipants received either a mail-out of a information leaflet or feedback from an expert computer system, based on a questionnaire, at baseline months 1, 3 and 6. This feedback was mailed after each completed questionnaire.
OutcomesSelf-reported PA
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskNot stated - Authors report that with the exception of the behavioral (P<0.05) and cognitive (P<0.05) processes of change, there were no significant between-group differences on any of the variables at baseline
Allocation concealment (selection bias)Unclear riskNot stated
Blinding of participants and personnel (performance bias)
All outcomes
Unclear riskClear presentation of participant numbers at each stage of trial
Blinding of outcome assessment (detection bias)
All outcomes
Low riskThe administrator of the PA recall PAR was blind to group assignment
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskAll outcomes reported
Selective reporting (reporting bias)Unclear riskAll outcomes stated were analysed
Other biasLow riskValidated outcome measures

van Stralen 2011

Methods 
ParticipantsInactive adults aged 50 plus years
InterventionsAll participants received computer generated tailored letters with personalised advice, at baseline 2 weeks and 2 months. Additional environmental information was sent plus access to website and e-buddy support system.
OutcomesSelf-reported PA
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskNot stated but authors report three research conditions were found to differ for education, BMI, and self-efficacy, but not PA
Allocation concealment (selection bias)Unclear riskNot stated
Blinding of participants and personnel (performance bias)
All outcomes
Unclear riskClear presentation of participant numbers at each stage of trial
Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskNot stated
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskAll outcomes reported
Selective reporting (reporting bias)Unclear riskAll outcomes stated were analysed
Other biasUnclear riskValidated outcome measures

Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion
Aggarwal 2010Multiple risk factor intervention
Aittasalo 2004Face-to-face intervention
Aittasalo 2006Less than 12 months follow-up
Akiyama 2007Less than 12 months follow-up
Albright 2005No appropriate control or intervention group
Albright 2012No appropriate control or intervention group
Andersen 2012Less than 12 months follow-up
Anderson 2005No appropriate control or intervention group
Armit 2005Less than 12 months follow-up
Armit 2009Less than 12 months follow-up
Baker 2008No appropriate control or intervention group
Baker 2008aNo appropriate control or intervention group
Baker 2011Less than 12 months follow-up
Baruth 2010More than 20% loss to follow-up
Baruth 2010aNo appropriate control or intervention group
Bennett 2008Less than 12 months follow-up
Berlant 2004No appropriate control or intervention group
Bowen 2006No appropriate control or intervention group
Buman 2011No appropriate control or intervention group
Calfas 2000Face-to-face intervention
Caperchione 2006No appropriate control or intervention group
Carr 2012Less than 12 months follow-up
Carroll 2010Less than 12 months follow-up
Cheung 2008Less than 12 months follow-up
Connell 2009Insufficient data
Cox 2006Study aim irrelevant
Cox 2008Study aim irrelevant
Cox 2011Study aim irrelevant
Cox 2011aStudy aim irrelevant
Cunningham 1987Face-to-face intervention
de Vreede 2007Less than 12 months follow-up
Dorgo 2009Less than 12 months follow-up
Dorgo 2011Less than 12 months follow-up
Dubbert 2002Less than 12 months follow-up
Duncan 2005No appropriate control or intervention group
Duru 2010Less than 12 months follow-up
Estabrooks 2011Less than 12 months follow-up
Evers 2012Less than 12 months follow-up
Farmandbar 2012Insufficient data
Ferney 2009Less than 12 months follow-up
Findorff 2007Inappropriate primary outcome
Finni 2011No appropriate control or intervention group
Fitzsimons 2008No appropriate control or intervention group
Fitzsimons 2012No appropriate control or intervention group
Fortier 2007Less than 12 months follow-up
Fortier 2007aLess than 12 months follow-up
Fortier 2011Less than 12 months follow-up
Fortier 2011aLess than 12 months follow-up
Freene 2011No appropriate control or intervention group
French 2011Less than 12 months follow-up
Froehlich-Grobe 2012More than 10% of participants with pre-existing medical condition
Fujita 2003Less than 12 months follow-up
Fukuoka 2011No appropriate control or intervention group
Gine-Garriga 2009More than 10% of participants with pre-existing medical condition
Godin 2010Less than 12 months follow-up
Goldstein 1999Less than 12 months follow-up
Grandes 2008Face-to-face intervention
Grandes 2009Face-to-face intervention
Grandes 2011Face-to-face intervention
Greaney 2008Multiple risk factor intervention
Green 2002Less than 12 months follow-up
Hardcastle 2012Non-randomised study
Harland 1999Face-to-face intervention
Harrison 2005More than 10% of participants with pre-existing medical condition
Havenar 2007More than 20% loss to follow-up
Heesch 2004Face-to-face versus remote and web 2.0 interventions
Herrera-Sanchez 2006Multiple risk factor intervention
Hillsdon 2002Face-to-face intervention
Hind 2010Less than 12 months follow-up
Hosper 2008Non-randomised study
Hovell 2008Multiple risk factor intervention
Hughes 2009Less than 12 months follow-up
Iliffe 2010Face-to-face intervention
Inoue 2003Less than 12 months follow-up
Isaacs 2007Less than 12 months follow-up
Jimmy 2005Non-randomised study
Jolly 2009Less than 12 months follow-up
Juneau 1987Less than 12 months follow-up
Katz 2008Face-to-face intervention
King 1988Less than 12 months follow-up
King 2006No appropriate control or intervention group
Kolt 2009No appropriate control or intervention group
Kolt 2012No appropriate control or intervention group
Kriska 1986Face-to-face intervention
Kriska 2012Study aim irrelevant
Lamb 2002No appropriate control or intervention group
LeCheminant 2011Less than 12 months follow-up
Leung 2012No appropriate control or intervention group
Lombard 1995Less than 12 months follow-up
Macmillan 2011Less than 12 months follow-up
Marcus 2007aNo appropriate control or intervention group
Marcus 2007bNo appropriate control or intervention group
Marshall 2003Less than 12 months follow-up
Marshall 2004Less than 12 months follow-up
McAuley 2007No appropriate control or intervention group
McEachan 2011No appropriate control or intervention group
McGowan 2009Less than 12 months follow-up
McGowan 2009aLess than 12 months follow-up
McMurdo 2010Less than 12 months follow-up
Merom 2007Less than 12 months follow-up
Muda 2006Less than 12 months follow-up
Murphy 2010More than 10% of participants with pre-existing medical condition
Newton 2004Less than 12 months follow-up
Nichols 2000Less than 12 months follow-up
Nies 2006No appropriate control or intervention group
Norris 2000Less than 12 months follow-up
Norton 2011Non-randomised study
Opdenacker 2008More than 20% loss to follow-up
Opdenacker 2011More than 20% loss to follow-up
Oppert 2007Less than 12 months follow-up
Paasche-Orlow 2012No appropriate control or intervention group
Pekmezi 2009Less than 12 months follow-up
Pekmezi 2010No appropriate control or intervention group
Petrella 2003No appropriate control or intervention group
Petrella 2006More than 20% loss to follow-up
Petrella 2010No appropriate control or intervention group
Pinto 2002Less than 12 months follow-up
Pinto 2005Less than 12 months follow-up
Plotnikoff 2007More than 20% loss to follow-up
Plotnikoff 2010More than 20% loss to follow-up
Poulsen 2007More than 20% loss to follow-up
Prestwich 2012Less than 12 months follow-up
Ransdell 2004Less than 12 months follow-up
Reed 2008Less than 12 months follow-up
Reid 1979Less than 12 months follow-up
Resnick 2002Less than 12 months follow-up
Sarkisian 2010No appropriate control or intervention group
Schneider 2011No appropriate control or intervention group
Sheeran 2012Less than 12 months follow-up
Simons-Morton 2001No appropriate control or intervention group
Skar 2011Less than 12 months follow-up
Slootmaker 2005Less than 12 months follow-up
Smith 2000Less than 12 months follow-up
Sorensen 2007Less than 12 months follow-up
Sorensen 2008Less than 12 months follow-up
Spittaels 2007Less than 12 months follow-up
Spittaels 2007aLess than 12 months follow-up
Steele 2007Less than 12 months follow-up
Steele 2009Less than 12 months follow-up
Stevens 1998Less than 12 months follow-up
Stewart 2001Face-to-face intervention
Talbot 2010Less than 12 months follow-up
Talbot 2011Less than 12 months follow-up
Tan 2006Less than 12 months follow-up
Taylor 2005Less than 12 months follow-up
Thogersen-Ntoumani 2010Less than 12 months follow-up
Thomas 2012No appropriate control or intervention group
Vainionpää 2007Study aim irrelevant
van Sluijs 2006Less than 12 months follow-up
Visek 2011Less than 12 months follow-up
von Thiele 2008Study aim irrelevant
Wadsworth 2010Less than 12 months follow-up
Wanner 2009No appropriate control or intervention group
Wanner 2010No appropriate control or intervention group
Watkinson 2010Less than 12 months follow-up
Whitehead 2007Less than 12 months follow-up
Wilcox 2007More than 20% loss to follow-up
Williams 2011No appropriate control or intervention group
Wilson 2009Less than 12 months follow-up
Wilson 2010Face-to-face intervention

