Face‐to‐face interventions for promoting physical activity

Abstract

Background

Face‐to‐face interventions for promoting physical activity (PA) are continuing to be popular but their ability to achieve long term changes are unknown.

Objectives

To compare the effectiveness of face‐to‐face interventions for PA promotion in community dwelling adults (aged 16 years and above) with a control exposed to placebo or no or minimal intervention.

Search methods

We searched CENTRAL, MEDLINE, EMBASE, CINAHL, and some other databases (from earliest dates available to October 2012). Reference lists of relevant articles were checked. No language restrictions were applied.

Selection criteria

Randomised controlled trials (RCTs) that compared face‐to‐face PA interventions for community dwelling adults with a placebo or no or minimal intervention control group. We included studies if the principal component of the intervention was delivered using face‐to‐face methods. To assess behavioural change over time the included studies had a minimum of 12 months follow‐up from the start of the intervention to the final results. We excluded studies that had more than a 20% loss to follow‐up if they did not apply an intention‐to‐treat analysis.

Data collection and analysis

At least two authors independently assessed the quality of each study and extracted data. Non‐English language papers were reviewed with the assistance of an interpreter who was an epidemiologist. Study authors were contacted for additional information where necessary. Standardised mean differences (SMDs) and 95% confidence intervals (CIs) were calculated for continuous measures of self‐reported PA and cardio‐respiratory fitness. For studies with dichotomous outcomes, odds ratios (ORs) and 95% CIs were calculated.

Main results

A total of 10 studies recruiting 6292 apparently healthy adults met the inclusion criteria. All of the studies took place in high‐income countries. The effect of interventions on self‐reported PA at one year (eight studies; 6725 participants) was positive and moderate with significant heterogeneity (I² = 74%) (SMD 0.19; 95% CI 0.06 to 0.31; moderate quality evidence) but not sustained in three studies at 24 months (4235 participants) (SMD 0.18; 95% CI ‐0.10 to 0.46). The effect of interventions on cardiovascular fitness at one year (two studies; 349 participants) was positive and moderate with no significant heterogeneity in the observed effects (SMD 0.50; 95% CI 0.28 to 0.71; moderate quality evidence). Three studies (3277 participants) reported a positive effect on increasing PA levels when assessed as a dichotomous measure at 12 months, but this was not statistically significant (OR 1.52; 95% CI 0.88 to 2.61; high quality evidence). Although there were limited data, there was no evidence of an increased risk of adverse events (one study; 149 participants). Risk of bias was assessed as low (four studies; 4822 participants) or moderate (six studies; 1543 participants). Any conclusions drawn from this review require some caution given the significant heterogeneity in the observed effects. Despite this, there was some indication that the most effective interventions were those that offered both individual and group support for changing PA levels using a tailored approach. The long term impact, cost effectiveness and rates of adverse events for these interventions was not established because the majority of studies stopped after 12 months.

Authors' conclusions

Although we found evidence to support the effectiveness of face‐to‐face interventions for promoting PA, at least at 12 months, the effectiveness of these interventions was not supported by high quality studies. Due to the clinical and statistical heterogeneity of the studies, only limited conclusions can be drawn about the effectiveness of individual components of the interventions. Future studies should provide greater detail of the components of interventions, and assess impact on quality of life, adverse events and economic data.

Plain language summary

Face‐to‐face interventions for promoting physical activity

Participating in insufficient amounts of physical activity leads to an increased risk of a number of chronic diseases, and physical and mental health problems. Regular physical activity should be a goal for all adults and can provide social, emotional and physical health benefits. The majority of adults are not active at recommended levels. We included a total of 10 studies recruiting 6292 apparently healthy adults in this review. The findings of the review indicate that interventions can successfully support adults' attempts to become active and fitter, for example with personal counselling and advice, feedback and offering choices of exercise, and supervision. Outcomes are improved if the intervention comprises a specified type of physical activity and is supervised by a non‐health professional using a combination of group and individual approaches. New physical activity can be maintained for up to at least one year and does not increase the risk of falls or exercise related injuries. More research is needed to establish which methods of exercise promotion work best in the long term to encourage specific groups of people to be more physically active.

Summary of findings

Summary of findings for the main comparison. Face‐to‐face interventions versus control for promoting physical activity.

Face‐to‐face interventions versus control for promoting physical activity
Patient or population: patients with promoting physical activity Settings: Intervention: face‐to‐face interventions versus control
Outcomes	Illustrative comparative risks* (95% CI)		Relative effect (95% CI)	No of participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Control	Face‐to‐face interventions versus control
Cardio‐respiratory fitness: 12 months Sub maximal assessment of cardio‐respiratory fitness Follow‐up: mean 12 months		The mean cardio‐respiratory fitness: 12 months in the intervention groups was 7.23 standard deviations higher (5.82 lower to 20.28 higher)		426 (2 studies)	⊕⊕⊕⊝ moderate1	SMD 7.23 (‐5.82 to 20.28)
Dichotomous outcomes: 12 months Self‐reported PA questionnaire Follow‐up: mean 12 months	Study population		OR 1.58 (0.91 to 2.75)	3261 (3 studies)	⊕⊕⊕⊕ high
	284 per 1000	385 per 1000 (265 to 521)
	Moderate
	300 per 1000	404 per 1000 (281 to 541)
Dichotomous outcomes: 24 months Self‐reported PA questionnaire Follow‐up: mean 24 months	Study population		OR 1.19 (1.02 to 1.39)	2701 (1 study)	⊕⊕⊕⊕ high
	346 per 1000	387 per 1000 (351 to 424)
	Moderate
	346 per 1000	386 per 1000 (350 to 424)
Self‐reported physical activity: 24 months Self‐reported PA questionnaire Follow‐up: median 24 months		The mean self‐reported PA: 24 months in the intervention groups was 0.18 standard deviations higher (0.1 lower to 0.46 higher)		4235 (3 studies)	⊕⊕⊕⊕ high	SMD 0.18 (‐0.10 to 0.46)
Self‐reported physical activity: 12 months Self‐reported PA questionnaire Follow‐up: mean 12 months		The mean self‐reported PA: 12 months in the intervention groups was 0.18 standard deviations higher (0.06 to 0.31 higher)		23825 (8 studies)	⊕⊕⊕⊝ moderate1	SMD 0.19 (0.06 to 0.31)
*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; OR: Odds ratio
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.

Background

This review focuses on face‐to‐face interventions that promote physical activity (PA). It is part of a suite of three complementary reviews that provide both an update and a progression for the previously completed Cochrane review assessing 'Interventions for promoting physical activity' (Foster 2005a). The titles of the other reviews in this suite are:

1. 'Face‐to‐face versus remote and web 2.0 interventions for promoting physical activity';

2. 'Remote and web 2.0 interventions for promoting physical activity'.

The evidence base for both face‐to‐face PA promotion and remote and web 2.0 interventions is rapidly growing and diverging. Consequently, we divided this Cochrane update into two separate reviews that focus on of each of these delivery methods compared to true control groups. The third review enabled a head‐to‐head comparison between these intervention approaches for promoting PA. In all of the reviews we also considered how the effectiveness of PA interventions is influenced by implementing the intervention to a group or individually. The paradigm through which we approached these different methods of PA intervention delivery in this suite of reviews is summarised below (Figure 1).

1.

Delivery of PA interventions described according to interaction with implementer and other participants.

