PRACTICAL APPLICATION

Appl Health Econ Health Policy 2008; 6 (4): 173-187 1175-5652/08/0004-0173/$48.00/0

ª 2008 Adis Data Information BV. All rights reserved.

Community-Based Interventions to Promote Increased Physical Activity A Primer Melissa Bopp and Elizabeth Fallon Department of Kinesiology, Kansas State University, Manhattan, Kansas, USA

Contents Abstract. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1. Rationale for Physical Activity Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. The Formative Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1 Theory-Based Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. Considerations for Appropriate Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.1 Healthcare Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.1.1 Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.1.2 Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.1.3 Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2 Faith-Based Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2.1 Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2.2 Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2.3 Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.3 Worksites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.3.1 Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.3.2 Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.3.3 Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.4 Schools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.4.1 Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.4.2 Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.4.3 Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4. Community-Based Approaches. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.1 Benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.2 Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.3 Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5. Considerations for Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.1 Small- versus Large-Group Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.2 Delivery Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.3 Intervention Components . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6. Considerations for Measurement and Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.1 Physical Activity Measurement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.1.1 Self-Report Surveys. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.1.2 Objective Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.1.3 Physiological Assessments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.2 Determining Intervention Success . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.3 Process Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

174 174 175 175 176 177 177 177 178 178 178 178 178 179 179 179 179 179 179 179 180 180 180 180 180 181 181 181 181 182 182 182 182 183 183 183 184

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Abstract

Current recommendations, based on an abundance of empirical data documenting the impact of physical activity (PA) on preventing morbidity and mortality associated with common chronic diseases, indicate that adults should accumulate 30 minutes of moderate-intensity PA ‡5 days per week. However, worldwide rates of PA remain low, indicating a great need for large-scale implementation of evidence-based PA interventions. We briefly present practical aspects of intervention planning, implementation and evaluation within common community settings. The first stage of intervention planning is formative research, which allows for a better understanding of the elements needed for a successful intervention. Partnering with community settings (schools, worksites, faithbased organizations and healthcare organizations) offers many benefits and the opportunity to reach specific populations. Setting-based approaches allow for multilevel strategies, ranging from individual-based programmes and educational initiatives to physical and social environmental changes. Various settings such as healthcare, worksite, and school- and community-based settings are discussed. Intervention delivery methods and strategies can range, depending on the population and setting targeted, from small-group approaches to mediated methods (e.g. print, telephone, electronic). The final phase of intervention planning and implementation is evaluation. Several objective and subjective methods of PA assessment are available to determine the effectiveness of the intervention. We have highlighted the need for process evaluation of intervention implementation to provide valuable information for the dissemination and sustainability of successful interventions. Although there are numerous considerations for the design, implementation, assessment and evaluation of PA interventions, the potential for positive impact on the overall health of the public indicates the necessity for programmes designed to increase PA.

1. Rationale for Physical Activity Interventions Worldwide, recommendations for physical activity (PA) indicate that individuals should accumulate 30 minutes of moderate-intensity PA ‡5 days per week.[1] This recommendation is based on strong empirical evidence showing a robust effect of regular PA for the prevention and treatment of obesity, cardiovascular disease, diabetes mellitus, cancer, and depression and other mental health problems.[2,3] Despite the documented benefits of regular PA, self-report data indicate suboptimal rates of PA in many countries.[4-7] Recent objective data within the US revealed that <5% of adults regularly meet recommendations ª 2008 Adis Data Information BV. All rights reserved.

for PA.[8-10] Furthermore, the WHO estimates that 1.9 million deaths annually result from physical inactivity, mainly due to closely related chronic diseases.[11] With such high rates of inactivity and the strong link with chronic disease, the direct and indirect costs of inactivity are substantial. In 1999, direct costs in Canada were estimated at $Can2.1 billion,[12] and in 2001, total costs in Canada were $Can5.3 billion per year ($Can1.6 billion in direct costs and $Can3.7 billion in indirect costs[13]). In the US, estimates of direct costs associated with physical inactivity range between $US5.4 billion (year 1996 values)[14] and $US24.3 billion (year 1995 values) per year.[15] Data from the UK suggest that d1.06 billion Appl Health Econ Health Policy 2008; 6 (4)

