Physical Activity: Community-Wide Campaigns

The CPSTF finding is based on evidence from a systematic review of 10 studies (search period 1980 – 2000). The review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice, and policy related to increasing physical activity.

Ten studies qualified for the review.

• Percentage of people who report being physically active: median net increase of 4.2 % (interquartile range: -2.9% to 9.4%; 6 study arms)
• Energy expenditure: median net increase of 16.3% (interquartile range: 7.6% to 21.4%; 3 study arms)
• Other measures of physical activity: all but one of five study arms showed increases in physical activity.
• This review also found evidence that community-wide campaigns are effective in increasing:
  • Knowledge about exercise and physical activity
  • The intention to be more physically active
• These campaigns can also reduce risk factors for cardiovascular disease. However, studies that measured body weight changes had mixed results. Some studies showed weight loss, but others showed no change or even slight weight gain.

An economic review of this intervention did not find any relevant studies.

The results of this review should be applicable to most communities in the United States if the campaign is adapted to specific needs and interests of the target population.

CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. (What are evidence gaps?)

• What characteristics and components of community-wide campaigns are most effective?
• How can community-wide efforts be institutionalized?
• What are the most effective and efficient delivery settings and channels (e.g., media, work settings)?
• Do coalitions enhance the delivery and effectiveness of interventions in community settings? If so, is the enhanced effect worth the potential added cost and burdens of implementation?

General Research Issues

The following outlines evidence gaps for reviews of these interventions to increase physical activity: Individually-Adapted Health Behavior Change Programs; Social Support Interventions in Community Settings; Family-Based Social Support; Enhanced School-Based Physical Education (archived); College-Based Physical Education and Health Education; Classroom-Based Health Education to Reduce TV Viewing and Video Game Playing; Community-Wide Campaigns; Mass Media Campaigns (archived); Classroom-Based Health Education Focused on Providing Information; Creation of or Enhanced Access to Places for Physical Activity Combined with Informational Outreach Activities.

Effectiveness

Several crosscutting research issues about the effectiveness of all of the reviewed interventions remain.

• What behavioral changes that do not involve physical activity can be shown to be associated with changes in physical activity?
  • For example, does a decrease in time spent watching television mean an increase in physical activity or will another sedentary activity be substituted?
  • Does an increase in the use of public transportation mean an increase in physical activity or will users drive to the transit stop?
• Physical activity is difficult to measure consistently across studies and populations. Although several good measures have been developed, several issues remain to be addressed.
  • Reliable and valid measures are needed for the spectrum of physical activity. Rationale: Current measures are better for vigorous activity than for moderate or light activity.
  • Sedentary people are more likely to begin activity at a light level; this activity is often not captured by current measurement techniques.
  • Increased consensus about “best measures” for physical activity would help to increase comparability between studies and would facilitate assessment of effectiveness.
• Note: This is not intended to preclude researchers’ latitude in choosing what aspects of physical activity to measure and to decide which measures are most appropriate for a particular study population. Perhaps a useful middle ground position would be the establishment of selected core measures that most researchers should use which could then be supplemented by additional measures. The duration of an intervention’s effect was often difficult to determine.

Applicability

Each recommended and strongly recommended intervention should be applicable in most relevant target populations and settings, assuming that appropriate attention is paid to tailoring. However, possible differences in the effectiveness of each intervention for specific subgroups of the population often could not be determined. Several questions about the applicability of these interventions in settings and populations other than those studied remain.

• Are there significant differences in the effectiveness of these interventions, based on the level or scale of an intervention?
• What are the effects of each intervention in various sociodemographic subgroups, such as age, gender, race, or ethnicity?

Other Positive or Negative Effects

The studies included in this review did not report on other positive and negative effects of these interventions. Research on the following questions would be useful:

• Do informational approaches to increasing physical activity help to increase health knowledge? Is it necessary to increase knowledge or improve attitudes toward physical activity to increase physical activity levels?
• Do these approaches to increasing physical activity increase awareness of opportunities for and benefits of physical activity?
• What are the most effective ways to maintain physical activity levels after the initial behavior change has occurred?
• Are there other benefits from an intervention that might enhance its acceptability? For example, does increasing social support for physical activity carry over into an overall greater sense of community?
• Are there any key harms?
• Is anything known about whether or how approaches to physical activity could reduce potential harms (e.g., injuries or other problems associated with doing too much too fast)?