Description of the condition

The health benefits of adequate levels of PA have been well documented (WHO 2010a). Previous systematic reviews and meta‐analyses of observational studies have demonstrated the role of PA in the prevention and treatment of coronary heart disease, hypertension, stroke, type II diabetes, obesity, metabolic syndrome, breast cancer, colon cancer, osteoporosis, falls, depression, anxiety and negative self‐concept (Haskell 2007; Janssen 2010; Kesaniemi 2001; Nelson 2007; Strong 2005; Warburton 2006; Williams 2001). It is estimated that in 2008 physical inactivity caused 9% of premature mortality and 5.3 million deaths worldwide (Lee 2012). This included between 6% to 10% of all deaths from major non‐communicable diseases globally. The burden of such diseases is also increasing rapidly in low‐ and middle‐income countries (Lee 2012; WHO 2010b). 

The World Health Organization (WHO) recommends that adults should accumulate at least 150 minutes of moderate intensity or 75 minutes of vigorous intensity PA, or an equivalent combination of aerobic PA, throughout the week  (WHO 2010a). This should be achieved in bouts of at least 10 minutes duration (WHO 2010a). Muscle strengthening activities involving the major muscle groups are also recommended on at least two days per week (WHO 2010a). Investigations into the dose‐response relationship indicate that PA at levels higher than the minimum recommendations confer greater health benefit (Kesaniemi 2001; WHO 2010a).

The available data suggest that 31.1% of the world's adult population are not meeting the minimum recommendations for PA (Hallal 2012). The direct economic burden of physical inactivity is 1.5% to 3.0% of healthcare system costs and it is an emerging expense in low‐and middle‐income countries (Oldridge 2008). It has been estimated that increasing the number of people that achieve the WHO PA recommendations by 10% or 25% would prevent more than 553,000 and 1.3 million deaths, respectively, globally each year (Lee 2012).

Description of the intervention

It has long been accepted that various interventions can promote PA participation and improve health (Dishman 1996). This has prompted growing global interest and investment in PA interventions by different stakeholders using a variety of methods (Heath 2012). It is evident that there are opportunities to influence personal, social and environmental determinants of PA in different contexts and populations (Bauman 2012). A previous Cochrane review found that PA interventions had a moderate effect on participation levels (Foster 2005a). However, conclusions could not be drawn about the effectiveness of isolated components for achieving and maintaining recommended levels of PA in the population. 

For the purposes of this review an intervention is any deliberate attempt to increase the PA levels of the participants. It may be delivered using various methods and implemented through a broad range of professions (for example health professional, exercise specialist, PA researchers). This is consistent with the principles of the previous versions of this review (Foster 2005a). The critical additional component of face‐to‐face interventions is that the interaction with the implementer occurs in person. These interventions can be delivered to groups or individually and several examples are presented below (Table 2).

1. Examples of strategies used in typical face‐to‐face physical activity interventions.

	Face‐to‐face intervention
Individual	1) Counselling session to assess self‐efficacy and skills training to enhance options to be physically active
	2) Personal training to improve fitness delivered directly by instructor in the gym
	3) Health professionals distributing booklets to patients that describe the benefits of physical activity
Group	1) Exercise class to improve strength delivered directly by instructor in a community park
	2) Education sessions for physical activity opportunities at a community health centre
	3) Group bush walking session co‐ordinated by a hike leader

How the intervention might work

One of the earliest reviews of determinants of PA stated that few interventions or adherence studies were based on any theoretical or psychological models (Dishman 1990). However, when the review was repeated four years later the authors noted a marked increase in the use of theories in studies and interventions (Dishman 1994). It is now accepted that well designed PA interventions are based upon behavioural theories (Bartholomew 2001), but understanding how these are translated into practical strategies needs further evaluation (Foster 2005a). Behavioural theories provide a foundation for an intervention that can explain the drivers of PA behaviour and potential pathways for change (Foster 2005b). They also inform the planning, development and implementation of PA interventions, and the majority of studies have adopted social psychology theories (Biddle 2011).

Most of the theory previously applied to PA interventions has stemmed from face‐to‐face approaches. Epidemiological studies have tried to explain the variation of PA behaviour by examining the impact of different factors or correlates. These have been described as operating at two levels, the intrinsic and extrinsic levels (Sallis 1997). Correlates like social class, personality, cognition, attitudes and beliefs operate at an intrinsic level. Extrinsic factors are divided into incentive structures like sports facilities or access to green spaces, and legal restrictions like prohibitive laws (Sallis 1999). Intrinsic factors have received greater attention than the external factors in attempts to explain behavioural choices influenced by face‐to‐face interventions.

Four common theories were cited in the reviews conducted by Dishman (Dishman 1990; Dishman 1994). These were the Health Belief Model (HBM) (Becker 1974); the Theory of Reasoned Action/Planned Behaviour (TRA) (Fishbein 1975); Social Cognitive Theory (SCT) (Bandura 1986); and the Transtheoretical Model of behaviour change (TTM) (Prochaska 1982). These models have 'conceptual convergence' (Biddle 2001) and share two common constructs (Rodgers 1991):

1. outcome expectancy, the belief that the behaviour will lead to a specific outcome;

2. social norms, the influence of expected behaviours within a social group.

More recently other theories have emerged that include the Health Action Process Model (Schwarzer 2008); the Common Sense Model of Illness Perceptions (Hagger 2003); and the Behavioural Choice Theory (Epstein 2001). These models tend to encompass the connection between intrinsic and extrinsic drivers of behaviour.

There are several common strategies used in face‐to‐face interventions for changing PA behaviour that can be grounded in each of these theoretical models, and some examples of applying these were described previously (Table 2). Firstly, stimulus control is the manipulation of factors that prompt and improve accessibility to PA opportunities while reducing the desirability and appeal of sedentary behaviour (Foster 2005b). The provision of exercise classes and walking groups in local communities are examples that are typically delivered face‐to‐face. Secondly, drawing the attention of the participant to the immediate benefits of PA reinforces the behaviour and may increase the likelihood that it will be repeated (Hillsdon 2002). This may include the face‐to‐face provision of rewards, progress reviews, and praise from practitioners or peers. Each of these strategies can contribute to building social support and developing self‐efficacy for engaging in PA (McAuley 1994). However, the key component of these face‐to‐face approaches may be the elicitation of empathy as the implementer (Miller 2012; Rogers 1969):

1. understands the participants' feelings;

2. responds to what has been said in a way that reflects the participants' mood;

3. conveys the ability to share the participants' feelings.

Why it is important to do this review

Although it is known that the behaviour of individuals can be influenced by PA interventions, the most effective delivery method is not clear (Foster 2005a). In recent times there has been an emergence of remotely delivered interventions that has accelerated with the advent of web 2.0 technology (van den Berg 2007). This impetus has displaced several more traditional face‐to‐face methods of implementing PA interventions (van den Berg 2007).

It is intended that this review will provide an up‐to‐date indication of the effectiveness of face‐to‐face PA interventions. Understanding the effectiveness of these more traditional approaches to implementation should influence PA policy makers and professionals. Completing this update ensures that the most effective implementation methods are identified and is integral for optimising health‐related outcomes related to the promotion of PA participation.

Objectives

Primary

To compare the effectiveness of face‐to‐face interventions for physical activity (PA) promotion in community dwelling adults (aged 16 years and above) with a control exposed to placebo or no or minimal intervention.

Secondary

If sufficient data exist, the following secondary objectives will be assessed.

1. Does delivering the intervention to a group versus individually versus mixed (a combination of group and individually) influence the effectiveness in changing PA?

2. Does the professional delivering the intervention (for example health professional, exercise specialist) influence the effectiveness in changing PA?

3. Does specifying PA type (for example walking, jogging, aerobics) influence the effectiveness in changing PA?

4. Does supervising the prescribed PA influence the effectiveness in changing PA?

5. Does including theory based counselling as part of the intervention influence the effectiveness in changing PA?

Methods

Criteria for considering studies for this review

Types of studies

Randomised controlled trials (RCTs) that compared face‐to‐face PA interventions for community dwelling adults with a placebo or no or minimal intervention control group. We included studies if the principal component of the intervention was delivered using face‐to‐face methods. To assess behavioural change over time the included studies had a minimum of 12 months follow‐up from the start of the intervention to the final results. We excluded studies that had more than a 20% loss to follow‐up if they did not apply an intention‐to‐treat analysis.