Community-Based Physical Activity

(year 2004 values) in healthcare costs per year are due to physical inactivity.[16] Fortunately, PA interventions are generally cost effective. Specifically, a recent review found that PA interventions were successful at encouraging participants to meet current PA recommendations at a cost of approximately h800 per year, potentially balancing costs associated with inactivity.[17] In the US, cost-effectiveness ratios of community-based PA interventions ranged between $US14 000 and $US69 000 per QALY gained, relative to no intervention.[18] The physical inactivity epidemic, the resulting chronic diseases and economic impact and the cost effectiveness of interventions provide a strong rationale for the continued development and implementation of public health interventions promoting PA. Therefore, we present a brief and practical approach for practitioners administering interventions to increase PA in the community. It is important to note that this is not intended to be a systematic review or critical analysis of the literature on the subject. Specifically, we discuss community engagement, the utility of common intervention settings and considerations for measurement and evaluation of programme effectiveness. 2. The Formative Process The formative and planning phases of an intervention are often the most difficult and tedious. However, without a thorough formative process, intervention messages and activities may be overlooked, ignored, misunderstood and poorly attended by the target population. Thus, although it is difficult to attain financial funding for formative research, and formative work is commonly misperceived as unnecessary, less valuable and inherently less exciting than implementation, a well thought-out formative process is imperative for the development and implementation of effective PA interventions. When conducting the formative phase of intervention planning, it is important to collect both quantitative and qualitative information. State and local statistics may already be available through national or state surveillance systems,[19-21] ª 2008 Adis Data Information BV. All rights reserved.

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local health departments and health clinics. In the event that information required is not available through these channels, it may also be collected via a health assessment fair, where individuals in the community can be recruited to complete self-report surveys and receive free health assessments (e.g. blood pressure, cholesterol, fasting blood glucose, etc). Of particular interest when examining the quantitative data is the identification of a target audience. Although prevalence of physical inactivity is high in all populations, health-behaviour interventions targeting high-risk subgroups are of better value than interventions targeting the general population.[22] After documenting quantitative health information, qualitative information should be gathered from community members to better understand the community’s unique attitudes, values and beliefs about PA, health and disease. This is usually accomplished using individual or group interviews, where a trained interviewer or facilitator asks open-ended questions of the target population. A group’s overall feelings and perceptions towards PA, health and disease may be shaped by many factors including age, race/ ethnicity, sex, socioeconomic status, geographic location, social and cultural norms, religious beliefs, family roles, body mass index and medical history. Based on this information, more effective recruitment, retention and intervention activities are possible, ultimately creating a greater change in PA among the participants. 2.1 Theory-Based Interventions

Although formative research is important for building effective interventions, the information gathered is best applied within a theoretical framework. Theories are useful for guiding programme planning, implementation and evaluation. Furthermore, theory-based interventions are more effective than non-theory-based interventions.[23] Thus, it is worthwhile for practitioners to carefully review the most prominent theories and models, and choose the model that best suits the situation and resources available. The ‘transtheoretical model’, ‘theory of planned behaviour’, ‘social cognitive theory’ and ‘social Appl Health Econ Health Policy 2008; 6 (4)

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ecological model’ have all been shown to be effective for programme planning, implementation and evaluation of PA interventions. For a brief overview of these and several other theories, the National Cancer Institute at the US Department of Health and Human Services has published Theory at a Glance: A Guide for Health Promotion Practice.[24] 3. Considerations for Appropriate Settings Taking into account the values, beliefs and PA preferences of the target population, attention should be turned to discussing the advantages and disadvantages of potential intervention settings. Settings can range from simple and small (e.g. homes) to large and complex (e.g. worksites). Thus, interventionists should take great care in matching the target population with the setting that will maximize reach and effectiveness. Conducting PA interventions within existing settings may offer many benefits. In most settings there is an established system for flow of information (emails, newsletters and websites), delegation of responsibilities, and established protocols for scheduling and facility use. Some larger settings may also have individuals or departments (e.g. human resources departments) specifically employed to create, modify and promote health-related policies and procedures. After identification and careful examination of how the existing systems operate, a PA intervention can be constructed such that it can be seamlessly integrated into these systems. Other advantages of partnering with settings to offer PA interventions include access to safe and well maintained buildings and properties for holding activities, greater likelihood of affecting subgroups of the population that may otherwise be difficult to reach and increased potential for sustainability of the intervention by training individuals within the setting to conduct the intervention. Perhaps the most valuable advantage afforded by intervening through settings is the ability to target the multiple levels of factors influencing PA. Individual-level factors can be targeted using educational materials and classes ª 2008 Adis Data Information BV. All rights reserved.

