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Community-based physical activityinterventions among women:a systematic review
Leila Amiri Farahani,1 Mohsen Asadi-Lari,2 Eesa Mohammadi,3 Soroor Parvizy,4,5
Ali Akbar Haghdoost,6 Ziba Taghizadeh7
To cite: Amiri Farahani L,Asadi-Lari M, Mohammadi E,et al. Community-basedphysical activity interventionsamong women: a systematicreview. BMJ Open 2015;5:e007210. doi:10.1136/bmjopen-2014-007210
▸ Prepublication history forthis paper is available online.To view these files pleasevisit the journal online(http://dx.doi.org/10.1136/bmjopen-2014-007210).
Received 28 November 2014Revised 2 March 2015Accepted 3 March 2015
For numbered affiliations seeend of article.
Correspondence toDr Ziba Taghizadeh;[email protected]
ABSTRACTObjective: Review and assess the effectiveness ofcommunity-based physical activity interventions amongwomen aged 18–65 years.Design: Systematic reviewMethods: To find relevant articles, the researcherselected reports published in English between 1January 2000 and 31 March 2013. Systematic searchwas to find controlled-trial studies that were conductedto uncover the effect of community-based interventionsto promote physical activity among women 18–65years of age, in which physical activity was reported asone of the measured outcomes. The methodologicalquality assessment was performed using a criticalappraisal sheet. Also, the levels of evidence wereassessed for the types of interventions.Results: The literature search identified nine articles.Four of the studies were randomised and the othersstudies had high methodological quality. There was noevidence, on the basis of effectiveness, for socialcognitive theory-based interventions and inconclusiveevidence of effectiveness for the rest of interventions.Conclusions: There is insufficient evidence to assessthe effectiveness of community-based interventions forenhancing physical activity among women. There is aneed for high-quality randomised clinical trials withadequate statistical power to determine whethermulticomponent and community-based interventionprogrammes increase physical activity among women,as well as to determine what type of interventions havea more effective and sustainable impact on women’sphysical activity.
INTRODUCTIONPhysical activity (PA) is recognised as one ofthe most important behaviours for reducingthe overall burden of disease in humans.1
The leading causes of death worldwide areprimarily found among four non-communicable diseases (NCDs): cardiovascu-lar diseases, cancers, diabetes and chronicrespiratory diseases. The burdens of these dis-eases are considerably heavier in developingand low-income countries where the rates ofthese NCDs continue to climb.2 Developing
countries have been experiencing a rapidphase of unplanned urbanisation and indus-trialisation, population-ageing and globalisa-tion. These result in unhealthy environments,with rapid social and economic transitionaccompanied by changes in PA. As a result,the growing prevalence of NCDs and theirrisk factors has become a global issue inundeveloped and developing countries.3
By 2030, low-income countries will haveeight times more deaths attributed to NCDsthan high-income countries.2 The WHO esti-mates that 80% of all deaths may be attribu-ted to NCDs by 2020.4
Tobacco use, harmful use of alcohol, insuf-ficient PA and unhealthy diet are the fourmain behavioural risk factors which induceNCDs and are expected to rise in developingcountries.5
In reference to the US physical activityguideline (2008), there is strong evidencethat PA reduces the risk of many adversehealth outcomes, such as early death, coron-ary heart disease, stroke, high-blood pres-sure, adverse blood lipid profile, type 2diabetes, metabolic syndrome and depres-sion;1 also PA is considered an independentcancer-protective factor.6
Although there are many benefits in adopt-ing PA, its rates have remained low.7 Dumith
Strengths and limitations of this study
▪ This is the first review to explore the effective-ness of community-based physical activity inter-ventions among women aged 18–65 years.
▪ The trial screening and data extraction were con-ducted using the strong appraisal sheets, inde-pendently by two authors.
▪ Owing to heterogeneity in the types ofcommunity-based interventions, methodologyquality and the impossibility of searching allelectronic and non-electronic databases with alanguage restriction, the ability of achievingstrong (solid) conclusions might be limited.