Types of participants

Community dwelling adults, aged 16 years to any age, who were free from pre‐existing medical conditions or with no more than 10% of participants with pre‐existing medical conditions that may have limited participation in PA.

We excluded interventions for trained athletes or sports students.

We only included studies that measured PA at an individual level.

Types of interventions

Face‐to‐face PA interventions could be delivered using supervised methods (for example exercise class) or an unsupervised approach (for example home exercise programme), or both. The interventions could be delivered to groups or individuals. They could involve one‐off or ongoing interactions between the implementer and the participants that included:

• counselling or advice, or both;

• self‐directed or prescribed exercise, or both;

• home based or facility based exercise, or both;

• written education or motivational support material, or both.

We excluded mass media and multiple risk factor interventions.

The comparison was with a control group exposed to placebo or no or minimal intervention.

Types of outcome measures

Primary outcomes

The primary outcomes of this review included data that assessed change between baseline and follow‐up for:

• cardio‐respiratory fitness (CF), which is often used as a marker for PA and demonstrates similar associations with health related outcomes (Blair 2001). It was either estimated from a submaximal fitness test or recorded directly from a maximal fitness test. CF was typically expressed as a VO₂ max score, which is an abbreviation for maximal oxygen uptake (ml/kg/min or ml/min).

• PA levels expressed as an estimate of total energy expenditure (kcal/kg/week or kcal/week), total minutes completed at a moderate or vigorous intensity, proportion that reached a predetermined threshold level (for example meeting current public health recommendations), or frequency of participation. PA could be assessed using objective methods (for example accelerometers, pedometers) or more subjective tools (for example PA diary, survey), or both.

Both 12 and 24 month outcomes were included in the analysis.

Secondary outcomes

The secondary outcomes of this review included data relevant to:

1. quality of life (for example quality‐adjusted life years (QALYs));

2. cost (for example cost‐benefit, cost‐utility);

3. adverse events (for example musculoskeletal injury, cardiovascular event). 

Search methods for identification of studies

Electronic searches

We searched the following databases between the 9 October 2012 and 11 October 2012:

• CENTRAL (Issue 9 of 12, September 2012) in The Cochrane Library;

• MEDLINE (Ovid) (1946 to week 4 September 2012);

• EMBASE Classic and EMBASE (Ovid) (1947 to Week 40 2012);

• CINAHL Plus with Full Text (EBSCO);

• PsycINFO (Ovid) (1806 to week 1 October 2012);

• Web of Science.

We based the search on the previous methods used for the 'Interventions for promoting physical activity' Cochrane review (Foster 2005a) (Appendix 1) and updated the methods with some amendments (Appendix 2).

The Cochrane RCT filter (sensitivity maximising) was applied to MEDLINE (Ovid) and search terms as suggested in the Cochrane Handbook for Systematic Reviews of Interventions were used to limit the studies to RCTs in EMBASE (Ovid) (Lefebvre 2011). Adaptations of these filters were used in the other databases except for CENTRAL.

We did not apply any language restriction to the searches.

Searching other resources

We conducted handsearching for the International Journal of Behavioural Nutrition and Physical Activity (February 2004 to October 2012). The reference lists of all relevant articles identified during the search were checked by the authors. We also used published systematic reviews of PA interventions as a source for identifying RCTs. 

We communicated directly with authors to identify and request unpublished studies and data. A comprehensive list of relevant articles along with the inclusion criteria for the review were sent to the first author of each paper that met the inclusion criteria to ask if they knew of any additional published or unpublished studies which were relevant.

Data collection and analysis

Selection of studies

Two authors (CF, JR) independently manually screened the titles identified in the initial search to exclude those that were obviously outside the scope of the review. The authors were conservative at this stage and where disagreement occurred the citation was included for abstract review. Two authors (CF, JR) independently reviewed the abstracts of all citations that passed the initial title screening. They applied the following inclusion criteria to determine if the full paper was needed for further scrutiny.

Did the study:

1. aim to examine the effectiveness of a PA or CF promotion strategy to increase PA or CF levels;

2. use principally face‐to‐face methods to promote PA to the intervention group;

3. allocate participants to the intervention or control group using a method of randomisation;

4. have a control group that was exposed to placebo or no or minimal intervention;

5. include adults aged 16 years and older;

6. recruit community dwelling adults that were free of chronic disease or with no more than 10% of participants with pre‐existing medical conditions that may limit participation in PA;

7. have a follow‐up period of at least 12 months between commencing the intervention and measuring the outcomes;

8. analyse the results by intention to treat or, failing that, was there less than a 20% loss to follow‐up.

The authors were conservative at this stage and where disagreement occurred the citation was included for full text review. Two authors (CF, JR) reviewed the full texts of all studies that passed the abstract screening, using the inclusion criteria described above, to identify a final set of eligible studies. The studies included in the previous 'Interventions for promoting physical activity' Cochrane review were also allocated within the new suite of reviews by two authors (CF, JR) (Foster 2005a). When there was persisting disagreement it was resolved by consensus after a third author (MH or MT) reviewed the study in question. Publications and reports that utilised the same data were linked to avoid replication in the analysis.  

Data extraction and management

The data extraction form was independently piloted by two authors (CF, JR) and subsequently adjusted to ensure that it captured the relevant data. One author (CF or JR) and a Research Fellow from the Warwick Medical School (NF) independently extracted the data from all of the selected studies using the standard form. When there was disagreement a third author reviewed the study and consensus was reached (CF or JR, the author out of these two that did not do the initial data extraction). We separately extracted the data from multiple publications of the same study and then combined them to avoid replication. Any missing or ambiguous data were clarified with the study first author via e‐mail.

Assessment of risk of bias in included studies

The risk of bias was only assessed and reported for studies that met the inclusion criteria (Higgins 2011).

Two authors (CF, JR) assessed the risk of bias. Where there was disagreement between the review authors in risk of bias assessment, a third author (MH or MT) was asked to independently appraise the study and discrepancies were resolved by consensus between all three authors.

We assessed the studies for the five general domains of bias: selection, performance, attrition, detection, and reporting. Quality scores were allocated for:

1. allocation sequence generation;

2. allocation concealment;

3. incomplete outcome data;

4. selective outcome reporting;

5. comparable groups at baseline;

6. contamination between groups;

7. validated outcome measures;

8. outcome measure applied appropriately;

9. final analysis adjusted for baseline PA levels;

10. outcome assessment that was independent and blinded;

11. intention‐to‐treat analysis.

When sufficient information was available, we classified each study as a 'high' or 'low' risk of bias for each item. When there was a lack of information or uncertainty over the potential for bias, we described the domain as 'unclear'. We judged the quality of the evidence as 'low', 'medium', or 'high' given consideration of the study design and size, and the potential impact of the identified weaknesses noted in the risk of bias table for each study.

Measures of treatment effect

For each study with dichotomous outcomes, we expressed the effect size using an odds ratio (OR). For each study with continuous outcomes, we expressed the effect size using the standardised mean difference (SMD) between the post‐intervention values of the randomised groups. We completed a narrative summary of the study results and when there were sufficient data we completed a formal meta‐analysis of the included studies.

Unit of analysis issues

When possible, we analysed the studies using the mean and standard deviation (SD) and visualised the results using forest plots. Alternatively we reported only the point estimates with confidence intervals (CIs) and P values.  

When a study had more than one study arm relevant to this review, we examined the overall effects of the intervention versus control by combining the data from the related study arms. We calculated the mean and SD according to the overall numbers within each arm using established approaches (Higgins 2011).