that improve knowledge, goal setting and problem solving. Mediated approaches targeting these behavioural skills, including telephone counselling, printed materials, or electronic media such as email and websites, have commonly been used in conjunction with setting-based approaches, or on their own.[25] Social-level factors can be changed within setting-based approaches using intervention components that enhance social support for PA. It is also possible to impact policies and physical environment, thereby making the setting more activity friendly. Taking this multi-level approach increases the impact of an intervention by reaching those who want to increase their PA as well as those who have not considered it. While there are numerous benefits to settingbased interventions, there are also some common challenges. It can be difficult to establish trusting, respectful partnerships within community settings. Many people may be sceptical of the intervention itself or suspicious of ‘outsiders’ who may be seen to have ulterior motives. There may be individuals or groups within the setting who have had unpleasant experiences with partnership in the past, or are not interested in a programme that may not be sustainable over the long term. For these reasons, a significant amount of time may be needed to address these concerns to ensure a successful and trusting partnership. Another common challenge for PA interventions is how to best fit the intervention components into the setting’s existing organizational structure and culture. There is likely to be frequent scheduling conflicts and ongoing negotiation of responsibilities and resources. It can be difficult for those organizing the PA intervention to remain open minded and flexible without sacrificing essential intervention elements critical to the effectiveness of the PA programme. Every setting offers unique benefits, challenges and approaches for PA interventions. Specific details for the most commonly used settings are presented, and table I provides a brief list of recommended readings sorted by setting and target population. Appl Health Econ Health Policy 2008; 6 (4)

65 54,58,60 59,61,62

67

57-60 56

50 50 50

38 37

45

29 27,28

Healthcare settings are logical settings for PA promotion programmes because of their healthoriented context. Patients typically expect to discuss health conditions and health-related behaviours while visiting their healthcare provider. Additionally, healthcare providers are generally seen as trusted and knowledgeable sources of health information, having positive attitudes toward health issues and possessing knowledge and skills for health promotion.[68,69] Because of the frequency of healthcare provider office visits (an average of 2–3 visits per year),[70,71] and the continuity of provider-patient relationships, the potential impact of these messages is elevated. A recent review indicated that PA counselling interventions targeting healthcare providers have substantial potential to be cost effective compared with interventions in general community settings.[17]

25,64 51

Worksite

Mediated approaches

42,43 School-based

ª 2008 Adis Data Information BV. All rights reserved.

Community-based

33 32 Healthcare

44

26 Faith-based

65,66

54,55 52,53

50

34,35

47-49

36

older adults

37

3.1.2 Challenges

adults adolescents

54,63

32,41 37,39,40

28-30

Latino low income

African American

rural

women

46

31

3.1.1 Benefits

children

Population Setting

Table I. References for recommended reviews and examples of physical activity interventions by setting and target population

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3.1 Healthcare Settings

clinical

Native American/ Pacific Islanders

Community-Based Physical Activity

Time and financial resources present great challenges to PA promotion programmes in healthcare settings. Healthcare providers have busy schedules and most report difficulty making time for PA counselling during patient examinations.[72] Additionally, in some countries, insurance companies reimburse for treatment-related services, not prevention-related services. This may result in little-to-no incentive for providers to begin PA counselling. Another potential challenge is the limited training and education about PA counselling within healthcare-provider training programmes or medical schools. Thus, providers may not be adequately familiar with prescribing appropriate amounts of PA (frequency, duration, type, intensity), and where they feel less confident in their abilities, they may shy away from educating and counselling their patients. Finally, like many individuals, healthcare providers may not be as physically active as they would like to be and therefore may not feel comfortable recommending PA as a prevention and treatment strategy.[72,73] Appl Health Econ Health Policy 2008; 6 (4)