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et al8 have presented a comprehensive worldwide estima-tion of physical inactivity in which the overall prevalenceof physical inactivity was 21.4%, that is, 23.7% prevalencefor women and 18.9% prevalence for men; however,their report was limited by many factors, such as nothaving access to data from many populous countries,and using a self-report questionnaire that caused under-estimation of physical inactivity.According to the second report of the urban health
equity assessment and response tool (Urban HEART)project conducted in 2011 in Tehran, Iran, only 20.5%women and 24.3% men exercise at least for theminimum time recommended by the guideline of PA(unpublished data). In this guideline, 150 min of mod-erate intensity exercise or 75 min of vigorous intensityexercise is considered as the minimum PA per week.1
The lower PA rate among women can be explainedby gender-norm limitations that they face in their life.The limitation includes child care responsibility, secur-ity, lack of time, lack of confidence on their physicalabilities, lack of knowledge about designing and main-taining a PA programme, traffic restrictions, financialinability,9 traditional views about women, weather con-dition, uncomfortable workout cloths and individualmotivation.10
Iranian women encounter exceptional social and cul-tural constraints, such as disagreement with their spouseor father about going to gyms or their participation inPA. There are also some sociocultural expectations, andenvironmental and religious constraints, such asbanning females from biking or exercising outdoor.11 Asthey play an important role in the nurturing andupbringing of children, being physically active is veryimportant for women’s health and could help to havehealthy future generations. Undoubtedly, lack of PAamong females can cause unrecoverable damages to thesociety as it negatively affects physical and mental healthof women, a half of the population. This shows thenecessity of improving PA in women.12
Although the benefits of PA are now well-established,there is not much established knowledge regarding theeffectiveness of interventions designed to improve popu-lation PA.13
The fast growth of chronic diseases in developing coun-tries has increased the awareness of correcting lifestyleinactivity and encouraged community-based interventions.Community-based interventions provide a cost-effectiveand reasonable way to promote health and access to PAresources for large groups of people, especially whenthere are limited resources within the community.14–16
Community-based interventions are multilevel appr-oaches and use an ecological perspective. Such interven-tions can be implemented at any of the four ecologicallevels: group, organisation, community and policy. Threetheories that have been used frequently in community-based approaches are the social cognitive theory (SCT),stages of change theory and social marketing theory.17
According to Bopp and Fallon,14 community-based PAinterventions involve community members and leadersfrom various settings and organisations (ie, at any of thefour ecological levels) in the design, implementationand evaluation of a PA intervention. Owing to commu-nity members’ involvement in the plan, implementationand evaluation of community-based interventions, theseinterventions can be more effective and sustainable thanindividual interventions.18 19
The majority of interventions have been delivered at theindividual level to change only the personal behaviour.20
Although some individual-level and face-to-face interven-tions are effective as well as the gold standard for promotingPA, transferring and delivering individual-level interventionsto community-level is challenging.21 It is necessary to runthe community-level interventions, which have the potentialto produce long-term benefits, for a large number ofpeople, but there is no strong evidence which type ofcommunity-based interventions are most effective.22
Although many interventions to improve PA are beingcarried out with women between 18 and 65 years of age,the types and effectiveness of most interventions havenot been systematically examined. Recently publishedreviews have mostly dealt with the increase PA amongboth genders or only included underserved and/orminority women. Previous endeavours to summarise theevidence were mostly allocated to particular settings andindividual interventions. They also did not assess theeffects of interventions on women with a community-based approach and did not assess the methodologicalquality of the studies.This paper describes a systematic literature review of
strategies for promoting PA among women aged18–65 years, and conducted with community-basedapproaches. This review is a small part of a larger projectentitled Improving PA among Women: a Mixed-methodAction Research in Iran. The overarching goal of thisproject is to develop a community-based interventions pro-gramme for promoting PA among women in Iran.
METHODSSearch strategy and inclusion criteriaTo the best knowledge of the author of this article, alldocuments, including articles, theses and conferenceabstracts, that were published between 1 January 2000and 31 March 2013 in electronic databases, such asPubMed, Science Direct, Google scholar and CochraneLibrary were searched.The search strategy was created and run by LAF with
assistance from the library and an information scienceexpert. Keywords and combinations (MeSH and textwords), such as physical activity, physical inactivity, exer-tion, fitness and community-based intervention,community-based research and population-based inter-vention and community-based research, were used(table 1).
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First, duplicate articles were removed by using EndNote Software and then any remaining duplicate articleswere deleted manually.We used an iterative approach, which maximises the
specifications of the search scope, to find the key litera-ture. Additional web searches were performed afterextracting relevant information, such as key words,phrases and authors, from the articles within the field ofPA and community-based research (snowball search).The title and abstract of all potentially relevant articleswere screened by two reviewers (LAF and OR) in orderto find applicable information about PA promotion inthe community-intervention section. If the abstract didnot have sufficient information, the full text of thearticle was screened for further information. Any dis-crepancies between the two reviewers were resolved withdiscussions and consensus. If the reviewers could notreach a final conclusion, the article was investigated bythe third reviewer (MA-L). The inclusion and exclusioncriteria for selecting the studies were shown on the basisof PICOS in table 2.
Assessment of methodological qualityQuality assessments of studies were performed using theinformation available in the articles through the criticalappraisal sheet. This appraisal is composed of sevenscales including Delphi List, PEDro, Maastricht,Maastricht-Amsterdam List, Bizzini, vanTulder andJadad. The appraisal was compiled in a set of 39 itemsby Olivo and et al,24 where the items were divided intofive categories: patient selection, blinding, interventions,outcomes and statistics (table 3).Each item listed in the critical appraisal sheet was spe-
cified by the score of one if it was included in thearticle, and specified by the score of zero if it was notincluded in the article or if the information provided bythe authors was not sufficient to make a clear statement.In the case where a study did not consider a particularitem, the item was marked as inapplicable in the critical
appraisal sheet. The total score of each study was calcu-lated by dividing the number of items included by thenumber of applicable items. The range of scores fellbetween zero and one. Finally, studies were gradedbased on the number of items that they had in the crit-ical appraisal sheet.24 If the score was between 0 and 0.5,it was considered a low methodological quality study,and if the score was between 0.51 and 1, it was consid-ered a high methodological quality study.The critical appraisal was independently completed by
the two reviewers (LAF and OR), and the results werecompared. Disagreements between the two reviewerswere discussed during a meeting to achieve consensus. Ifthey could not reach an agreement, the third reviewer(MA-L) was consulted to make the final decision.