For each study with dichotomous outcomes we calculated an OR and 95% CI. We used the number of participants in each arm that were reported as an event (for example active at a predetermined level) or no event (for example not active). Where appropriate, we calculated individual study effects and then the pooled effect sizes as ORs with 95% CIs using a random‐effects model. We calculated any missing 95% CIs using established approaches (Higgins 2008).

Dealing with missing data

We excluded studies that had a high degree of incomplete data (that is less than 40% of data) during the risk of bias assessment or when it appeared that missing data were likely to be associated with the reported intervention effect. We contacted the authors of potentially included studies if missing data were unclear or the data had not been fully reported. Missing data were captured in the data extraction form and reported in the risk of bias table.

Assessment of heterogeneity

We quantified and evaluated the amount of heterogeneity to determine whether the observed variation in the study results was compatible with the variation expected by chance alone (Deeks 2011). Heterogeneity was assessed through examination of the forest plots and quantified using the I² statistic.

Assessment of reporting biases

We plotted trial effect against standard error and presented it as a funnel plot (Sterne 2011). Asymmetry could be caused by a relationship between effect size and sample size or by publication bias, and we also examined any observed effect for clinical heterogeneity (Sterne 2011).

Data synthesis

When possible we reported all continuous outcomes on the original scale. If the outcomes were combined from different scales we standardised them as required for the analysis. We only completed a meta‐analysis when the data were clinically homogeneous, and we followed established Cochrane methods (Deeks 2011). If data were available, sufficiently similar, and of adequate quality, we used the Cochrane Collaboration's statistical software, Review Manager 2012, to perform the statistical analyses. We used a random‐effects model as the default to incorporate heterogeneity between studies. We did not combine evidence from differing study designs and outcome types in the same forest plot (Christinsen 2009).

Subgroup analysis and investigation of heterogeneity

We performed subgroup analyses to compare interventions that were delivered:

1. to a group versus individually versus mixed (combined group and individually);

2. by a health professional versus a non‐health professional;

3. with a PA type specified versus not specified;

4. with direct supervision versus unsupervised;

5. with theory based counselling versus without theory based counselling.

Sensitivity analysis

We conducted a sensitivity analysis for studies that definitively definitively met at least 50% of the applicable criteria reported in the 'Risk of bias' tables.

Results

Description of studies

See 'Characteristics of included studies'; 'Characteristics of excluded studies'; 'Characteristics of studies awaiting classification'; 'Characteristics of ongoing studies'

Results of the search

From 27,299 de‐duplicated hits, the full texts of 193 papers were retrieved for examination against the inclusion criteria (Figure 2). There were 12 papers describing 10 studies that met the inclusion criteria (Aittasalo 2004; Calfas 2000; Cunningham 1987; Grandes 2011; Harland 1999; Hillsdon 2002; Katz 2008; King 1991; Kriska 1986; Stewart 2001).

2.

Study flow diagram.

All searches were completed in October to November 2012. The results of the searches of the electronic databases are found in Table 3.

2. Search results for electronic databases.

Database searched	Number of hits
CINAHL	4454
The Cochrane Library	6703
EMBASE	8930
MEDLINE Ovid	11431
PsycINFO Ovid	4156
Science Citation Index Expanded	6756
Total	42430
After de‐duplication	27299

Included studies

There were 7265 apparently healthy adults who participated in the 10 included studies. The majority of studies recruited both genders, with one study recruiting women only (Kriska 1986) and one study recruiting men only (Cunningham 1987). The stated age range of participants was from 18 to 90 years, and five of the studies specifically targeted adults aged between 40 and 65 years (Cunningham 1987; Harland 1999; Hillsdon 2002; King 1991; Kriska 1986). Details on the ethnic groups of participants were reported in four studies (Cunningham 1987; Hillsdon 2002; Katz 2008; King 1991), with proportions of participants in ethnic minorities ranging from 0% to 68%. Participants were recruited from primary healthcare setiings in five studies (Calfas 2000; Grandes 2011; Harland 1999; Hillsdon 2002; Katz 2008) and the workplace in one study (Aittasalo 2004). All of the studies took place in high‐income countries.

The intervention was delivered individually in five studies (Aittasalo 2004; Grandes 2011; Harland 1999; Hillsdon 2002; Katz 2008) and as a mix between individual and group delivery in the other five studies (Calfas 2000; Cunningham 1987; King 1991; Kriska 1986; Stewart 2001). In four of the studies the intervention was delivered by health professionals (Aittasalo 2004; Grandes 2011; Harland 1999; Katz 2008), and was primarily supervised in three studies (Cunningham 1987; King 1991; Kriska 1986). The PA type was specified in three studies (Cunningham 1987; Kriska 1986; Stewart 2001), and theory based counselling formed part of the intervention in five studies (Aittasalo 2004; Harland 1999; Hillsdon 2002; Katz 2008; Stewart 2001).

Eight studies included PA self‐report at 12 months as an outcome measure (Aittasalo 2004; Calfas 2000; Cunningham 1987; Grandes 2011; Hillsdon 2002; Katz 2008; Kriska 1986; Stewart 2001) and this was sustained for 24 months in three of these studies (Calfas 2000; Grandes 2011; Kriska 1986). Three studies reported a dichotomous outcome variable for PA at 12 months (Aittasalo 2004; Grandes 2011; Harland 1999) and one of these presented follow‐up data at 24 months (Grandes 2011). There were two studies that reported cardiovascular fitness at 12 months (Cunningham 1987; King 1991).

Eight of the included studies were from the Foster 2005a review (Aittasalo 2004; Calfas 2000; Cunningham 1987; Harland 1999; Hillsdon 2002; King 1991; Kriska 1986; Stewart 2001) and two studies were identified by the updated search (Grandes 2011; Katz 2008).

Excluded studies

The reasons for excluding papers that underwent full text review are outlined in the 'Characteristics of excluded studies' table. Three main reasons contributed to more than 80% of the exclusions. The most prevalent was less than 12 months follow‐up (n = 78), followed by no appropriate control or intervention group (n = 37) or a remote and web 2.0 intervention only (n = 31). There were also two ongoing studies that met the inclusion criteria but had insufficient data at the time of this review (Iliffe 2010; Wilson 2010).

Risk of bias in included studies

We assessed the risk of bias of the included studies as low in four studies (Grandes 2011; Hillsdon 2002; King 1991; Stewart 2001) and there was a moderate risk of bias in the remaining six studies (Aittasalo 2004; Calfas 2000; Cunningham 1987; Harland 1999; Katz 2008; Kriska 1986) (Figure 3; Figure 4).

3.

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

4.

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Allocation

All of the included studies used randomised controlled designs. One study was assessed to have low risk of bias for both allocation sequence generation and concealment (Hillsdon 2002). Grandes 2011 was assessed to have a low risk of bias only for allocation sequence generation, and all other studies were unclear in their approach to allocation generation or concealment. Five studies were assessed as having a low risk of selection bias as they reported comparable groups at baseline (Harland 1999; Hillsdon 2002; King 1991; Kriska 1986; Stewart 2001).

Blinding

We did not rate studies on whether participants were blinded to their group allocation. This would not be appropriate for studies of this type as it would be impossible to blind participants to a PA intervention. We did assess studies on their performance bias, which included an evaluation of whether the outcome assessments were performed independently and by an assessor who was blinded to participant allocation status. Only three studies were assessed to have a low risk of performance bias on these criteria (Grandes 2011; Harland 1999; King 1991). Five studies were assessed to have a high risk of bias for blinding and independence of outcome assessment (Calfas 2000; Cunningham 1987; Hillsdon 2002; Kriska 1986; Stewart 2001), with two studies rated as unclear (Aittasalo 2004; Katz 2008).