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3.1.3 Approaches

The nature of healthcare settings dictates that the majority of approaches will be individually based. This approach typically involves a healthcare provider offering brief (<5 minutes) oneon-one counselling for PA, tailored on some factors (e.g. stage of readiness for change, age, sex matched). When possible, other activities should be implemented that reinforce the messages delivered by healthcare providers. These activities may include mailings to follow-up on the PA message, small group-based behaviourchange classes and individually tailored telephone/ internet approaches. A study examining the cost effectiveness of PA counselling in New Zealand general practice found a monthly cost-effectiveness ratio for total energy expenditure of $NZ11/kcal/kg/day in a sample of middle-aged adults.[74] This nationwide study provided evidence that brief advice on PA from a healthcare provider has a potentially significant economic impact, as well as the potential to result in clinically significant improvements in health-related outcomes. 3.2 Faith-Based Settings 3.2.1 Benefits

Faith communities serve individuals of all ages, ethnic groups and socioeconomic status, and offer an opportunity to target families and multicultural groups. Faith-based organizations have extensive experience in organizing programmes and activities, often serve as a focal point or social centre in the community, have facilities that can be used for PA programmes, provide a marketing outlet (e.g. Sunday bulletins), offer an existing social-support network, and are generally concerned with the well-being of their members and the community.[75] When appropriate, these settings may also offer the opportunity to deliver culturally relevant interventions, increasing acceptability and participation in the intervention. Additionally, the faith leader is often well respected by church members and can provide positive influence for participation and sustainability of PA promotion programmes. ª 2008 Adis Data Information BV. All rights reserved.

3.2.2 Challenges

Faith-based settings are often charged with addressing a variety of issues and it can be difficult for PA programmes to compete for the time and attention of members. Additionally, many PA programmes rely heavily on unpaid church volunteers to deliver intervention activities. While there are cases where this has been largely successful, there are others where the PA programme becomes unduly burdensome for the volunteers. To prevent volunteer burnout, it may be useful to recruit and train a team of volunteers and establish a process whereby the leadership role is rotated among members in an effective and equitable manner.[27,76] Another important consideration is whether the incorporation of health messages into the beliefs, values and mission of a faith-based organization is acceptable to church leaders and members. While some faith-based organizations may embrace health promotion as central to their mission, others may reject it as a misuse of their religion, values and belief systems. Thus, it is imperative to address this issue thoroughly during the formative process and to form a committee of church leaders and members to help guide the intervention messages and activities. 3.2.3 Approaches

Common approaches include educational activities reflecting the ethnic and cultural make-up of the congregation and incorporating the faith’s values and beliefs. Typically, ‘action-oriented’ programmes are also developed to offer the opportunity to participate in PA programmes (e.g. aerobics classes, walking clubs) alongside other church members.[77] Since faith-based settings already offer structured physical and social environments, there may be an opportunity to target these levels of influence. Within the social environment, approaches could include church leaders (e.g. Priest, Pastor, Rabbi) endorsing PA or intervention activities.[28] Church policies may also be instated to require an ‘exercise break’ during meetings or offering PA at institutional events (e.g. picnics or gatherings) to offer a chance for individuals to walk, stretch or take part in group exercises. Appl Health Econ Health Policy 2008; 6 (4)

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3.3 Worksites 3.3.1 Benefits

Worksite-based interventions offer the opportunity to reach large and diverse populations in a setting in which they spend a lot of time. Worksites provide physical spaces where programmes can be carried out, ranging from small rooms to deliver educational classes to larger rooms for actual PA. They also provide an established social structure that may facilitate social support for PA and, occasionally, human resources staff who are responsible for medical and safety issues. Furthermore, most individuals hold a job for several years, potentially offering the opportunity to engage an employee through several intervention components over time. Additionally, in situations where employers pay for all or large parts of their employees’ healthcare, the employer may have a vested interest in offering PA programmes to reduce employee healthcare costs. Those employers who do not pay for employee healthcare may value the reductions in rates of illness, injuries and job-absenteeism, increases in productivity, morale and employee retention, and improvement of corporate image. Specifically, one study found the total net costs of a health behaviour intervention were h305 per participant, while the benefits from sick leave reduction were estimated at h635 per participant (year value not stated).[78] 3.3.2 Challenges

