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versão On-line ISSN 1518-8345
Rev. Latino-Am. Enfermagem vol.17 no.6 Ribeirão Preto nov./dez. 2009
ARTIGO DE REVISÃO
Integrative review: behavioral interventions for physical activity practice
Thaís Moreira SpanaI; Roberta Cunha Matheus RodriguesII; Laura Bacelar de Araújo LourençoIII; Roberto Della Rosa MendezIV; Maria Cecília Bueno Jayme GallaniII
IRN, M.Sc., Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Brazil
IIRN, Associate Professor, Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Brazil, e-mail: firstname.lastname@example.org, email@example.com
IIIRN, Hospital e Maternidade Celso Pierro, Pontifícia Universidade Católica de Campinas, Brazil, e-mail: firstname.lastname@example.org
IVRN, Doctoral Student, Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Brazil, e-mail: email@example.com
This study aimed to carry out an integrative literature review on the effectiveness of interventions in physical activity (PA) practice in the general population. The search was carried out in articles indexed in online databases: Scopus, CINAHL and Medline. Studies in English or Brazilian Portuguese were included, with evidence levels 2 or 3, published between 2004 and 2008. The final sample consisted of 14 studies. In 57.1% of the studies, interventions were effective for behavior change to practice PA. The diversity of target populations, assessment instruments and intervention designs makes it difficult to compare results and build evidence on the effectiveness of interventions for PA promotion.
Descriptors: motor activity; behavior; intervention studies
Regular physical activity (PA) results in systemic benefits, such as a lower heart frequency, increased cardiac debit and decreased blood pressure. The effects of physical exercise are not only related to the biological sphere, but also to its positive effects on psychological and psychosocial health(1). Adherence to physical exercise programs aiming for health promotion is low in the general population, representing a major public health concern. Countless personal and environmental factors are implied in how demographic, biological, psychological, social and physical factors are related to the program. Strategies need to be developed that make people adopt a more active lifestyle, knowing, preventing and/or controlling the risk factors present in their lifestyle(2). Changes in health behavior result from reciprocal relations between the environment, personal factors and behavioral attributes(3). Considering the importance of adopting a more active lifestyle, nurses, as one of the categories responsible for educative activities with the healthy or ill population, need to develop, put in practice and assess the effectiveness of interventions aimed at optimizing regular PA practice and, consequently, a healthier lifestyle.
This study aimed to carry out an integrative review of Brazilian and international literature about the design and effectiveness of interventions used to stimulate PA practice in different population groups.
The steps recommended by literature were used to elaborate the integrative review(4-5).
Identification of review problem
The following guiding question was chosen: What is the design and effectiveness of behavioral interventions to promote physical activity in the general population?
Articles in English or Brazilian Portuguese were considered eligible if published in journals indexed in Medical Literature Analysis and Retrieval System on-line (MEDLINE, PubMed version), Cumulative Index to Nursing and Allied Health Literature (CINAHL) and SCOPUS, between August 2004 and August 2008, departing from the descriptors Intervention Studies, Motor Activity and Behavior, according to the Medical Subject Headings (MeSH), and their equivalents in Brazilian Portuguese according to the Health Sciences Descriptors (DeCS). The search was carried out in the three databases at the same time, in September 2008, using the descriptors combined by the Boolean connector "AND". As a result, 102 articles were found: 64 in SCOPUS, 26 in MEDLINE and 12 in CINAHL. The titles and abstracts of these 102 articles were carefully read, 40 were excluded because they were inadequate for the guiding questions, 3 were duplicates (found in more than one database), 15 were not available online in their full version in the collection of the University's Library System and 16 were meta-analyses or reviews. Twenty-eight articles were selected for analysis of their full version, including articles with evidence level 2 (individual research with experimental design) or 3 (research with quasi-experimental design)(6). The final sample consisted of 14 articles(7-20), in compliance with literature, which recommends that at least 30% of articles attending to the established inclusion criteria be included(5).
Study categorization, analysis and interpretation
A specific instrument was used to assess articles for inclusion in reviews, which Ursi constructed and validated in an earlier study(21). The analysis of the articles was based on the concepts of quantitative research with experimental and quasi-experimental designs(22) and on literature about the research theme(5).
Most studies (64%) are indexed in SCOPUS, in journals within the theme area Health Sciences, particularly Medicine (28.5%), followed by Oncology (21.4%), Metabolism, Psychology and Nutrition Sciences (21.4%); Geriatrics (14.3%) and Public Health (14.3%); with an average impact factor of 3.7(±3.9). Half of the production comes from the United States, followed by Europe (21.4%), Australia (21.4%) and Canada (7.1%); 57.1% of studies were developed at universities, 35.7% in multicenter research centers and 7.1% in hospitals. Homogeneous distribution was found between experimental and quasi-experimental studies (50%, respectively), predominantly randomization (64.3%) and control group (85.7%). The mean sample size was 452(±518) subjects. Most studies (78.6%) covered male and female subjects, 14.3% did not inform the participants' gender and 7.1% included women only. Great variation in subjects' age range was observed, with most studies including adults and/or elderly.