Characteristics of studies awaiting assessment [ordered by study ID]

Peels 2012

MethodsRCT
ParticipantsOlder inactive adults recruited from 7 different areas, 50% aged 50-64 years old and 50% aged 65+ years old
InterventionsParticipants received either a basic print delivered intervention; a print delivered intervention with environmental information; a basic web based intervention; and a web based intervention with environmental information) in a clustered RCT. The control group did not receive advice to undertake PA.
OutcomesSelf-reported PA
NotesThe print delivered interventions had a higher response rate than the web based interventions. Participants of both low and high socioeconomic status were reached by both print delivered and web based interventions.

Characteristics of ongoing studies [ordered by study ID]

McAuley 2012

Trial name or titleFlexibility, Toning, and Balance (FlexToBa™) Trial
MethodsTwo-armed randomised controlled trial
Participants300 low active adults aged 65 and older
InterventionsThe FlexToBa™ condition will receive the DVD delivered PA program which incorporates behavior change principles based in social cognitive theory [7]. The control group will receive a commercial DVD (Healthy Aging™ by Andrew Weil, MD) delivering educational information related to healthy aging (for example healthy eating, social and cognitive health) with no specific emphasis on PA.
OutcomesTwo self-report measures, the PA Scale for the Elderly (PASE; [10]) and the Godin Leisure Time Exercise Questionnaire (GLTEQ; [11]), will be completed at each measurement period. PA will also be assessed objectively by accelerometry at each time point using an ActiGraph accelerometer (Model GT3X 16MB; Actigraph, LLC, Pensacola, FL) at 12 months post-baseline.
Starting date2011
Contact informationProfessor E McAuley, Department of Kinesiology and Community Health, University of Illinois, Urbana, IL 61801, USA. emcauley@illinois.edu
Notes 

Ancillary