Data extractionStandardised data extraction forms were preparedthrough consultation with a methodological expert.They were then verified and completed by one reviewer(LAF), and furthermore checked by another reviewer(MA-L) for accuracy. The extracted data included the
Table 1 A sample of the search string was used in the
study
Databases (hits) Key words used
PubMed (n=467)
Science Direct,
Google scholar and
Cochrane Library
(n=1643)
(1) physical activity; (2) physical
inactivity; (3) exertion; (4) fitness;
(5) community-based intervention;
(6) community-based research;
(7) population-based intervention;
(8) community-based research;
(9) 1 or 2 or 3 or 4 or 5 or 6 or 7
or 8; (10) randomised controlled
trial; (11) controlled trial; (12) 9
and 10; (13) 9 and 11
Limit 12 and 13 to all women
(18–65 years old) and English
and humans
Table 2 The inclusion and exclusion criteria for selecting
the studies on the basis of PICOS
PICOS
criteria
Participants ▸ Participants were to be 18–65 years of
age.
▸ The study did not involve disease-state
populations (for example multiple
sclerosis rehabilitation patients.
Interventions ▸ Interventions must be designed to
improve PA and to prevent physical
inactivity, cardiovascular disease,
diabetes and other side effects of
sedentary life style.
▸ The study only included
community-based interventions.
Comparisons ▸ Studies must provide an assessment
of an intervention group through
comparison with a control or
comparison group which was
simultaneously derived from the same
or similar settings.
Outcomes ▸ Participants were to be 18–65 years of
age.
▸ Participation in PA must be one of the
measured outcomes.
▸ Studies must at least demonstrate a
specific measure of PA (objective,
self-reported or both) at the baseline
and follow-up.
Study design ▸ In this review articles with both random
and non-random allocation of
participants to study groups were
included, but results from observational
studies were not reported.
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title, year, country, design of the study along with partici-pant characteristics, randomisation procedure, interven-tion description, control or comparison groups, lengthof follow-up, measure of PA, health indicators and mainresults.During the data extraction process additional details
were considered: was it a theory-based intervention?;which constructs did the researchers use?; what was thenumber of participants at the baseline, the end of inter-vention and follow-up?; what was the effectiveness of themain outcome measures for assessing the level of evi-dence?; and, what were the details regarding the specificintervention and type of measurement tools (objectiveor subjective tools)?
Strength of evidence and data synthesisHeterogeneity in the type of interventions preventedreviewers from conducting a meta-analysis of the studies;therefore, narrative synthesis was used. As previouslyused in best evidence syntheses, conclusions regardingthe effectiveness of programmes on PA outcome mea-sures were drawn using a rating system referencing thelevels of evidence on the basis of study design and meth-odological quality.25–27 ̒Five levels of evidence weredefined: (1) strong evidence: at least 2 RCTs of highquality with ‘consistent’ (significant) results; (2) moder-ate evidence: 1 RCT of high quality and at least 1 RCT oflow quality, or 1 RCT of high quality and at least 1 con-trolled trial of high quality (for both situations, consist-ent results were required); (3) limited evidence: 1 RCTof high quality and at least 1 controlled trial of lowquality or more than 1 RCT of low quality or more than1 controlled trial of high quality (for all situations, con-sistent results were required); (4) inconclusive evidence:only 1 study or multiple-controlled trials of low qualityor contradictory results; and (5) no evidence: more than1 study with no significant or relevant results to a spe-cific intervention. When the results of the studies wereconsidered with regard to statistical significance, the pvalue was less than 0.05. If at least 75% of each of therelevant studies were reported to have significant resultsin the same direction then we considered the overallresults to be consistent’. In a stratified analysis weassessed and reported levels of evidence for studiesaccording to type of intervention.
