Effectiveness of physical activity promotion based in primary care: systematic review and meta-analysis of randomised controlled trials

In the paper

“Most studies selected participants for sedentary behaviour, but the percentage meeting recommended guidelines for physical activity at baseline ranged from 0%19 20 to 44%18 in the nine studies reporting this outcome.”

What the sources say

• Not checked yetcites [18] Van Sluijs EM, van Poppel MN, Twisk JW, Chin APM, Calfas KJ, van MW. Effect of a tailored physical activity intervention delivered in general practice settings: results of a randomized controlled trial. Am J Public Health 2005; 9510: 1825-31. PMC1449443 16186461
• Not checked yetcites [19] Jimmy G, Martin BW. Implementation and effectiveness of a primary care based physical activity counselling scheme. Patient Educ Couns 2005; 56: 323-31. 15721975
• Not checked yetcites [20] Harrison RA, Roberts C, Elton PJ. Does primary care referral to an exercise programme increase physical activity one year later? A randomized controlled trial. J Public Health 2004; 271: 25-32. 15564275

In the paper

“Data for self reported physical activity were collected in 14 studies using various assessment tools, including questionnaires or logbooks either self administered or administered by an interviewer (table 4).”

In the paper

“In four trials reporting cardiorespiratory fitness, a medium positive effect at 12 months was non-significant (standardised mean difference 0.51, −0.18 to 1.20).”

In the paper

“We included 15 trials (n=8745).”

• Also stated in: § Study and participant characteristics · plain

  “In 15 trials, 8745 participants aged between 17 and 92 years were randomised.”

In the paper

“Most interventions took place in primary care, included health professionals in delivery, and involved advice or counselling given face to face or by phone (or both) on multiple occasions.”

• Also stated in: § Intervention characteristics · plain

  “Primary care doctors or nurses were involved in eight studies; physiotherapists in two studies; and health visitors, health educators, health counsellors, health promotion specialists, or trained facilitators from a range of health professions in a further five studies.”

In the paper

“Only three trials investigated exercise referral.”

• Also stated in: § Intervention characteristics · plain

  “Of the three exercise referral studies, one involved referral to a leisure centre based programme, one to a community walks programme, and one involved small group exercise sessions at an unspecified location.”

In the paper

“In two studies, they related to whether participants had increased their level of physical activity from baseline.26 27”

What the sources say

• Not checked yetcites [26] Harland J, White M, Drinkwater C, Chinn D, Farr L, Howel D. The Newcastle exercise project: a randomised controlled trial of methods to promote physical activity in primary care. BMJ 1999; 319: 828-32. 10496829 PMC314213
• Not checked yetcites [27] Chambers R, Chambers C, Campbell I. Exercise promotion for patients with significant medical problems. Health Educ J 2000; 59: 90-8.

In the paper

“All studies reported outcome data at 12 months after randomisation, apart from one19 reporting at 14 months, and another28 reporting at 24 months.”

What the sources say

• Not checked yetcites [19] Jimmy G, Martin BW. Implementation and effectiveness of a primary care based physical activity counselling scheme. Patient Educ Couns 2005; 56: 323-31. 15721975
• Not checked yetcites [28] The Writing Group for the Activity Counseling Trial Research Group. Effects of physical activity counseling in primary care: the activity counseling trial: a randomized controlled trial. JAMA 2001; 286: 677-87. 11495617

In the paper

“Only one study found a significant intervention effect on adverse events, reporting a relative 11% increase in falls and a 6% increase in injuries among intervention participants between baseline and 12 months’ follow-up, compared with control participants.21”

What the sources say

• Not checked yetcites [21] Lawton BA, Rose SB, Elley CR, Dowell AC, Fenton A, Moyes SA. Exercise on prescription for women aged 40-74 recruited through primary care: two year randomised controlled trial. BMJ 2008; 337: a2509. 19074218 PMC2769033

In the paper

“In the six studies that compared physical activity promotion to no intervention, we saw a medium, positive, and significant intervention effect on self reported physical activity at 12 months (odds ratio 1.74 (95% confidence interval 1.39 to 2.18), I2=21% (0% to 71%); standardised mean difference 0.36 (0.28 to 0.43), I2=0% (I2 0% to 61%)).”