Despite documented benefits of PA promotion at worksites,[47] many employers and supervisors may not be aware or convinced of the benefits of PA interventions. Furthermore, they may not be willing to impose PA policies on employees who may not want to change their PA behaviours. Those employees inclined to engage in worksite PA programmes may struggle with a lack of adequate facilities and the social norms of their work environment (e.g. expectations to work through lunch or work longer hours). 3.3.3 Approaches

The most successful worksite interventions have included individually tailored or smallgroup behaviour modification approaches.[47] ª 2008 Adis Data Information BV. All rights reserved.

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Facilitation of social support for PA through team-based walking competitions can be effective in providing motivation in the short term, while environmental approaches such as construction of walking trails, locker rooms and point-ofdecision prompts (e.g. signs near the elevator indicating the health benefits of stair use) may be more effective in the long term. 3.4 Schools 3.4.1 Benefits

A large number of children are enrolled and attend school outside of the home; as a result, school-based interventions offer the opportunity to reach a large and diverse population of children and adolescents in a single setting. This approach also allows for targeting of young individuals who are developing attitudes, beliefs and behavioural habits. Similar to other settings, schools offer existing facilities and social structures to support PA messages and programmes. Additionally, many schools may already offer physical education, health education, and various clubs and after-school programmes where PA messages and activities are already delivered or could be incorporated. Because these programmes take place on school property, the school also has the potential to become a community focal point where volunteers, parents and children can come together to address physical inactivity. 3.4.2 Challenges

Financial resources for physical education, sports and recreation are often limited, requiring athletics programmes to be partially or completely self-financed and often eliminating physical education and after-school recreation programmes. Teachers have enormous time burdens for delivering content-based curricula, and additional PA-related programmes may be difficult to incorporate. For schools offering physical education, many curricula are centred on acquiring and mastering sports-related knowledge and skills. Thus, children may spend much of their time waiting in lines for their turn on a given task. This focus on competitive sport can also lead to a dislike of PA Appl Health Econ Health Policy 2008; 6 (4)

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for children who are uncomfortable with competition or who lack the skills to be successful. In addition to economic and curriculum constraints, parents, teachers and administrators may believe it is in the best interests of the children to reduce recreation and PA to focus on homework and academically related after-school activities. Thus, although children may want to take part in sports and recreation, their control over this decision may be influenced by adults. 3.4.3 Approaches

The most successful approach for increasing PA within schools is altering existing physical education programmes to encourage increased moderate- to vigorous-intensity PA.[42,43] Common strategies are to encourage games in which most or all of the students are moving at a moderate intensity, limit games in which children stand or sit and alter ‘elimination’ or ‘knock-out’ games (e.g. dodge ball, tag) so the child can reenter the game after doing some sort of physically active task.[42] Environmental approaches may also be successful for increasing PA in school settings.[44] For example, offering a variety of playground equipment, tailoring activities and equipment to age and sex, and incorporating new kinds of games and activities, such as physically active video games, alters the environment in which children spend a significant amount of time. For schools with limited space and play equipment, policy changes such as mandating 10-minute PA breaks a few times a day in classrooms, encouraging active transportation to and from school, and PA promotion within the curriculum can also be effective. 4. Community-Based Approaches Community-based approaches involve community members and leaders from various settings and organizations coming together to promote PA in an organized and integrated fashion. They all have the common goal of PA promotion, but by pooling their resources can offer more comprehensive intervention components and reach a larger number of community members ª 2008 Adis Data Information BV. All rights reserved.

collectively than they could by operating independently. Generally, the community is defined in geographical terms (e.g. a city, town or county), but can also be defined by characteristics of the target population (e.g. women, older adults, members of an ethnic minority group). Worldwide, there are hundreds of examples of community-based interventions targeting different age, racial or ethnic groups, or geographical areas using different strategies. Because of their broad nature, it is essential to include members of the community as a part of the intervention design, implementation and evaluation. Community coalitions are commonly used in these largerscale interventions and often result in greater improvements in outcomes than less engaged interventions as well as increased sustainability over time (see table I for some examples). 4.1 Benefits

