Physical Activity: Creation of or Enhanced Access to Places for Physical Activity Combined with Informational Outreach Activities

• In all 10 studies reviewed, creating or enhancing access to places for physical activity was effective in getting people to exercise more.
  • Aerobic capacity: median increase of 5.1% (Interquartile interval [IQI]: 2.8% to 9.6%; 8 study arms)
  • Energy expenditure: median increase of 8.2% (IQI: -2.0% to 24.6%; 3 study arms)
  • Percentage of participants reporting some leisure-time physical activity: median increase of 2.9% (IQI: -6.0% to 8.5%; 4 study arms)
  • Exercise score: median increase of 13.7% (IQI: -1.8% to 69.6%; 6 study arms)
• Most of the studies also reported weight losses or decreases in body fat among program participants.

• Two studies were included in the economic review.
• A 4-year study conducted a cost benefit analysis of a structured physical fitness program for employees of an insurance company that provided exercise classes and health seminars.
  • Program benefits included savings in major medical costs, reduction in average number of disability days, and reduction in direct disability dollar costs.
  • Program costs included personnel, non-salary operating expenses, and medical claims.
  • The adjusted estimates for benefits and costs for 1 year of the program were $1106 and $451, respectively.
• A 5-year study with projections for an additional 10 years was conducted in a workplace setting among 36,000 employees and retirees of an insurance company. Researchers conducted a cost benefit analysis of a company-sponsored health and fitness program that used health promotion centers, newsletters, medical reference texts, videotapes, and quarterly media blitzes.
  • Program benefits included cost savings from healthcare costs averted, absenteeism reduction, deaths averted, and increased productivity.
  • Program costs included personnel, overhead, capital equipment, materials, and rent; employee time away from the job was not included as a program cost.
  • The adjusted estimates for benefits and costs were $139 million and $43 million, respectively.

• What characteristics of a community are necessary for the optimal implementation of policy and environmental interventions?
• Does the effectiveness vary by type of access (e.g., worksite facility or community facility) or socioeconomic group?
• How can the necessary political and societal support for this type of intervention be created or increased?
• Does creating or improving access motivate sedentary people to become more active, give those who are already active an increased opportunity to be active, or both?
• If you build it, will they come? In other words, is enhanced access to places for activity sufficient to create higher physical activity levels, or are other intervention activities also necessary?
• What are the effects of creating new places for physical activity versus enhancing existing facilities?
• Which neighborhood features (e.g., sidewalks, parks, traffic flow, proximity to shopping) are the most crucial in influencing activity patterns?
• How does proximity of places such as trails or parks to residence affect ease and frequency

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?

• Evaluated interventions provided access to weight and aerobic fitness equipment in fitness centers or community centers, created walking trails, or provided access to nearby fitness centers.
• In addition to promoting access, many of these studies incorporated components such as training on equipment, health behavior education and techniques, seminars, counseling, risk screening, health forums and workshops, referrals to physicians or additional services, health and fitness programs, and support or buddy systems.
  • These multicomponent interventions were evaluated together because it was not possible to separate out the incremental benefits of each component.
• All of the studies were conducted in the United States.
• Studies were conducted at worksites, which included industrial plants (automotive, brewing, printing), universities, and federal agencies (8 studies), or in low-income communities (2 studies).

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.

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?. 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

Bertera RL. Behavioral risk factor and illness day changes with workplace health promotion: two-year results. Am J Health Promot 1993;7:365 73.

Blair SN, Piserchia PV, Wilbur CS, Crowder JH. A public health intervention model for work-site health promotion. Impact on exercise and physical fitness in a health promotion plan after 24 months. JAMA 1986;255:921 6.

Brownson RC, Smith CA, Pratt M, et al. Preventing cardiovascular disease through community-based risk reduction: the Bootheel Heart Health Project. Am J Public Health1996;86:206 13.

Heirich MA, Foote A, Erfurt JC, Konopka B. Work-site physical fitness programs: comparing the impact of different program designs on cardiovascular risks. J Occup Med 1993;35:510 7.

Henritze J, Brammell HL, McGloin J. LIFECHECK: a successful, low touch, low tech, in-plant, cardiovascular disease risk identification and modification program. Am J Health Promot1992;7:129 36.

King AC, Carl F, Birkel L, Haskell WL. Increasing exercise among blue-collar employees: the tailoring of worksite programs to meet specific needs. Prev Med 1988;17:357 65.

Larsen P, Simons N. Evaluating a federal health and fitness program: indicators of improving health. AAOHN J 1993;41:143 8.

Lewis CE, Raczynski JM, Heath GW, Levinson R, Hilyer JJ, Cutter GR. Promoting physical activity in low-income African-American communities: the PARR project. Ethn Dis 1993;3:106 18.

Linenger JM, Chesson CV, Nice DS. Physical fitness gains following simple environmental change. Am J Prev Med 1991;7:298 310.

Ostwald SK. Changing employees’ dietary and exercise practices: an experimental study in a small company. J Occup Med 1989;31:90 7.

Economic Review:

Bowne DW, Russell ML, Morgan JL, Optenberg SA, Clarke AE. Reduced disability and health care costs in an industrial fitness program. J Occup Med 1984;26:809 16.

Golaszewski T, Snow D, Lynch W, Yen L, Solomita D. A benefit-to-cost analysis of a work-site health promotion program. J Occup Med 1992;34(12):1164 72.

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

• Creation of or enhanced access to facilities is time and resource intensive. It requires careful planning and coordination, as well as resources sufficient to carry out the construction.
• Success is greatly enhanced by community buy-in, which can take a great deal of time and effort to achieve.

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 and muscle-strengthening activity — PA-05
• Increase the proportion of children who do enough aerobic physical activity — PA-09
• Increase the proportion of adolescents who do enough aerobic physical activity — PA-06