RESULTSOverall, the initial search identified 2110 publications.After deduplication, 1218 relevant articles remained.At first the screening of titles led to 315 potentially rele-vant articles. The abstract content of all 315 studies werethen screened and finally 53 articles remained, whichhad inclusion and exclusion criteria of systematic reviewon the basis of titles and abstracts assessment. The fulltext of the 25 studies were included for details assess-ment, resulting in 16 articles being excluded (figure 1).The reasons for exclusion were irrelevant outcomes for
Table
3Methodologicalqualityscoresandratings
Study
Item
scoring
PatientSelection
Blinding
Interventions
Outcomes
Statistics
Scores/
Rating
12
34
56
78
910
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
Albrightetal28
11
00
01
NA
NA
0NA
NA
01
0NA
NA
NA
10
10
10
10
11
11
11
01
11
00
1NA
0.56/high
Gastonetal32
10
00
01
NA
NA
1NA
NA
01
0NA
NA
NA
00
10
00
11
11
11
01
01
10
00
0NA
0.44/low
Keyserlingetal21
11
11
11
NA
NA
1NA
NA
01
0NA
NA
NA
00
11
10
11
11
11
10
11
11
11
1NA
0.78/high
Lombard
etal29
11
11
11
NA
NA
1NA
NA
11
0NA
NA
NA
00
00
00
10
11
11
00
11
11
10
1NA
0.62/high
Napolitanoetal30
11
00
01
NA
NA
1NA
NA
01
1NA
NA
NA
00
11
00
11
10
11
11
01
11
00
1NA
0.59/high
Pazokietal35
11
00
01
NA
NA
0NA
NA
00
1NA
NA
NA
00
00
00
10
11
11
00
01
10
01
1NA
0.4/low
Ransdelletal33
11
00
00
NA
NA
0NA
NA
01
0NA
NA
NA
00
10
00
10
11
11
11
11
11
00
1NA
0.5/low
Sharpeetal34
10
00
01
NA
NA
0NA
NA
01
1NA
NA
NA
00
10
00
10
11
11
00
11
11
00
1NA
0.47/low
Yanceyetal31
11
11
11
NA
NA
1NA
NA
01
1NA
NA
NA
00
00
10
11
11
11
10
11
11
10
1NA
0.72/high
1,eligibility
criteria;2,describedasrandomised;3,randomisationperform
ed;4,randomisationdescribedasappropriate;5,randomisationconcealed;6,baselinecomparability;7,describedas
double
blind;8,blindingdescribedasappropriate;9,blindingofinvestigator/assessor;10,blindingofsubject/patient;11,blindingoftherapist;12,blindingoftheoutcome(results);13,treatm
ent
protocoladequately
describedforthetreatm
entandcontrolgroups;14,controlandplaceboadequate;15,cointerventionsavoidedorcomparable;16,cointerventionsreportedforeachgroup
separately;17,controlforcointerventionsin
design;18,testingofsubjectadherence;19,adherenceacceptable
inallgroups;20,descriptionofwithdrawals
anddropouts;21,withdrawals/
dropouts
rate
describedandacceptable;22,reasonsfordropouts;23,adverseeffects
described;24,follow-updetails
reported;25,follow-upperiodadequate;26,shortfollow-upperform
ed;27,
timingofoutcomescomparable
inallgroups;28,descriptionofoutcomemeasures;29,relevantoutcomesincluded;30,validityreportedformain
outcomemeasure;31,reliability
reportedfor
main
outcomemeasure;32,responsivenessreportedformain
outcomemeasure;33,useofquantitativeoutcomemeasures;34,descriptivemeasuresreportedforthemain
outcome;35,
appropriate
statisticalanalysis
included;36,sample
sizecalculatedapriori;37,adequate
sample
size;38,sample
sizedescribedforeachgroup;3,intention-to-treatanalysis
included;NA,not
applicable.
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this review (n=5), PA interventions without evaluation(n=4), non-community-based intervention (n=2),involvement of disease-state populations and participantswho were more than 65 years of age in the study (n=3),publication of two similar articles in different journals(n=1) and the use convenience sampling (n=1).Nine articles were selected from this literature review.
Table 4 provides the characteristics (ie, population,general intervention, outcome measure, measurementtimes and results) of all studies included in the review.
Methodological qualityTable 3 shows the methodological quality of theincluded studies. Agreement was 92.6% on the 325items scored through the quality assessment. Full con-sensus on all items was reached after discussion betweenthe two reviewers. Five of the 9 articles were consideredhigh quality.21 28–30 31 There was not sufficient informa-tion about random allocation used in most studies asonly 3 of these (33%) described random allocation21 29 31
and only 3 (33%) provided sufficient information aboutallocation concealment at the time of outcome assess-ment.21 29 31 There were blinding issues due to nature ofPA interventions as it was not possible to blind partici-pants to the types of intervention. However, some studiesused blinding of investigator/assessor and statistician toincrease study accuracy. Five studies (55%) appliedblinding of the investigator21 29–32 and 1 study (11%)solely used blinding of statistician.29 Most studies hadsimilar periods which passed before conducting theoutcome assessment. Only 4 studies (44%) had afollow-up of 3 months or longer.21 30–32
Study characteristicsSeven of 9 studies were carried out in the USA,21 28 30–34
1 in Australia,29 and 1 in Iran.35
The intervention studies were categorised as: physicalactivity only, nutritional and physical activity interven-tions. There were 5 of nine articles where programmeswere designed to modify PA28 30 33–35 and the remainder
Figure 1 Flow diagram used for the identification, screening, eligibility and inclusion of studies.23
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were designed as both PA and nutritional interven-tions.21 29 31–32
The most common duration for interventions was 12months.21 28 34 Other interventions lasted 8 weeks,31 35
10 weeks32 or 4 months.29
All of the studies were designed on the basis of a multi-component approach. All studies evaluated social sciencetheory-based interventions; seven of nine studies usedapplied social cognitive theories,21 28–30 32 33 35 while 1used both SCTand social marketing theory (SMT),34 andanother used the social ecological model.31 The mostcommon constructs of SCT were used, including socialsupport, goal setting, overcoming potential barriers andself-monitoring. Some studies have emphasised specificconstructs or applied particular interventions that didnot exist in other studies. For example, Albright et al28
used verbal encouragement and written reinforcement toachieve short-term and long-term PA goals. Gaston et al32
and Pazoki et al35 used cultural facilitators and expertconsultants for teaching behavioural strategies and skillsto help the women implement an individualised healthplan. Keyserling et al21 gave contact information to parti-cipants for local healthy PA resources. Lombard et al29
offered problem-solving training for overcoming the bar-riers of PA. Ransdell et al33 used a daughter and motherexercise strategy to produce social support and motiv-ation to increase PA. Sharpe et al used media messagesfor promotion of PA.34 Yancey et al31 applied an economicincentive of a free 1-year gym membership for allparticipants.Measurement of PA was mostly focused on self-report
questionnaires or recall instruments (using differenttypes of PA questionnaire). Four of nine articles usedboth self-report questionnaires or recall instruments andpedometers for measurement of PA.21 28–29 34
Evidence of effect on physical activitySeven studies reported a positive intervention effect(77.7%), and in 4 of these studies statistical significancewas achieved (44.45%). Significant results ranged froman increase of 2.07 days per week in doing aerobic exer-cise to a 10.4% increase in participation in regular PA(at least 30 min of moderate intensity PA for at least5 days a week, or at least 20 min of vigorous PA for atleast 3 days a week).Seven studies evaluated social cognitive theory-based
interventions, including 2 high-quality randomised con-trolled trials,21 29 2 high quality controlled trials28 30 and3 low quality controlled trial.32 33 35 Two of these studieswere high quality and randomised controlled trials,21 29
but had no statistically significant intervention effect;therefore, there was no evidence on the basis of effect-iveness for social cognitive theory-based interventions.With regard to other social science theory-based inter-
ventions, there was only 1 low quality controlled trialintervention accomplished on the basis of a mix of SCTand SMT, and 1 high-quality randomised controlled trialwhich used the social ecological model.31 34 These two
articles illustrated the inconclusive evidence of interven-tion effectiveness.