Using a community-building approach and involving multiple partners contributes to community empowerment, enhances community morale and builds strong foundations for longterm sustainability. The scope and magnitude of a community-based approach affords the opportunity to reach a large number of people. 4.2 Challenges

Successfully reaching large numbers of people may mean losing the ability to individually tailor messages and activities, ultimately resulting in a smaller impact at the individual level. Another challenge is the additional time needed for community partners to agree on what activities should be offered, where they should be offered, who should be in charge of implementation and how to spend the community’s financial resources. 4.3 Approaches

The activities in a community-based intervention will range widely depending on the goals, resources and interests of the community partners. One of the most common approaches is increasing awareness of PA benefits using some Appl Health Econ Health Policy 2008; 6 (4)

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combination of mass media campaigns, weekly educational classes and self-help groups, weekly newspaper columns, community-wide newsletters, enhancing existing facilities (e.g. increasing programmes, extending hours of operation, decreasing fees) or planning and building new facilities or points of access (e.g. building walking trails, extending bicycle lanes).[79] 5. Considerations for Implementation 5.1 Small- versus Large-Group Interventions

PA interventions have been successfully delivered in a variety of settings and targeting a variety of populations.[80] However, it is often difficult to decide whether to intervene with small or large groups. Although formative work may have helped to answer this question, it may also be useful to weigh the benefits and limitations of small- and large-group intervention strategies. Typically, small-group interventions target only 10–20 individuals at a time, often using intensive cognitive-behavioural strategies (e.g. education, behavioural skills training, tailored feedback). This approach is highly effective for increasing PA on an individual level and it can be conducted by volunteer health educators with few financial resources. However, the trade-off may be that a small-group strategy usually relies on individuals from the target group to volunteer for the intervention and has limited utility for affecting individuals least likely to change their behaviour. Additionally, because they are limited to 10–20 individuals at a time, there is limited potential for affecting large numbers of people. Furthermore, if an individual exits the intervention without successfully changing their social-support network and environment to support their lifestyle changes, they are likely to return to a physically inactive lifestyle. Growing from these small-group interventions are community- and setting-based interventions combining some elements from small-group approaches with contextually specific social-, environmental- and policy-level changes to increase PA in a large number of people. The major appeal of large community/setting-based interventions is the prospect of creating a social movement toª 2008 Adis Data Information BV. All rights reserved.

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wards healthy lifestyles that will be sustained over the long term. Specifically, community-level interventions are often associated with changes in social norms, policy and environment in support of PA, which result in long-term change for large numbers of people. However, a frequent trade-off for community interventions is the need for greater buy-in and functional/social support from policy makers, supervisors and other influential leaders. Additionally, the health impact per individual in the target population will likely be smaller than with small-group strategies. A common misconception is that large-group interventions require large financial commitments, but effective low-cost strategies have been documented.[21] 5.2 Delivery Method

Empirical data document the effectiveness of interventions delivered through face-to-face activities, mediated methods (e.g. mailing of print materials, telephone-based health coaching, websites and email) and a combination of these methods.[25] Each of these delivery methods has potential to impact the targeted group, but the delivery method chosen for a specific intervention may be a function of available intervention resources, resources of the target population, and acceptability of a delivery method by the population. For example, although there may be the resources and capability to offer an Internetbased PA intervention programme, a group of elderly individuals living in a retirement community with limited access to or experience with the internet may prefer face-to-face methods or print materials. Thus, if the intervention was delivered via the internet, the reach of the intervention to its target population would be greatly diminished. 5.3 Intervention Components

Thus far, several intervention approaches and components have been mentioned. But it is important to refer PA interventionists to the extensive review of evidence-based intervention strategies conducted by the US Task Force for Community Preventive Services.[80,81] Interventionists can be confident that proper Appl Health Econ Health Policy 2008; 6 (4)

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Table II. US Task Force on Community Preventive Services summary of physical activity intervention recommendations[80]

elsewhere.[82] Table III briefly summarizes considerations for choosing PA measures.