Nine studies were judged to have a low risk of detection bias (Aittasalo 2004; Calfas 2000; Cunningham 1987; Grandes 2011; Hillsdon 2002; Katz 2008; King 1991; Kriska 1986; Stewart 2001). This was an assessment of the validity and quality of outcome measures plus their appropriateness of application with the participants. The outcome measure used by Harland 1999 did not report any measurement metrics and was adapted from a national survey tool.

Incomplete outcome data

Two studies were assessed as being at low risk of attrition bias as they had reported complete outcome data and presented reasons for any participant dropouts (Cunningham 1987; Hillsdon 2002). Three studies were assessed as being at high risk of bias for not reporting any attrition data (Aittasalo 2004; Calfas 2000; King 1991), with five studies assessed as unclear (Grandes 2011; Harland 1999; Katz 2008; Kriska 1986; Stewart 2001).

Selective reporting

Six studies were assessed as at low risk of reporting bias (Aittasalo 2004; Calfas 2000; Cunningham 1987; Harland 1999; Hillsdon 2002; King 1991), with the remaining four studies assessed as unclear (Hillsdon 2002; Katz 2008; Kriska 1986; Stewart 2001).

Other potential sources of bias

Other potential sources of bias included two criteria assessed in the earlier version of this review (Foster 2005a). These were: adjusting the final results for baseline values of PA, and adopting an intention‐to‐treat analysis approach.

Adjusting for baseline values of PA is particularly important in behaviour change studies as there is a likelihood of overestimating effects if baseline adjustment is not performed when using dichotomous outcome measures (for example per cent of adults achieving recommended level of PA). Only six studies had a low risk of bias for this criterion (Aittasalo 2004; Calfas 2000; Grandes 2011; Hillsdon 2002; King 1991; Stewart 2001). Three studies did not adjust their final results for baseline PA levels (Cunningham 1987; Harland 1999; Kriska 1986) with Katz 2008 assessed as unclear.

Intention‐to‐treat analysis underpins the principles of an RCT design to minimise bias. Therefore, we considered failure to include all randomised participants in the final outcome analysis within their allocated group as a critical risk of bias. Five studies were assessed to have conducted an intention‐to‐treat anlaysis (Grandes 2011; Harland 1999; Hillsdon 2002; Kriska 1986; Stewart 2001), with the other five studies not meeting this criterion (Aittasalo 2004; Calfas 2000; Cunningham 1987; Katz 2008; King 1991). The proportion of participants in studies that did not perform an intention‐to‐treat analysis and who were lost to follow‐up ranged from 3.9% to 15.9%.

Effects of interventions

See: Table 1

Cardio‐respiratory fitness

Two studies (349 participants) reported the effect of their intervention on cardio‐respiratory fitness (Cunningham 1987; King 1991). The pooled effect was positive and moderate with no significant heterogeneity in the observed effects (SMD 0.50; 95% CI 0.28 to 0.71), see Analysis 1.1.

1.1. Analysis.

Comparison 1 Face‐to‐face interventions versus control, Outcome 1 Cardiorespiratory fitness: 12 months.

King 1991 reported a significant difference in VO₂ max between the intervention and control groups at 12 months follow‐up (SMD 0.57; 95% CI 0.24 to 0.89). Participants received baseline physiological assessments and then were prescribed group based training at high intensity plus written information, PA logs, and phone calls. They attended local exercise classes at least three times per week for 12 months. Telephone calls were made once a week for the first four weeks, twice a week for the next four weeks, and then once a month for 12 months.

Cunningham 1987 reported a significant difference in VO₂ max between the intervention and control groups at 12 months follow‐up (SMD 0.44; 95% CI 0.16 to 0.72). Participants received three group exercise sessions per week and were encouraged to do one additional home based session.

Self‐reported physical activity ‐ reported as a dichotomous measure

Three studies (3277 participants) reported the effect of their intervention on PA as a dichotomous measure at 12 months (Aittasalo 2004; Grandes 2011; Harland 1999). The pooled effect was positive but not statistically significant (OR 1.52; 95% CI 0.88 to 2.61), see Analysis 1.2.

1.2. Analysis.

Comparison 1 Face‐to‐face interventions versus control, Outcome 2 Dichotomous outcomes: 12 months.

Aittasalo 2004 found significant differences in the proportion of participants reporting increases in leisure time PA levels at 12 months (OR 3.65; 95% CI 1.53 to 8.68). The participant’s current leisure time PA was assessed by a trained nurse and an individual goal was set. All participants were given a supplementary leaflet about PA, developed for the contemplation and preparation stages, plus a written weekly PA plan and a self‐monitoring PA diary for the next follow‐up visit. At the follow‐up visits (after eight weeks, six and 12 months) progress was reviewed and, if necessary, the plan modified. During all the visits emphasis was put on strengthening the participant’s positive impressions of his or her capability to follow the plan (self‐efficacy). Three fitness tests were also administered at baseline, six and 12 months.

Harland 1999 reported a similar result but it was not statistically significant (OR 1.29; 95% CI 0.73 to 2.28). All participants completed a baseline assessment of self‐reported PA, physical measures, and a cycle ergometer fitness test. They received feedback of their results, brief advice about their present level of PA in comparison to recommended levels, written health information, and 19 leaflets about local PA facilities and activities. In addition, each participant was allocated to one of four intervention groups: (i) one motivational interview; (ii) one motivational interview plus vouchers for free use of local facilities; (iii) six motivational interviews over 12 weeks; and (iv) six motivational interviews over 12 weeks plus vouchers.

Grandes 2011 found no significant difference after 12 months in the proportion of participants reporting that they achieved the recommended level of 150 minutes of at least moderate intensity PA per week (OR 1.13; 95% CI 0.96 to 1.33). However, after 24 months there was a significant difference between the intervention and control groups (OR 1.19; 95% CI 1.02 to 1.39), see Analysis 1.3. Participants received brief advice from physicians and educational materials within a 15 minute intervention plus an individualised PA plan. The intervention was supported by web based software to prompt and guide the physician and patient session.

1.3. Analysis.

Comparison 1 Face‐to‐face interventions versus control, Outcome 3 Dichotomous outcomes: 24 months.

Self‐reported physical activity ‐ reported as a continuous measure

Eight studies (6725 participants) reported their main outcome as one of several continuous measures of PA (Aittasalo 2004; Calfas 2000; Cunningham 1987; Grandes 2011; Hillsdon 2002; Katz 2008; Kriska 1986; Stewart 2001). Measures included estimated energy expenditure (kcals/day, kcals/week of moderate or vigorous PA (MVPA)), total time of PA (mean mins/week of MVPA), and mean number of occasions of PA in past four weeks. The pooled effect at 12 months was positive and moderate with significant heterogeneity (I² = 74%) (SMD 0.19; 95% CI 0.06 to 0.31), see Analysis 1.4.

1.4. Analysis.

Comparison 1 Face‐to‐face interventions versus control, Outcome 4 Self reported physical activity: 12 months.

Three of these studies (4235 participants) reported follow‐up measures at 24 months (Calfas 2000; Grandes 2011; Kriska 1986). Kriska 1986 found a significant difference in weekly total energy (kcal/week) at 12 months (SMD 0.26; 95% CI 0.00 to 0.52) and 24 months (SMD 0.54; 95% CI 0.27 to 0.80). The participants received a baseline physical assessment, eight week walking training programme with organised walks, and then a choice of group or independent walking. Participants monitored their walking with monthly logs and were also offered social meetings. Participants received follow‐up phone calls, cards, and incentives to maintain compliance. Calfas 2000 found no significant difference in total energy expenditure (kcal/kg/wk) at 12 months (SMD 0.16; 95% CI ‐0.06 to 0.38) and 24 months (SMD 0.06; 95% CI ‐0.16 to 0.29). The participants received a 15 week cognitive behavioural education course, which comprised 15 x 50 minute lectures followed by 15 x 110 minute laboratory experiences that were led by peer health facilitators and included the practice of behavioural management strategies as homework. Participants received two course credits and could attend two supervised exercise sessions per week. All participants received monthly follow‐up phone calls and monthly written materials for 15 months. The pooled effect at 24 months was not statistically significant (SMD 0.18; 95% CI ‐0.10 to 0.46), see Analysis 1.5.