DISCUSSIONSummary of evidenceThe purpose of this systematic literature review was toassess the effectiveness of community-based PA interven-tions for women. Many studies were found in the litera-ture, but a very small number of studies werecommunity-based interventions performed amongwomen or met the inclusion criteria of this study.Consequently, this problem brought about a smallnumber of studies being included in the review. Most ofthese studies modified PA and were multicomponentinterventions. However, reviewers attempted to categor-ise the studies in a meaningful and logical model, butwere unable to recognise any consistent evidence tosupport the effectiveness of community-based interven-tions to enhance PA level. Heterogeneity existedbetween the types of interventions, intensity of activities,study designs, the duration of follow-ups and assessmenttools. Reviewers found that social cognitive theory-basedinterventions had no evidence of an effect of interven-tions on PA and the evidence of an effect for othersocial science theory-based interventions was inconclu-sive. Most of these studies were not random and did nothave any statistical significance. More high quality andrandomised studies are required to strengthen andconfirm these results. In overall, due to specificcharacteristics of interventions, reviewers could notdetermine which type of interventions, intensity, fre-quency or type of PA were successful in promoting PAamong women.
Implementation of interventionsResults showed that most of the articles were limited orhad inconclusive evidence of an interventions’ effect.There were many factors which contributed to therestricted effectiveness of interventions: small samplesize, small power to detect differences between groups,baseline differences between groups, the intensity levelsof interventions, lack of wait-list control group by com-paring the intervention group results with another inter-vention type or minimal intervention, and adherence.Several studies which were included had these problems.For example, all of the papers described did not haveacceptable adherence and most of them did not have acontrol group. All studies had a sociological basis;however, even those that used same theories had differ-ent constructs.
Limitations and recommendation for future studiesThere are a number of limitations to this study. First,reviewers limited the search to English language articlesand did not include other language interventions, suchas German or Italian. Second, the search strategycovered resources published between 2000 and 2013 as
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Table
4Characteristicsofincludedstudies
Study(year)ref
Country
Design
ofstudy
Population(n)
Generalintervention
Outcomemeasure
Measurement
times
Results
Albrightetal
(2005)28
USA
CT
Baseline:Phone+MailCounselling
group=35,MailSupportgroup=37;
there
are
noexactinform
ationfor
follow-ups
▸Allparticipants
received2monthsof
Weekly
1hclasses(groupactivities,
small-groupdiscussions,and
question-and-answergames).
▸Random
allocationto
10monthsof
eitherhome-basedtelephone
counselling,additionalinform
ation,
andfeedbackforPAbymailed
newsletters
(Phone+MailCounselling
condition)oronly
themailed
newsletters
(MailSupportcondition).
PA
Baseline,
10weeks,6and
12monthsafter
baseline
▸There
wasnotanysignificant
differencein
thepercentageof
participationsin
30ormore
ofMVPA
atleast5daysweekly
betweenthe
Phone+MailCounsellinggroup
(49%)andMailSupportgroup(35%)
after12months
▸Resultsofbetweengroup
comparisonafter10monthsshowed,
there
isasignificantlygreater
increasein
totalenergyexpenditure
via
PAin
phone+mailcounselling
groupthanthemailsupportgroup
(p<0.05)
Gastonetal
(2007)32
USA
CT
Baseline:interventiongroup=106,
comparisongroup=28;follow-up
(10weeks):interventiongroup=83,
comparisongroup=23;follow-up
(6months):interventiongroup=?,
comparisongroup=?,sample
sizein
both
groups:42;follow-up(12months):
interventiongroup=45,comparison
group=7
▸Interventiongroupreceived
curriculum-,culture-and
gender-specific
basedapproachesto
behaviouralchange.Participants
were
dividedinto
10structuredintervention
groupswith8–13womenpergroup.