Strongly recommended Community-wide campaigns

6.1 Physical Activity Measurement

School-based physical education Social support interventions in community settings Individually-adapted health behaviour change programmes Creation of or enhanced access to places for physical activity, combined with informational outreach activities Recommended Point-of-decision prompts Insufficient evidence Mass media campaigns Classroom-based education focused on information provision College-based health education and physical education Classroom-based health education focused on reducing television viewing and video game playing Family-based social support

implementation of strategies labelled as ‘recommended’ and ‘strongly recommended’ will have the best chance of producing increases in PA (see table II). Labelling strategies as ‘insufficient evidence’ may not necessarily mean that these intervention strategies will not work, but further investigation and refinement of these strategies is warranted before interventionists can be confident in their effectiveness. 6. Considerations for Measurement and Evaluation Because of the vast amounts of time and money spent on PA interventions, it is important to document the effectiveness of the intervention for the community and key decision makers. Planning for evaluation should occur during the design and planning phase to ensure the evaluation tools are (i) appropriate for the setting; (ii) deemed acceptable by members of the target population; (iii) valid and reliable; and (iv) sensitive enough to measure small changes in behaviour. Planning for adequate financial resources to conduct an appropriate evaluation and weighing the evaluation’s rigor with the cost are also considerations. Although we present some information on PA measurement below, a more detailed discussion of PA measurement is found ª 2008 Adis Data Information BV. All rights reserved.

6.1.1 Self-Report Surveys

Generally, self-report surveys are acceptable to most participants for measuring PA. These surveys range widely in the number of questions and in the type of PA they propose to measure. For example, some surveys assess leisure-time PA,[84] while others are able to capture transportation activity, household activities and occupational activity.[85] It is important to select the measure that matches the type(s) of activity targeted by the intervention. 6.1.2 Objective Measures

Objective measures of PA are also available and financially feasible for most budgets. Highquality step-counters (pedometers) cost $US10–20 and are worn clipped to the waistband, directly over the hipbone. Participants can record their steps daily, or the pedometer can be taped shut, worn for a few days and then the total number of steps recorded. Taping the pedometer shut prevents participants from looking at the pedometer frequently and taking more steps than usual to ‘run-up’ the count. If purchasing pedometers for every person in the target population is not possible, a smaller sample can be used. Accelerometers are an additional option for objectively assessing PA, although they may not be as feasible for some community organizations. These small devices are also worn on the hip in a similar way to pedometers, but measure PA duration and intensity throughout the day, compared with pedometers, which simply give a cumulative daily step count. The devices are also more expensive ($US200–600) and require technical knowledge for processing and analysis. However, these devices give a much more valid measure of PA than other methods and have been used with all age groups.[82,86,87] Another objective PA measurement technique is the collection of direct observation data. This involves a trained individual objectively observing and documenting the PA behaviour targeted Appl Health Econ Health Policy 2008; 6 (4)

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Table III. Physical activity assessment methods[2,82,83] Method

Appropriate groups

Ease of use and analysis

Financial cost

Participant time consumption

Participant burden

Activity specific

Subjective Physical activity diary

Adults, older adults

Moderate

Low

High

High

Yes

Self-report recall survey

Adults, older adults, adolescents

Easy

Low

Low

Low

Yes

Job classification

Adults

Easy

Low

Low

Low

Yes

Behavioural observation

All ages

Moderate

High

High

Low

Yes

Heart rate monitor

All ages

Moderate

High

High

Low

No

Pedometer

Adults, older adults

Easy

Low

Low

Low

No

Accelerometer

All ages

Difficult

High

Low

Low

No

Objective

by the intervention. For example, if a worksite places point-of-decision signs promoting stair use near the elevators, direct observations taken before and after the signs are put up would document changes in the number of individuals taking the stairs instead of the elevator. 6.1.3 Physiological Assessments