In the paper

“Nine studies reported the proportion of participants meeting recommended levels of physical activity at baseline and 12 months (or at the next available time point, if 12 month data were not available).”

In the paper

“Eleven studies reported positive intervention effects on self reported physical activity at 12 months; these effects were significant in six studies.”

In the paper

“a sensitivity analysis showed that this was attributable to one outlying study with strong positive results,31 without which heterogeneity was low (I2=0%).”

• Also stated in: § Summary and interpretation of findings · hedged

  “The effect sizes showed high heterogeneity, and sensitivity analyses suggested that this was attributable to one outlying study with strong positive findings.31”

What the sources say

• Not checked yetcites [31] Petrella RJ, Koval JJ, Cunningham DA, Paterson DH. Can primary care doctors prescribe exercise to improve fitness?: The step test exercise prescription (STEP) project. Am J Prev Med 2003; 24: 316-22. 12726869

In the paper

“In the meta-analysis of continuous physical activity data (fig 4), removal of two studies that did not present an outcome measure for total activity reduced the pooled effect estimate but did not affect the direction or significance of the findings (standardised mean difference 0.20 (0.05 to 0.35), I2=72% (18% to 85%)).”

In the paper

“The pooled standardised mean difference had a medium effect size but was non-significant (0.51 (95% confidence interval −0.18 to 1.20); fig 5). Heterogeneity was high (I2=97% (96% to 98%))”

• Also stated in: § Summary and interpretation of findings · plain

  “Only four trials reported cardiorespiratory fitness and pooled analysis showed no significant effect.”

In the paper

“A third study used a no intervention control, and found small to medium sized positive effects on self reported activity, which were significant for continuous (frequency of exercise sessions) but not dichotomous data (proportion of participants who had become more active from study entry).27”

What the sources say

• Not checked yetcites [27] Chambers R, Chambers C, Campbell I. Exercise promotion for patients with significant medical problems. Health Educ J 2000; 59: 90-8.

In the paper

“The additional percentage of participants who reported meeting international activity recommendations at 12 months, compared with baseline, was 11-47% in participants allocated to receive an intervention, and 8-47% in those allocated to receive a comparator intervention. The corresponding range for those allocated to receive no intervention was from −2% to +19% (fig 8).”

In the paper

“Three studies examined exercise referral interventions.20 27 36”

What the sources say

• Not checked yetcites [20] Harrison RA, Roberts C, Elton PJ. Does primary care referral to an exercise programme increase physical activity one year later? A randomized controlled trial. J Public Health 2004; 271: 25-32. 15564275
• Not checked yetcites [27] Chambers R, Chambers C, Campbell I. Exercise promotion for patients with significant medical problems. Health Educ J 2000; 59: 90-8.
• Not checked yetcites [36] Lamb SE, Bartlett HP, Ashley A, Bird W. Can lay-led walking programmes increase physical activity in middle aged adults? A randomised controlled trial. J Epidemiol Community Health 2002; 56: 246-52. 11896130 PMC1732126

In the paper

“For both dichotomous and continuous data, we found significant differences in effect size between these two sets of studies (dichotomous data, χ²=6.9 df=1, P=0.008; continuous data, χ²=21.7, df=1, P<0.00001).”

• Also stated in: § Summary and interpretation of findings · plain

  “A planned subgroup analysis showed significantly larger intervention effects on self reported activity in studies where control participants received no intervention than where they received a comparator intervention.”

In the paper

“Four studies reported cardiorespiratory fitness.”

In the paper

“At a review level, our search was systematic but we did not identify any unpublished trials.”

In the paper

“Although all the interventions in our review are potentially reproducible in real life settings in primary care, most involved multiple contacts over time.”

In the paper

“Trial personnel or outcome assessors were not blinded to allocation in five studies, and management of incomplete outcome data was inadequate in six studies.”

In the paper

“Furthermore, no additional studies were identified by an independent expert on the topic.”

In the paper

“The funnel plots did not suggest publication bias, although these plots are difficult to interpret with a small number of studies.”

In the paper

“Two reviewers independently assessed studies for inclusion, appraised risk of bias, and extracted data.”

• Also stated in: § Search methods, study selection, and data extraction · plain

  “Two reviewers (GO and SSu) assessed retrieved papers independently.”