Thegroupsmetfor90min
for
10weeks,ledbyfacilitators
and
receivedtheGastonbook.All
participants
signedagroupcontract
forim
provingPAatthefirstsession.
▸Controlgroupreceivedthecopyofthe
Gastonbutdid
notreceivea
curriculum,facilitatorandexpert
consultants.
Perceptionofoverall
health,Health
attitudes,eating
patternsandPA
Baseline,10
weeks,6and
12months
▸Statistically
significantincreasein
the
women’s
involvementin
aerobic
exercise(from
1.9
dayperwkat
baselineto
3.97,2.48and3.21day
perweekat10weeks,6and
12months).
▸Asignificant.10-w
eekdifferencewas
foundin
thewomen’s
diet,withthem
reportingeatingmore
nutritious
foods(p<0.001)
Keyserlingetal
(2008)21
USA
RCT
Baseline:EIgroup=118,MI
group=118;follow-up(6
months):EI
group=108,MIgroup=110;follow-up
(12months):EIgroup=106,MIgroup
intervention=106
▸EIgroupreceivedtwo6-m
onth
phases,firstphaseincluded3group
sessions,2individualcounselling
sessions,and3phonecalls
from
an
expertcounsellor;secondphase
(maintenancephase)included1
individualcounsellingsessionand
7monthly
peercounsellorcalls.
▸MIgroupconsistedofaone-tim
e
mailingofpamphlets
onPAanddiet
PA,Dietary
intake,
fastingbloodlipids,
bloodpressure,weight,
andpsychosocial
variables
Baseline,6and
12months
▸PAoutcomesbyusinga
questionnaire:atthe6and12month
follow-up,theEIgroupreported
significantlymore
moderate
(p=0.001)andvigorous(p=0.03)PA
andthere
isnosignificant
differencesbetweenEIandMI
groupsbyusingaccelerometerat6
and12months(p>0.05).
▸Dietary
intakeim
provedmore
inthe
EIcomparedto
theMI(questionnaire
at6and12months,p=0.001;serum
carotenoid
index,p=0.05)
Continued
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Table
4Co
ntinued
Study(year)ref
Country
Design
ofstudy
Population(n)
Generalintervention
Outcomemeasure
Measurement
times
Results
Lombard
etal
(2009)29
Australia
RCT
Baseline:interventiongroup=127,
comparisongroup=123;follow-up
(4months):interventiongroup=88,
comparisongroup=85
▸Interventiongroupconsistedof4
sessionsincluding31hinteractive
groupsessionsin
thefirstmonth
plus
onereview
sessionat4months;
Contentincludedmessageswithclear
goals
onPAandbehaviourchange.
Participants
were
encouragedto
enter
voluntary
school-basedwalkinggroups
orto
walk
withfriendsforsocial
support;moreover,theyused
pedometerforself-m
onitoring,and
receivedoneinstructionforusingit.
▸Comparisongroupparticipatedin
individual30mins,non-interactive
healtheducationgrouplecture
and
receivedapedometerwithoutsetting
thegoal.
PA,diet,
self-m
onitoring,
self-efficacy,
anthropometric
measures
Baselineand
4months
▸Theinterventiongroupreportedmore
improvements
inPAleveleven
thoughthedifferencebetweenthe
twogroupswasnotsignificant.The
differencein
scoresbetweengroups
onthebasis
ofMETwas35(−315
to416),67(−
389to
525),46(−
412
to506)forwalking,moderate
and
vigorousPA,respectively
▸Participants
inboth
groups
decreasedweightwithnosignificant
differencebetweengroups(p=0.95)
Napolitanoetal
(2006)30
USA
CT
Baseline:CTM=93,Jumpstart=95,
Wellnesscontrol=92;numberof
participants
did
notreportfor
follow-ups1,3,6and12months
▸CTM
groupreceiveda12-w
eek
programmeandonemailingbooklet
coveringatopic
weekly
onthebasis
of
AmericanHeartAssociationguideline
forPA.
▸TheJumpstartgroupcompleteda
65-item
questionnaireforassessing
thestageofchange,processesof
changeandself-efficacyrelatedto
PA
atbaselineandpriorto
the1-m
onth,
3-m
onth
and6-m
onth
timepoints.
Participants
receivedabooklet
matchedto
stageofchangeandan
individually
tailoredfeedbackreport
addressingbarriers,benefits,
self-efficacy,socialsupportandgoal
setting.
▸TheWellnessgroupreceivedone
mailingofwomen’s
healthinform
ation
aboutsleep,cancerprevention,and
nutrition.
PA,stageofchange,
processofchange,
self-efficacy
Baseline,3and
12months
▸At3months,participants
inthe
Jumpstartgroupreported
significantlymore
minutesofPAper
weekthanparticipants
inthe
Wellnessgroup(respectively,140.4
±14.82,98.1±15.09)(p<0.05).
▸TheJumpstartgroupshowedan
inclinationtowardssignificance
(p=0.054)whencomparedwiththe
CTM
group(99.5±15.11);there
was
nosignificantdifferencebetweenthe
CTM
andWellnessgroups.