1.5. Analysis.

Comparison 1 Face‐to‐face interventions versus control, Outcome 5 Self reported physical activity: 24 months.

The interventions for Aittasalo 2004, Cunningham 1987 and Grandes 2011 were described previously. Aittasalo 2004 found no significant difference at 12 months in the number of minutes of leisure time PA each week (SMD 0.02; 95% CI ‐0.31 to 0.36). Cunningham 1987 found a significant difference at 12 months in the number of minutes of high intensity PA (SMD 0.40; 95% CI 0.13 to 0.67). Grandes 2011 found no significant difference in PA volume (unit used to estimate the metabolic cost of physical activity ‐ MET/h/week) at both 12 months (SMD 0.00; 95% CI ‐0.06 to 0.07) and 24 months (SMD 0.01; 95% CI ‐0.05 to 0.08). Hillsdon 2002 reported no significant difference between the participants receiving either advice or counselling to exercise and control participants (SMD 0.05; 95% CI ‐0.05 to 0.15).

Katz 2008 tested the effectiveness of the Pressure Systems Model for PA promotion and reported positive effects at 12 months for outcomes, assessed by the Yale Physical Activity Survey (SMD 0.47; 95% CI 0.24 to 0.71). Intervention patients were categorised into groups and received tailored counselling based on motivational interviewing plus handout materials. Categorisation was based on answers to two questions that determined the approach undertaken by the counselling physician, and these included prompts on how to overcome specific patient barriers to exercise.

Stewart 2001 reported a significant net difference of 82 kcal per day between the intervention and control arms (95% CI 73.9 to 90.1), with a positive effect (SMD 0.32; 95% CI 0.02 to 0.63). The intervention group received face‐to‐face counselling based on social cognitive theory (Bandura 1986). In addition, they were offered further individual follow‐up appointments, educational materials, phone calls and monthly workshops about PA.

We found no evidence of publication bias (Figure 5).

5.

Funnel plot of comparison: 1 Face‐to‐face interventions versus control, outcome: 1.4 Self‐reported physical activity: 12 months.

Sensitivity analysis by study quality

We examined the pooled effects for the three types of outcome data (self‐reported PA, dichotomous and cardio‐respiratory fitness outcomes) by an assessment of study risk of bias. We stratified studies based on their risk of bias assessments (ROB), see Table 4 and Table 5, by only pooling estimates of effects for studies that had a lower risk of bias (≥ 50% of the ROB criteria). Pooled estimates were presented for each outcome type, see Analysis 2.1, Analysis 2.2, Analysis 2.3, Analysis 2.4, Analysis 2.5. Four studies were included (5636 participants) after the sensitivity analysis (King 1991; Grandes 2011; Hillsdon 2002; Stewart 2001). A positive but non‐significant pooled estimate was found for the three studies reporting self‐reported PA effects at 12 months (SMD 0.05; 95% CI ‐0.05 to 0.15), see Analysis 2.4. Grandes 2011 found a positive effect on PA levels at 24 months when reported as a dichotomous variable (OR 1.19; 95% CI 1.02 to 1.39) but found no interim effect at 12 months.

3. Risk of bias and quality scores for included studies.

Study	Allocation sequence generation	Allocation concealment	Incomplete outcome data	Selective outcome reporting	Comparable groups at baseline	Contamination between groups
Aittasalo 2004	U	U	N	Y	U	U
Calfas 2000	U	U	N	Y	U	NA
Cunningham 1987	U	U	Y	Y	U	NA
Grandes 2011	Y	N	U	Y	U	NA
Harland 1999	U	U	U	Y	Y	NA
Hillsdon 2002	Y	Y	Y	U	Y	NA
Katz 2008	U	U	U	U	U	NA
King 1991	U	U	N	Y	Y	NA
Kriska 1986	U	U	U	U	Y	NA
Stewart 2001	U	U	U	U	Y	NA

4. Risk of bias and quality scores for included studies.

Study	Validated outcome measures	Applied appropriately	Final analysis adjusted for baseline physical activity levels	Outcome assessment independent and blinded	Intention‐to‐treat analysis
Aittasalo 2004	Y	Y	Y	U	N
Calfas 2000	Y	U	Y	N	N
Cunningham 1987	Y	Y	N	N	N
Grandes 2011	Y	Y	Y	Y	Y
Harland 1999	U	U	N	Y	Y
Hillsdon 2002	Y	Y	Y	N	Y
Katz 2008	Y	Y	U	U	N
King 1991	Y	Y	Y	Y	N
Kriska 1986	Y	Y	N	N	Y
Stewart 2001	Y	Y	Y	N	Y

2.1. Analysis.

Comparison 2 Face‐to‐face interventions versus control (risk of bias score ≥ 50%), Outcome 1 Cardiorespiratory fitness: 12 months.

2.2. Analysis.

Comparison 2 Face‐to‐face interventions versus control (risk of bias score ≥ 50%), Outcome 2 Dichotomous outcomes: 12 months.

2.3. Analysis.

Comparison 2 Face‐to‐face interventions versus control (risk of bias score ≥ 50%), Outcome 3 Dichotomous outcomes: 24 months.

2.4. Analysis.

Comparison 2 Face‐to‐face interventions versus control (risk of bias score ≥ 50%), Outcome 4 Self reported physical activity: 12 months.

2.5. Analysis.

Comparison 2 Face‐to‐face interventions versus control (risk of bias score ≥ 50%), Outcome 5 Self reported physical activity: 24 months.

Quality of life

Only one study reported quality of life outcomes, using the Short Form (SF)‐36 measure, see Table 6 (Grandes 2011). The authors reported no differences between the intervention and control groups for Physical And Mental Component scores for the SF‐36 (assessed at 12 and 24 months). No other study reported any quality of life outcomes.

5. Quality of life outcomes.

Study	Quality of life outcomes
Aittasalo 2004	Not reported
Calfas 2000	Not reported
Cunningham 1987	Not reported
Grandes 2011	Physical And Mental Component scores for SF‐36 were assessed at 12 and 24 months but no differences were reported between intervention and control groups for these variables
Harland 1999	Not reported
Hillsdon 2002	Not reported
Katz 2008	Not reported
King 1991	Not reported
Kriska 1986	Not reported
Stewart 2001	Not reported

Cost effectiveness

No studies reported report data on cost effectiveness, see Table 7.

6. Cost effectiveness.

Study	Cost effectiveness
Aittasalo 2004	Not reported
Calfas 2000	Not reported
Cunningham 1987	Not reported
Grandes 2011	Not reported
Harland 1999	Not reported
Hillsdon 2002	Not reported
Katz 2008	Not reported
King 1991	Not reported
Kriska 1986	Not reported
Stewart 2001	Not reported

Adverse events

Only King 1991 reported data on adverse events, see Table 8. PA related non‐cardiac injuries were few and were similar in number across the study arms. These included mild muscular fatigue, strain, or soreness during the initial three to four months of intervention across both PA arms.