In the paper

“We adjusted for clustering in two studies18 29 by calculating the effective sample size.37”

What the sources say

• Not checked yetcites [37] Higgins JPT, Green S, eds. Cochrane Handbook for Systematic Reviews of Interventions version 5.0.2 (updated September 2009). Chapter 16.3.4. Cochrane Collaboration, 2009.

In the paper

“Five prespecified meta-analyses were conducted using a random effects model in RevMan.”

In the paper

“Sensitivity analyses explored effects of decisions about outcome selection and design effects. These analyses were planned after data extraction but before undertaking the meta-analyses.”

In the paper

“Blinding of participants to study group allocation was achieved in one study, not achieved in one, not reported in seven, and not possible in six (in which control participants received no intervention).”

In the paper

“A third reviewer (ALK) resolved any conflicts.”

In the paper

“If a study presented both a trial completers’ analysis and a full intention to treat analysis using imputed values, we used the intention to treat analysis.”

In the paper

“Assessing the sustainability of impact of interventions is important, because observational research shows that the health benefits of physical activity are lost with reversion to a sedentary lifestyle.16”

What the sources say

• Not checked yetcites [16] Paffenbarger RS Jr, Wing AL, Hyde RT. Physical activity as an index of heart attack risk in college alumni. Am J Epidemiol 1978; 108: 161-75. 707484

In the paper

“Alternatively, social desirability bias could explain why control participants who received an intervention reported more activity at 12 months than those who received no intervention.”

In the paper

“Self reported achievement of these activity levels was associated with a 19% reduction in the rate of all cause mortality, compared with sedentary behaviour, in a large meta-analysis of cohort studies.2”

What the sources say

• Not checked yetcites [2] Woodcock J, Franco OH, Orsini N, Roberts I. Non-vigorous physical activity and all-cause mortality: systematic review and meta-analysis of cohort studies. Int J Epidemiol 2011; 40: 121-38. 20630992

In the paper

“The United Kingdom’s chief medical officers recommend that adults undertake at least 150 minutes of moderate intensity activity each week.1”

What the sources say

• Not checked yetcites [1] Chief medical officers of England, Scotland, Wales and Northern Island. Start active, stay active: a report on physical activity from the four home countries’ chief medical officers. Department of Health, 2011.

In the paper

“This absence of effect could have been due to the small number of studies recruiting through primary care that reported fitness data, three of which also found no significant effect on self reported physical activity.”

In the paper

“A Cochrane systematic review of interventions to promote physical activity in community dwelling adults showed a moderate effect on self reported physical activity and cardiorespiratory fitness at a minimum of six months of follow-up.17”

What the sources say

• Not checked yetcites [17] Hillsdon M, Foster C, Thorogood M. Interventions for promoting physical activity. Cochrane Database Syst Rev 2005; 1: CD003180. 15674903 PMC4164373

In the paper

“The UK has seen a marked expansion in exercise referral schemes over the past two decades,24 but there are concerns that these might not produce sustained changes in physical activity beyond the typical programme length of 12 weeks.25”

What the sources say

• Not checked yetcites [24] Labour Research Department. Exercise on prescription: a report for the Chartered Society of Physiotherapists. Labour Research Department, 2004.

In the paper

“In developed countries, 70-80% of adults visit their general practitioner at least once a year,6 and patients are interested in discussing health promotion issues with primary care health professionals.7”

What the sources say

• Not checked yetcites [7] Stott NC, Pill RM. “Advise yes, dictate no.” Patients’ views on health promotion in the consultation. Fam Pract 1990; 7: 125-31. 2369980

In the paper

“We found no effect of interventions on cardiorespiratory fitness at 12 months across four trials, by contrast with the systematic review by Hillsdon and colleagues, which identified a positive effect on fitness at a minimum of six month follow-up.17”

What the sources say

• Not checked yetcites [17] Hillsdon M, Foster C, Thorogood M. Interventions for promoting physical activity. Cochrane Database Syst Rev 2005; 1: CD003180. 15674903 PMC4164373

In the paper

“Yet only 39% of men and 29% of women achieved these levels in the 2008 Health Survey for England.3”

What the sources say

• Not checked yetcites [3] Joint Health Surveys Unit. Health survey for England 2008. Physical activity and fitness. The Stationery Office, 2009.