▸At12months,nosignificant
differencesexistedbetweenanyof
thetreatm
entgroups
Continued
8 Amiri Farahani L, et al. BMJ Open 2015;5:e007210. doi:10.1136/bmjopen-2014-007210
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Table
4Co
ntinued
Study(year)ref
Country
Design
ofstudy
Population(n)
Generalintervention
Outcomemeasure
Measurement
times
Results
Pazokietal
(2007)35
Iran
CT
Baseline:Intervention=179,
control=179;follow-up(8
weeks):
Intervention=170,control=160
▸Theinterventiongroupreceivedan
8-w
eekprogrammerelatedto
the
AmericanHeartAssociationPAfor
women,audio-tapedactivity
instructionsandaneducational
packagewhichwere
givenweekly
thoroughhome-visitsbylocal
volunteers.
▸Controlgroup:notreported.
PA
Atbaselineand
8weeks
▸Increasingin
PAfrom
3%
and2.7%
atbaselineto
13.4%
and3%
after
8weeksin
theinterventionand
controlgroups.
▸Interventiongroupreportedmore
minutesofPAperwk(m
ean=139.81,
SE=23.35)thanwomenin
the
controlgroup(m
ean=40.14,
SE=12.65)atweek8andthe
differencebetweentwogroupswas
statistically
significant(p<0.0001)
Ransdelletal
(2003)33
USA
CT
Baseline:home-basedintervention=20,
community-basedintervention=20;
follow-up:home-based
intervention=14,community-based
intervention=20
▸CBactivitieswere
completedata
fitnessfacility
within
auniversityand
met3timesperweekand
fitness-orientedactivities2timesa
week,Fitnessactivitydayslasted60–
75min
andconsistedofa5min
warm
-up,20–30min
ofaerobic
activity,20–30min
ofweighttraining,
and5–10min
ofstretchingand
abdominalstrengtheningexercises.
▸HBgroupreceivedadetailedpacket
includingacalendarofrecommended
activities,picturesofvariousstretches,
andstrength-trainingactivities,plus
someadviceforovercomingbarriers,
andsentorfaxedtheirPAlogsto
the
leadauthorevery
2weeks.
PA,health-related
fitness,BP
Atbaselineand
12weeks
▸There
were
nodifferencesbetween
changesin
PAforhome-basedand
community-basedgroups.
▸Mothers
anddaughters
inboth
groupssignificantlyincreasedtheir
participationin
aerobic,muscular
strength,andflexibility
activities
(p=0.02to
0.000).
Sharpeetal
(2010)34
USA
CT
Baseline:fullintervention=430,
community-m
edia
exposure
only=245,
nointervention:234;follow-up:full
intervention=217,community-m
edia
exposure
only=820,nointervention:
822
▸Interventionconsistedoftwo
components:(a)ayear-longmedia
campaignto
increase
moderate-intensityexercise,where
27
womenfrom
thecommunitywere
socialmodels
andtheirphotoswere
in
printandtelevisionsportsand
participatedin
the13monthly
exercise
events.(b)Behaviouralintervention
consistedofanintensive,24-w
eek,
minim
al-contactinterventionwhich
includedanorientationpacketand
weekly
tips,apedometer,aguideto
exerciseandagoal-setting.Women
participatedin
groupexercisewhich
gavethem
anopportunityto
enjoy
newactivitiesandmeetexercise
partners.
PA,self-efficacy,
anthropometric
in
form
ation,counting
steps
Baselineand
12months
▸Behaviouralinterventionwithmedia
messageswasmore
effectivethan
media
messagesaloneorno
intervention
▸Womenin
thebehavioural
interventionhadthegreatestpre-to
post-programmepositivedifferences
andhadsignificantlyhigherrecallof
programmeadsandofthemain
messagethandid
themedia
only
sample
Continued
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Table
4Co
ntinued
Study(year)ref
Country
Design
ofstudy
Population(n)
Generalintervention
Outcomemeasure
Measurement
times
Results
▸Group1receivedthefullintervention,
enrolledin
thefull24-w
eek
behaviouralprogrammeandwas
exposedto
countywidemedia
messages.
▸Group2livedin
themedia
exposed
county
butnotenrolledin
the
behaviouralintervention.
▸Group3receivednointervention.
Yanceyetal
(2006)31
USA
RCT
Baseline:intervention=193,
ccontrol=183;follow-up(2
months):
intervention=158,control=156;
follow-up(6
months):intervention=118,
control=110;intervention(12months)
=135,control=128
▸Theinterventiongroupincluded8
weekly
2hinteractivegroupsessions,
skillstrainingin
aregularexercise
regim
en,interview
byadieticianabout
theirfoodintake3or4timesduring
theinterventionandfeedbackonthe
qualityandadequacyoftheirintake.
Participants
were
encouragedto
invite
oneclosefemale
relativeorfriendto
accompanythem
during
postinterventionuseofhealthclub
facilities.
▸Controlgroupreceived8weekly,2h
interactivegroupsessionsonhealth
topicssuchastobaccoandcancer
screeningwithouttheexternalsocial
support.