The result was assessed through PA questionnaires, objective PA measures (physical capacity, pedometer, accelerometer), or by behavioral variables (motivation, self-efficacy, stages of change), or by symptom perception (fatigue). Psychometric scales to measure motivation, fatigue and perceived effort stood out, as well as to measure psychosocial variables knowingly influenced by PA, as evidenced in other review studies(23-24). Instruments were frequently used to quantify the duration, intensity and frequency of PA. Most studies (64.3%) used biological markers, such as maximum oxygen consumption, serum cholesterol levels and body mass index (BMI)(7,11,14-19,20) and half of them applied physical tests, such as load and walking tests(8,11,14-15,17-18,20) (Table 1).
In half of the studies, the intervention was based on a theoretical framework: 28.6% was based on Motivational Theories and 21.4% on Multiple-Stage Models (Table 3). A majority (71.4%) used the isolated increase in PA as the dependent variable, with walking as the most explored target behavior, followed by the association between PA and healthy eating (28.6%), and between PA, healthy eating and giving up smoking (7.1%). The mean duration of interventions was 37.9(±23.3) weeks, with a minimum duration of 8 and a maximum of 72 weeks. The methodology was considered appropriate in 42.8% of the studies(10-11,15,19-20), considering criteria as viability, reproducibility, method clarity and application of instruments and objective measures; in 14.3%, the design of the steps was not clear, impeding reproducibility(13,16); and, in 28.6%, no criteria were mentioned for including/excluding subjects. In data analysis, parametric (42.8%) and variance and co-variance (42.8%) models predominated.
The interventions were effective to promote PA behavior in 57.1% (n=8) of the analyzed studies and ineffective in 14.3% (n=2)(7,13). The result of the intervention was not reported in 28.6% (n=4) of the studies(12,15,18-19). In the eight studies in which the intervention was considered effective, the assessed outcome was increased PA frequency (75%, n=6)(9-11,14,16,20), increased PA frequency associated with another behavior (7.1%; n=1)(17) and improved Quality of Life (QoL) and muscle force (7.1%; n=1)(14). No negative effects of the interventions were reported on.
The findings evidence that most of the publications on PA interventions has been disseminated in journals from the Health Science Area, classified in different subjects.
None of the studies was found in nursing journals, which evidences the need for nursing research in this area. The methodological design showed incoherence in terms of sampling process, as well as lack of clarity in the intervention phases. These findings are consistent with other reviews(23-24). The mean follow-up period coincided with the duration of the intervention, indicating the need for longitudinal designs, with a view to evidence on the long-term effectiveness of the intervention.
In half of the studies analyzed, strategies were theory-based, especially motivational theories. However, among the 57.1% whose results evidenced a significant increase in PA, strategies had been theory-based in only 28.6%, corresponding to a mere 14.3% of the sample. Nowadays, there is a large-scale debate among experts about the utility and perceived barriers in the application of behavioral theories(23-25). These theories point towards a generalized and carefully interpreted systematic summary of empirical evidence on behavior, and its application is expected to improve the effectiveness of interventions for behavioral modification. It has been argued, however, that most theories offer important support as to which needs should be changed, and not how these changes can be induced(26). Hence, it would be important for theories, besides explaining the subject's motivation to adopt the behavior, to advance in knowledge about how behavioral determinants of change can be modified and how these determinants can be translated into methods, strategies and effective instruments for behavioral change(26). The diversity of the target population, the intervention methods and assessment measures used, as well as the lack of standardization in self-reports on PA in the studies under analysis, limit the identification of which of strategies' potential attributes are associated with the effectiveness of an intervention.
Among the 57.1% of studies with a significant increase in PA, intervention strategies comprised counseling, written information/orientations and didactical material, either separately or jointly, with substantially different application/follow-up periods. These disparities do not permit comparisons and generalization of findings and, consequently, make it more difficult to construct evidence on the effectiveness of the interventions for PA promotion. Although this review involved a limited number of studies, its findings indicate the short-term effectiveness of interventions for PA promotion, in line with results from earlier reviews(24,26). The small number of interventions incorporated into the (health and education) service routine is highlighted, which reveals a continuing gap between theoretical conception and practical application. Interventions with a multidisciplinary approach were also rare, directed at the family's involvement in the adoption of PA practice.
Limitations were related to the exclusive use of DeCS and MeSH descriptors to locate the articles in the electronic databases, which can explain that a limited number of studies was recovered during the period, and also that studies accessed electronically were included, which restricted access to all studies elected for the review.
This integrative review about the use of behavioral interventions in the period from August 2004 to August 2008 evidenced that, in 57.1% of the studies, interventions effectively promoted PA; of these, however, intervention strategies had been based on theory in few studies. The range of assessment instruments and interventions limits comparisons and result generalizations and make it more difficult to construct evidence about the effectiveness of interventions to promote PA in the short and long terms.
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Recebido em: 23.4.2009
Aprovado em: 28.7.2009