The intervention team may also consider using physiological assessments to determine the effectiveness of the intervention. These assessments could be directly related to PA and assess components of fitness that could be affected by the intervention (cardiorespiratory fitness, muscular strength and endurance, flexibility or body composition), for which there are many different types of clinical and field tests.[88] Additionally, other outcome variables related to chronic disease (e.g. cardiovascular disease or diabetes) could be assessed including measurement of blood pressure, blood lipid levels or fasting blood glucose. The intervention team should consider feasibility (time, resource and skills needed) and acceptability by participants prior to including these as a part of an evaluation plan. 6.2 Determining Intervention Success

After compiling measurement information, the intervention team should examine whether the intervention was effective, which some practitioners have found to be a rather ‘grey’ area. For example, improvements in PA may be eviª 2008 Adis Data Information BV. All rights reserved.

dent, but physiological changes in body mass index or blood pressure may not be observed. While some interventionists may be disappointed that they did not see improvements in physiological measurements, it is important to consider that PA changes did occur and that more time may be needed to see changes in physiological measurements. Furthermore, considering that most adults experience ‘creeping’ weight gain over time, an intervention successful in stabilizing weight and other physiological measures can be viewed as a great success. 6.3 Process Evaluation

The envisioned intervention is often slightly (or drastically) different from what was actually implemented. If this is the case, the results may also be different from those expected. Without process evaluation, an intervention team may be left to ponder the discrepancy between expected and actual outcomes. Worse still, they may erroneously conclude that the intervention was completely ineffective and decide to stop the intervention. Process evaluation is information collected during the intervention and used to help understand how well the intervention was delivered and the extent to which participants received it as intended. Traditionally, process evaluation has attempted to capture several key elements, including dose of the intervention delivered by the programme staff as well as that received by participants, reach of the intervention Appl Health Econ Health Policy 2008; 6 (4)

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into the target population, fidelity to original conceptualization of the intervention and context-specific elements (considering the larger social, political and economic environment).[89] For example, process evaluation may offer insight into (i) which components of the intervention were implemented properly (or poorly); (ii) which components were most effective and which could be discontinued; (iii) whether staff members need more training and the type of training needed; and (iv) whether participants were disinterested, did not attend, or did not understand the intended message. Other models of complete programme evaluation examine the greater public health impact of an intervention. The RE-AIM framework of programme evaluation includes assessment of Reach of the intervention, Efficacy or effectiveness of the intervention on outcomes, Adoption of the intervention by organizations or institutions, Implementation of the intervention, and individual- and institutionallevel Maintenance of the intervention and/or behaviour.[90,91] As an example of the importance of process evaluation, assume a PA intervention was delivered successfully at school ‘A’ and was then translated to school ‘B’ but did not have equal success. Without process evaluation information, intervention directors will not be able to explain why the intervention did not work at school ‘B’. However, with process evaluation information, they may have discovered that teachers at school ‘B’ did not believe the intervention would work and failed to implement the intervention activities as frequently as intended. Furthermore, when PA activities were implemented, the teachers used the same activities repeatedly and children became bored and disinterested. Thus, although process evaluation may seem like an unnecessary step in the intervention process, it will provide insight into the intervention’s results. 7. Conclusions Regular PA participation has the potential to have a significant impact both on public health outcomes related to prevention and treatment of chronic diseases and on economic outcomes ª 2008 Adis Data Information BV. All rights reserved.

related to health-related expenditures. Settingbased PA interventions are effective for targeting physical inactivity, although they can be complex, time consuming and associated with many challenges. To maximize existing resources, interventionists should incorporate thorough formative phases and strive for high-quality programme evaluation to provide evidence of the effectiveness of the intervention or provide guiding information for intervention modification. Finally, PA interventionists are encouraged to share their experiences, successes, challenges and lessons learned through conferences and professional journals so their knowledge can be disseminated, ultimately resulting in nationwide and worldwide decreases in physical inactivity and chronic disease. This transfer of knowledge from research to practice and vice versa is an essential element of achieving the greater goal of increased PA worldwide. Acknowledgements No sources of funding were used to assist in the preparation of this article. The authors have no conflicts of interest that are directly relevant to the content of this article.

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Correspondence: Dr Melissa Bopp, Department of Kinesiology, 1A Natatorium, Kansas State University, Manhattan, KS 66506, USA. E-mail: [email protected]

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