BIA,WHR,BMI,
sedentary
behaviour,
PA,fitness
Atbaseline,2,6,
and12months
▸There
wasasignificanteffectofthe
interventiononPAat2months
(p=0.0148),remainingmarginally
significantat12months(p=0.058)
▸Participants
intheinterventiongroup
showedatrendtoward
weight
stability
at2monthscomparedwith
controlgroup(p=0.75;p=0.08,
respectively),disappearingat
12months(p=0.0001;p=0.001,
respectively)
BIA,bioelectricalim
pedanceanalyser;CAB,CommunityAdvisory
Board;COMBO,pedometer-plusgroup;CTM,chooseto
move;EI,enhancedintervention;MET,metabolic
equivalent;MI,
minim
um
intervention;MVPA,moderate-to-vigorousphysicalactivity;PED,pedometer-only
group;TTM,trans-theoreticalmodel;WHR,waist/hip
ratio.
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the process of conducting the systematic review andreviewing the article was long.Third, due to the small number of included papers
and the lack of statistically significant differences, theresults of this review are difficult to interpret. Fourth,methodological limitations across studies included theshort time of intervention or follow-up, insufficientadjustment for potential confounders, lack of randomisa-tion procedure and blinding at outcome assessment.Fifth, there was a lack of precision in the measurement ofPA outcomes in some studies. Sixth, a conclusivemeta-analysis cannot be achieved with these studiesbecause of the heterogeneous nature of these studies andexplanations cannot be made concerning the effect sizeof the interventions. Seventh, reviewers could not distinctbiased publications that only reported positive findings incommunity-based interventions for PA improvement asthese publications were some of the available resources.Reviewers also faced the challenge that measures of PAdiffered markedly and were reported both as indirect anddirect measures. Though reviewers had planned a priorito conduct subgroup analysis of direct (eg, accelerometeror pedometer) versus indirect (eg, self-report) measuresof PA, this was not possible because of the heterogeneityof measurement tools and interventions.To have a fair assessment, future studies on PA meas-
urement should have similar approaches and tools.There is a need for more rigorous research designs,including higher quality randomised controlled trials inthis age group and culture-based multicomponent andcommunity-based intervention programmes that con-sider either individual or environmental factors forchanging PA levelsOne of the goals of the community intervention is to
design programmes that include the majority of thepopulation, but it seems including personal desires andinterests into the design of PA programmes couldprovide better results. One intervention approach maynot fit all, therefore, different approaches should beoffered: some people may prefer the private feedbackfrom a device such as pedometer; others may respond tointerventions delivered through the internet, others maybenefit from the social support in doing a PA group,whereas others may increase PA in response to tele-phone counselling or facilitator counselling.In community-based interventions, the number of par-
ticipants that contribute in all levels of measurement,design, application and assessment increase the chanceof success for an intervention programme. At the sametime, the efficacy and reliability of an intervention pro-gramme is more important than the number of peoplethat an intervention could involve.
CONCLUSIONTo our extensive search, this is the first published system-atic review aimed at community-based PA interventionstudies for 18–65 years-old women. This review found
low-quality to high-quality evidence of how to improvePA, although due to the inadequate supply of informa-tion reviewers could not determine which specific type,intensity, frequency or amount of intervention could sig-nificantly improve PA, or which intervention is moreeffective and sustainable. In addition, more studies areneeded to address these gaps in knowledge for PAimprovement among women. Based on the publishedevidence to date, it is necessary to conduct a multilevelapproach for promoting PA. Reviewers have recognisedthe necessity of collaborations among communitymembers, policymakers, as well as governmental andnon-governmental organisations in developing moreeffective PA interventions for women.
Author affiliations1Department of Midwifery, School of Nursing and Midwifery, TehranUniversity of Medical Sciences, Tehran, Iran2DG Int’l Relations Department, MOHME, IR Iran Head- OncopathologyResearch Centre, IUMS, Tehran, Iran3Nursing Department, Faculty of Medical Sciences, Tarbiat ModaresUniversity, Tehran, Iran4Department of Pediatric Nursing, Nursing and Midwifery Faculty, IranUniversity of Medical Sciences, Tehran, Iran5Centre for educational Research in Medical Sciences (CERMS) Iran Universityof Medical Sciences, Tehran, Iran6The Research Centre for Modelling in Health, Institute for Future Studies inHealth, Kerman University of Medical Sciences, Kerman, Iran7Faculty Member of Nursing and Midwifery Care Research Centre, Nursingand Midwifery School, Tehran University of Medical Sciences, Tehran, Iran
Acknowledgements The authors would like to thank Dr Susan Armijo-Olivo,Adjunct Professor at the Faculty of Rehabilitation Medicine, University ofAlberta, Canada, for her constructive help, Dr Owais Reza (OR), PhDcandidate in clinical epidemiology at Tehran University of Medical Sciences forhis help and consultation throughout some steps of the study, Kayla J Powerfor her valuable and kind assistance in finding the full text of articles andEnglish language editing of the article.
Contributors MA-L and LAF conceived and designed the review. MAL, LAFand OR extracted and analysed the data. EM, SP and ZT wrote the paper.AAH revised the paper.
Funding This work is a part of the author’s PhD thesis in Tehran Universityof Medical Sciences. This study was funded and supported by TehranUniversity of Medical Sciences (grant no. 93-02-28-26113).
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement No additional data available.
Open Access This is an Open Access article distributed in accordance withthe terms of the Creative Commons Attribution (CC BY 4.0) license, whichpermits others to distribute, remix, adapt and build upon this work, forcommercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/
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