7. Adverse events.

Study	Adverse events
Aittasalo 2004	Not reported
Calfas 2000	Not reported
Cunningham 1987	Not reported
Grandes 2011	Not reported
Harland 1999	Not reported
Hillsdon 2002	Not reported
Katz 2008	Not reported
King 1991	There were several sprains and fractures reported, but there was no difference between the groups and none of the injuries caused any of the participants to withdraw from the study. No cardiac events were reported
Kriska 1986	Not reported
Stewart 2001	Not reported

Secondary objectives

See Table 9 and Table 10

8. Who delivers intervention and follow‐up, and individual or group approach.

Study	Who delivered the primary dose of intervention?	Intervention individual or group based primary dose	Who delivered the follow‐up dose of intervention?	Intervention individual or group based follow‐up
Aittasalo 2004	Occupational nurse	Individual	Occupational nurse	Individual
Calfas 2000	Behavioural and exercise science lecturers	Group	Peer health educators	Group and individual
Cunningham 1987	Exercise leaders	Group	Exercise leaders	Group and individual
Grandes 2011	Physicians	Individual	Physicians	Individual
Harland 1999	Health visitor	Individual	Health visitor	Individual
Hillsdon 2002	Exercise specialist	Individual	Exercise specialist	Individual
Katz 2008	Physicians	Individual	Physicians	Individual
King 1991	Project staff member	Individual	Group based training provided by community exercise instructors with physical education degrees. Project staff member made follow‐up phone calls	Individual and group
Kriska 1986	Exercise leaders	Individual and group	Exercise leaders	Individual and group
Stewart 2001	Trained staff	Individual and group	Counsellor	Individual and group

9. Intensity of primary intervention and follow‐up, and physical activity choice and supervision.

Study	Primary dose intensity	Physical activity choice	Physical activity supervision	Follow‐up frequency and dose
Aittasalo 2004	Counselling session focusing on assessment of PA and construction of PA plan	Participants choose own activities	Unsupervised	Follow up meetings at 8, 24 and 12 months. Fitness group received additional fitness tests at baseline and 6 months
Calfas 2000	50 minute faculty led lecture	Participants choose own activities	Unsupervised	Additional weekly lectures and peer led laboratories plus phone calls and written materials
Cunningham 1987	Participants were instructed to participate in 3 group exercise sessions per week and were encouraged to do one additional home based session	Three group based exercise classes plus one additional occasion per week	Supervised	Three group based exercise classes per week
Grandes 2011	GPs provided brief advice about the benefits of PA, or brief advice plus a 3 month PA prescription	Participants choose own activities	Unsupervised	An additional 15 minute appointment was offered to the brief advice group to prescribe a 3 month PA plan. Review of progress was conducted opportunistically
Harland 1999	40 minute motivational interview counselling plus a PA plan. Additional group received vouchers to use local PA facilities	Participants choose own activities	Unsupervised	Up to five additional interviews offered over the first 12 weeks of the intervention, plus vouchers
Hillsdon 2002	30 minute motivational interview counselling using decisional balance, assessment of current PA etc., or advice to exercise, plus printed materials	Participants choose own activities	Unsupervised	All participants received follow up phone calls at 2, 6, 10, 18, 26, 34 weeks. Calls were supposed to last no more than 3 minutes
Katz 2008	Motivational interview counselling using decisional balance, assessment of current PA, plus printed materials	Participants choose own activities	Unsupervised	Follow‐up arranged by consent between physicians and patients if needed. Identified local opportunities to exercise plus additional written materials
King 1991	Participants received a baseline physiological assessment and then were prescribed group based training at high intensity plus written information for 12 months 30‐40 minutes duration	Group based attended local classes (3 x week)	Supervised	Four phone calls in first four weeks, then two calls in next four weeks, followed by once a month for 12 months. Phone calls were used to monitor progress, answer questions and provide feedback from activity logs
Kriska 1986	Participants received eight weeks of walking training in groups, plus encouraged to walk once a week independently	Prescribed group walking plus independent walking	Supervised	After the walking training the participants could choose group or independent walking up to 3 miles per walk. Monthly walking self‐monitoring sheets were collected at end of each month, plus frequent social gatherings, phone calls, mail‐outs, and birthday cards. Rewards and incentives were given for distances achieved, plus newsletters. Unspecified frequency of follow‐up activities
Stewart 2001	Participants received a client centred interview using motivational, cognitive, behavioural techniques. Plus access to 10 workshops with emphasis on attending the first two workshops	Participants choose own activities but emphasis on walking	Unsupervised	Access to 10 follow‐up workshops plus phone calls and written information

Does delivering the intervention to a group versus individually versus mixed (combined group and individually) influence the effectiveness in changing PA?

Only four studies adopted an individual approach as part of their intervention (5801 participants), with a non‐significant pooled estimated effect (SMD 0.11; 95% CI ‐0.04 to 0.27) (Aittasalo 2004; Grandes 2011; Hillsdon 2002; Katz 2008), see Analysis 3.1. No studies adopted a consistent group based approach as part of their intervention. Four studies used both individual and group approaches (924 participants) with a positive pooled estimate effect (SMD 0.27; 95% CI 0.14 to 0.40) with no significant heterogeneity (Calfas 2000; Cunningham 1987; Kriska 1986; Stewart 2001), see Analysis 3.2.

3.1. Analysis.

Comparison 3 Face‐to‐face interventions versus control (subgroup analysis ‐ self reported physical activity: 12 months), Outcome 1 Delivery: individual.

3.2. Analysis.

Comparison 3 Face‐to‐face interventions versus control (subgroup analysis ‐ self reported physical activity: 12 months), Outcome 2 Delivery: mixed (individual and group).

Does the professional delivering the intervention (for example health professional, exercise specialist) influence the effectiveness in changing PA?

Three studies (4145 participants) delivered their interventions via a health professional, with a positive but non‐significant pooled effect estimate (SMD 0.16; 95% CI ‐0.15 to 0.48) (Aittasalo 2004; Grandes 2011; Katz 2008), see Analysis 3.3. Five studies (2580 participants) delivered their interventions via a non‐health professional with a positive and significant pooled effect estimate (SMD 0.20; 95% CI 0.06 to 0.35) (Calfas 2000; Cunningham 1987; Hillsdon 2002; Kriska 1986; Stewart 2001), see Analysis 3.4. Although it appears that there is a differential effect between non‐ versus heath professional intervention delivery, only two of the five studies in the non‐health professional group had low risk of bias and their combined effect estimate was positive but not significant (SMD 0.15; 95% CI ‐0.11 to 0.40) (Hillsdon 2002; Stewart 2001).

3.3. Analysis.

Comparison 3 Face‐to‐face interventions versus control (subgroup analysis ‐ self reported physical activity: 12 months), Outcome 3 Implementer: health professional.

3.4. Analysis.

Comparison 3 Face‐to‐face interventions versus control (subgroup analysis ‐ self reported physical activity: 12 months), Outcome 4 Implementer: non‐health professional.

Does specifying physical activity type (for example walking, jogging, aerobics) influence the effectiveness in changing PA?

Three studies (609 participants) specified the type of PA for their participants (Cunningham 1987; Kriska 1986; Stewart 2001) with a positive pooled effect estimate (SMD 0.33; 95% CI 0.17 to 0.49), see Analysis 3.5. Five studies (6116 participants) offered a choice of PA to their participants (Aittasalo 2004; Calfas 2000; Grandes 2011; Hillsdon 2002; Katz 2008) and their combined effect estimate was positive but not significant (SMD 0.12; 95% CI ‐0.01 to 0.25), see Analysis 3.6.

3.5. Analysis.

Comparison 3 Face‐to‐face interventions versus control (subgroup analysis ‐ self reported physical activity: 12 months), Outcome 5 Physical activity type: specified.

3.6. Analysis.

Comparison 3 Face‐to‐face interventions versus control (subgroup analysis ‐ self reported physical activity: 12 months), Outcome 6 Physical activity type: not specified.

Does supervising the prescribed physical activity influence the effectiveness in changing PA?