Economic Evidence

The available economic data were limited. Therefore, considerable research is warranted on the following questions:

• What is the cost-effectiveness of each of these interventions?
• How can effectiveness in terms of health outcomes or quality-adjusted health outcomes be better measured, estimated, or modeled?
• How can the cost benefit of these programs be estimated?
• How do specific characteristics of each of these approaches contribute to economic efficiency?
• What combinations of components in multicomponent interventions are most cost-effective?

Barriers

Research questions generated in this review include the following:

• What are the physical or structural (environmental) barriers to implementing these interventions?
• What resource (time and money) constraints prevent or hinder the implementation of these interventions?

• In addition to addressing sedentary behavior, most of the included studies also addressed other cardiovascular disease risk factors, particularly diet and smoking.
• Communication techniques were a common element in all of the campaigns.
  • Campaign messages were directed to large and relatively undifferentiated audiences through diverse media, including television, radio, newspaper columns and inserts, direct mailings, billboards, advertisements in transit outlets, and trailers in movie theaters.
  • Messages were delivered in the form of paid advertisements, donated public service announcements, press releases, the creation of feature items, or a combination of two or more of these approaches.
• Multicomponent interventions were typically evaluated as a “combined package” because it was impossible to distinguish the relative contributions of each component. These interventions most often included some combination of the following.
  • Social support, such as self-help groups
  • Risk factor screening, counseling, and education about physical activity in a variety of settings, including worksites, schools, and community events
  • Environmental or policy changes such as the creation of walking trails
• Many of the studies evaluated interventions delivered over a period of several years, though a few were limited to between 6 weeks and 6 months.

Kahn EB, Ramsey LT, Brownson RC, et al. The effectiveness of interventions to increase physical activity: a systematic review. American Journal of Preventive Medicine 2002;22(4S):73-107.

Task Force on Community Services. Recommendations to increase physical activity in communities. American Journal of Preventive Medicine 2002;22(4S):67-72.

Centers for Disease Control and Prevention. Increasing physical activity. A report on recommendations of the Task Force on Community Preventive Services. MMWR 2001;50(RR-18):1-16. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5018a1.htm.

Wilcox S, Shephard D, Martin SL, et al. Informational approaches to promoting physical activity. In: Promoting Physical Activity: A Guide for Community Action. Promoting Physical Activity: A Guide for Community Action. Champaign (IL): Human Kinetics; 2010. Available at: http://www.humankinetics.com/products/all-products/the-promoting-physical-activity—2nd-edition.

Roux L, Pratt M, Tengs TO, et al. Cost effectiveness of community-based physical activity interventions. American Journal of Preventive Medicine 2008;35(6):578-88. Available at: http://www.ajpmonline.org/article/S0749-3797(08)00770-8/abstract.

Dunn AL, Blair SN. Translating evidence-based physical activity interventions into practice. American Journal of Preventive Medicine 2002;22(4S):8-9.

Task Force on Community Services, Zaza S, Briss PA, Harris KW. Physical activity. In: The Guide to Community Preventive Services: What Works to Promote Health? Atlanta (GA): Oxford University Press; 2005:80-113.

Effectiveness Review

Analytic Framework see Figure 1 on page 76

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Effectiveness Review

Summary Evidence Table – Effectiveness Review

The number of studies and publications do not always correspond (e.g., a publication may include several studies or one study may be explained in several publications).

Effectiveness Review

Goodman RM, Wheeler FC, Lee PR. Evaluation of the Heart To Heart Project: lessons from a community-based chronic disease prevention project. Am J Health Promot 1995;9:443 55.

Jason LA, Greiner BJ, Naylor K, Johnson SP, Van Egeren L. A large-scale, short-term, media-based weight loss program. Am J Health Promot 1991;5:432 7.

Luepker RV, Murray DM, Jacobs DJ, et al. Community education for cardiovascular disease prevention: risk factor changes in the Minnesota Heart Health Program. Am J Public Health 1994;84:1383 93.

Malmgren S, Andersson G. Who were reached by and participated in a one year newspaper health information campaign? Scand J Soc Med 1986;14:133 40.

Meyer AJ. Skills training in a cardiovascular health education campaign. J Consult Clin Psychol 1980;48:129 42.