In the paper

“The best estimate of the number needed to treat with a physical activity promotion intervention for one additional sedentary adult to report recommended levels of activity at 12 months was 12, which compares favourably to the estimated numbers needed to treat of 50-120 for smoking cessation advice.8”

What the sources say

• Not checked yetcites [8] Stead LF, Bergson G, Lancaster T. Physician advice for smoking cessation. Cochrane Database Syst Rev 2008; 2: CD000165. 18425860

In the paper

“Furthermore, participants in the included trials could have been more motivated to increase their physical activity than the primary care populations from which they were recruited.”

In the paper

“Cost effectiveness was not assessed in this review, but recent research suggests that most physical activity interventions based in primary care have comparable cost effectiveness to funded pharmaceutical interventions.44”

What the sources say

• Not checked yetcites [44] Garrett S, Elley CR, Rose SB, O’Dea D, Lawton BA, Dowell AC. Are physical activity interventions in primary care and the community cost-effective? A systematic review of the evidence. Br J Gen Pract 2011; 61: 125-33. PMC3047345 21375895

In the paper

“It is difficult to conceal the study group from participants in physical activity trials, and self reported measures are therefore susceptible to differential social desirability bias, which could inflate estimates of intervention effect.”

In the paper

“Removal of these data in a sensitivity analysis led to an increase in the pooled intervention effect on self reported physical activity that retained statistical significance, suggesting that the decision to include these studies in the main analysis led, at worst, to an underestimation of the pooled intervention effect.”

In the paper

“Our findings extend the evidence from two previous systematic reviews of community based interventions17 41 in two ways. Firstly, we included only studies recruiting through primary care to more directly inform commissioning in general practice. Secondly, we included studies with longer follow-up to inform sustainability of effect.”

What the sources say

• Not checked yetcites [17] Hillsdon M, Foster C, Thorogood M. Interventions for promoting physical activity. Cochrane Database Syst Rev 2005; 1: CD003180. 15674903 PMC4164373
• Not checked yetcites [41] Muller-Riemenschneider F, Reinhold T, Nocon M, Willich SN. Long-term effectiveness of interventions promoting physical activity: a systematic review. Prev Med 2008; 47: 354-68. 18675845

In the paper

“When reported, most trial participants were white, and socioeconomic characteristics were poorly reported; therefore, we do not know whether our findings apply to adults with different ethnic, social, and economic characteristics.”

In the paper

“Brief interventions have shown effectiveness in the promotion of smoking cessation and alcohol reduction,8 9 and further research is warranted to assess their effectiveness for physical activity promotion.”

What the sources say

• Not checked yetcites [8] Stead LF, Bergson G, Lancaster T. Physician advice for smoking cessation. Cochrane Database Syst Rev 2008; 2: CD000165. 18425860
• Not checked yetcites [9] Kaner EF, Beyer F, Dickinson HO, Pienaar E, Campbell F, Schlesinger C, et al. Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database Syst Rev 2007; 2: CD004148. 17443541

In the paper

“They found a 16% increase in the relative risk of achieving recommended levels of physical activity at six to 12 months with exercise referral schemes compared with usual care, but no significant difference between exercise referral schemes and alternative physical activity interventions.”

What the sources say

• Not checked yetcites [40] Pavey TG, Taylor AH, Fox KR, Hillsdon M, Anokye N, Campbell JL, et al. Effect of exercise referral schemes in primary care on physical activity and improving health outcomes: systematic review and meta-analysis. BMJ 2011; 343: d6462. 22058134 PMC3209555

In the paper

“Only one reviewer screened titles and abstracts, and although papers could have been missed at this stage, seven databases were systematically searched on two occasions (May 2009; repeated May 2010), supplemented by hand searching of reference lists.”

In the paper

“Two fifths of included studies were conducted in the UK and most of the remaining trials took place in countries with broadly comparable primary care services, enhancing the generalisability of our findings to these settings.”

In the paper

“In summary, although no significant pooled effect was found, in individual studies, the likelihood of meaningful effect was highest in the comparison of exercise referral schemes with no intervention and weakest for the comparison of exercise referral schemes with advice given face to face.”