Osler M, Jespersen NB. The effect of a community-based cardiovascular disease prevention project in a Danish municipality. Dan Med Bull 1993;40:485 9.

Owen N, Lee C, Naccarella L, Haag K. Exercise by mail: a mediated behavior-change program for aerobic exercise. J Sport Psychol 1987;9:346 57.

Tudor-Smith C, Nutbeam D, Moore L, Catford J. Effects of the Heartbeat Wales programme over five years on behavioural risks for cardiovascular disease: quasi-experimental comparison of results from Wales and a matched reference area. BMJ 1998;316(7134):818 22.

Wimbush E, MacGregor A, Fraser E. Impacts of a national mass media campaign on walking in Scotland. Health Promot Internation 1998;13:45 53.

Young DR, Haskell WL, Taylor CB, Fortmann SP. Effect of community health education on physical activity knowledge, attitudes, and behavior. The Stanford Five-City Project. Am J Epidemiol 1996;144:264 74.

Effectiveness Review

The search for evidence started with seven computerized databases (MEDLINE, Sportdiscus, Psychlnfo, Transportation Research Information Services [TRIS], Enviroline, Sociological Abstracts, and Social SciSearch) and included reviews of reference lists and consultations with experts in the field. Studies were eligible for inclusion if they:

• Were published in English during 1980-2000
• Were conducted in an Established Market Economy*
• Assessed a behavioral intervention primarily focused on physical activity
• Were primary investigations of interventions selected for evaluation rather than, for example, guidelines or reviews
• Evaluated outcomes selected for review; and
• Compared outcomes among groups of persons exposed to the intervention with outcomes among groups of persons not exposed or less exposed to the intervention (whether the study design included a concurrent or before-and-after comparison)

* Established Market Economies as defined by the World Bank are Andorra, Australia, Austria, Belgium, Bermuda, Canada, Channel Islands, Denmark, Faeroe Islands, Finland, France, Germany, Gibraltar, Greece, Greenland, Holy See, Iceland, Ireland, Isle of Man, Italy, Japan, Liechtenstein, Luxembourg, Monaco, the Netherlands, New Zealand, Norway, Portugal, San Marino, Spain, St. Pierre and Miquelon, Sweden, Switzerland, the United Kingdom, and the United States.

Economic Review

The databases MEDLINE, Transportation Research Information Services (TRIS), Combined Health Information Database (CHID), ECONLIT, PsychInfo, Sociological Abstracts, Sociofile, Social SciSearch, and Enviroline were searched for the period 1980 2000. In addition, the references listed in all retrieved articles were reviewed and experts were consulted. Most of the included studies were either government reports or were published in journals. To be included in the review a study had to:

• Be a primary study rather than, for example, a guideline or review
• Take place in an Established Market Economy
• Be written in English
• Meet the team’s definitions of the recommended and strongly recommended interventions
• Use economic analytical methods such as cost analysis, cost-effectiveness analysis, cost-utility, or cost-benefit analysis; and
• Itemize program costs and costs of illness or injury averted

The following considerations are drawn from studies included in the evidence review, the broader literature, and expert opinion. The Community Guide does not conduct systematic reviews of implementation.

• Community-wide education campaigns may produce additional benefits including the following.
  • Through working together communities may develop a greater sense of cohesion and collective self-efficacy.
  • Social networks may be developed or strengthened to achieve intervention goals, and community members may become involved in local government and civic organizations, thereby increasing social capital.
• Community-wide campaigns require careful planning and coordination, well-trained staff, and sufficient resources to carry out the campaign as planned.
• Success is greatly enhanced by community buy-in, which can take a great deal of time and effort to achieve.
• If there are not enough resources, community exposure to messages and other planned campaign interventions may be inadequate to achieve changes knowledge, attitudes, or behavior over time, especially among high-risk populations.

Evidence-Based Cancer Control Programs (EBCCP)

Find programs from the EBCCP website that align with this systematic review. (What is EBCCP?)

Healthy People 2030

Healthy People 2030 includes the following objectives related to this CPSTF recommendation.

• Reduce the proportion of adults who do no physical activity in their free time — PA‑01
• Increase the proportion of adults who do enough aerobic physical activity for substantial health benefits — PA‑02
• Increase the proportion of adults who do enough aerobic physical activity for extensive health benefits — PA‑03
• Increase the proportion of adults who do enough aerobic and muscle-strengthening activity — PA‑05