Two studies (445 participants) supervised their participants performing their PA prescription (Cunningham 1987; Kriska 1986) while six studies (6280 participants) did not supervise the participants (Aittasalo 2004; Calfas 2000; Grandes 2011; Hillsdon 2002; Katz 2008; Stewart 2001). The pooled effect estimate for supervised studies was positive (SMD 0.33; 95% CI 0.14 to 0.51), see Analysis 3.7. However, these two studies had a high risk of bias. The three low risk of bias studies in the unsupervised group did not have a significant positive pooled effect estimate (SMD 0.05; 95% CI ‐0.05 to 0.15).

3.7. Analysis.

Comparison 3 Face‐to‐face interventions versus control (subgroup analysis ‐ self reported physical activity: 12 months), Outcome 7 Prescribed physical activity: supervised.

Does including theory based counselling as part of the intervention influence the effectiveness in changing PA?

Four studies based their interventions and strategies on an expressed theory or model of behaviour change (Aittasalo 2004; Hillsdon 2002; Katz 2008; Stewart 2001). Aittasalo 2004 adapted strategies based upon the Transtheoretical Model of behaviour change (Prochaska 1982). Hillsdon 2002 and Katz 2008 used similar motivational based counselling strategies to support change, for example exploring patient ambivalence to change. Stewart 2001 delivered face‐to‐face counselling based on social cognitive theory (Bandura 1986). These studies produced a positive but non‐significant pooled effect estimate (SMD 0.21; 95% CI ‐0.02, 0.44), see Analysis 3.9. The four studies that did not base their interventions on an expressed theory also produced a positive but non‐significant pooled effect estimate (SMD 0.18; 95% CI ‐0.01, 0.37) (Calfas 2000; Cunningham 1987; Grandes 2011; Kriska 1986), see Analysis 3.10.

3.9. Analysis.

Comparison 3 Face‐to‐face interventions versus control (subgroup analysis ‐ self reported physical activity: 12 months), Outcome 9 Intervention: includes theory based counselling.

3.10. Analysis.

Comparison 3 Face‐to‐face interventions versus control (subgroup analysis ‐ self reported physical activity: 12 months), Outcome 10 Intervention: does not include theory based counselling.

Discussion

Summary of main results

We found consistent evidence to support the effectiveness of face‐to‐face interventions for promoting PA. These interventions have a positive moderate sized effect on increasing self‐reported PA and measured cardio‐respiratory fitness, at least at 12 months. However, the effectiveness of these interventions was not significant when considering only the higher quality studies, particularly for self‐reported PA at 12 months. We were not able to more rigorously assess the longer term effectiveness of face‐to‐face interventions to promote PA, beyond 12 months.

Including some group work in the intervention appeared to improve the effectiveness of the intervention. However, we were unable to assess the effectiveness of face‐to‐face interventions delivered in a group setting only. Instead, several studies included multiple intervention methods, which made it difficult to tease apart which intervention components were the active ingredients. The complexity of PA interventions appears to have increased over time. Indeed, it may actually be the interaction of multiple intervention components that is critical in facilitating PA behaviour change and this requires further investigation. Despite this, it appears that supervising participants' PA and specifying its type may improve the effectiveness of an intervention. Conversely, non‐health professionals appeared to deliver more effective interventions than health professionals.

There was a paucity of data reporting cost effectiveness, quality of life and adverse events. Given the apparent evolution towards more complex and multi‐faceted PA interventions, we believe that these are important considerations when assessing the public health value of an intervention. This should be a priority for future research.

Overall completeness and applicability of evidence

Our review demonstrates that there is moderate quality evidence to support the effectiveness of face‐to‐face interventions for promoting PA, but we note that the majority of studies targeted adults aged 40 to 65 years. Our conclusions are however limited because of the homogeneity of the target populations in the included studies. The participants in the studies that were reviewed were generally white, well educated and middle aged, and it is possible that the observed effects may be different in the wider population. There were no studies in this review that examined the effectiveness of interventions in minority groups of any kind or low‐ and middle‐income countries. Although studies in these settings were identified in the initial literature search, there continues to be a dearth of quality research in marginalised and poorer populations.

Furthermore, there were only a small number of new long term studies of face‐to‐face intervention for PA promotion. There was also a paucity of studies reporting data on quality of life, cost effectiveness and adverse events.

The completion of studies and applicability of this evidence may be limited by the relative cost of face‐to‐face interventions. Although the success of interventions delivered partly in groups and by non‐health professionals may improve intervention accessibility and cost effectiveness, this is offset by the apparent importance of intervention supervision. Further research is indicated exclusively into group based interventions and cost effectiveness.

Quality of the evidence

Since eight of the 10 included papers were from the previous review of interventions to promote PA to adults (Foster 2005a), the overall quality of the included studies did not remarkably improve in this update. However, it is promising to see that the most recent included study (Grandes 2011) scored the best of all the studies on the risk of bias assessment. We can only speculate that this is in response to our call for improved study quality to assess PA intervention effectiveness (Foster 2005a).

An overall strength of the studies was the consistent application of appropriate and validated outcome measures. This is particularly important given the small differences in changing levels of PA between the intervention and control groups, as intervention effects wane. We recognise that most studies used self‐report measures of PA, which are subject to recall bias and may lack precision but any misclassification is non‐differential (as both intervention and control groups complete the measure) and attenuate the effect of the intervention. This problem did not apply to measures of cardio‐respiratory fitness.

However, there were mixed responses to the other risk of bias criteria and several factors were widely unreported. This accounted for the few studies that were retained in the sensitivity analysis by study quality. It is important to recognise that none of the studies blinded participants to their group allocation, and we felt that this criterion was not appropriate to our studies because it is very difficult to do this for PA interventions.

It is also worth noting the large number of papers that were excluded from this review because they had an inadequate follow‐up period or did not have an appropriate control group. There is clearly an indication for future PA intervention studies to address these basic quality criteria.

Potential biases in the review process

One limitation of this review is potential publication bias. Other types of interventions may exist but have not been submitted or accepted for publication, or only those with positive results have been published. However, we identified little evidence of publication bias from our funnel plots.

Agreements and disagreements with other studies or reviews

Our results are consistent with recent systematic reviews of face‐to‐face interventions focusing on middle aged or older adults. We undertook a more stringent set of inclusion criteria than our previous review and only two new studies were added to our previous set (Foster 2005a). Our review is based on an increase in length of follow‐up from six to 12 months and a tighter focus on face‐to‐face interventions. Although our findings show a positive and moderate pooled effect on self‐reported PA at 12 months (SMD 0.19; 95% CI 0.06 to 0.31), the eight studies in the analysis had significant heterogeneity and suffered from a high risk of bias. Only one of the two new studies (Grandes 2011) was assessed to have a low risk of bias. These findings are mirrored in other systematic reviews of PA interventions for older adults. Hobbs 2013 reported an identical pooled effects size for PA interventions for older adults using counselling and lifestyle advice for self‐reported PA outcomes (SMD 0.19; 95% CI 0.10 to 0.28). Conn 2011 reported on randomised and non‐randomised PA interventions (n = 99,011 participants) and calculated a mean effect size for the comparison of intervention groups versus control groups that was positive but not significant (SMD 0.19; 95% CI –0.14 to 0.53). Both reviews were also unable to tease out what the active ingredients of a face‐to‐face intervention were and they were limited by the poor quality of the included studies. There was also significant heterogeneity among the included studies as reflected by the l² statistic.

Our review highlighted the narrow type of participants who are recruited to participate in PA studies, for example five of the studies specifically targeted adults aged between 40 and 65 years. As such, any successful intervention may be at risk of increasing existing health inequalities because of differential responses in recruitment (Foster 2011). This concern is also shared by Humphrey and Ogilvie's innovative systematic review of reviews (Humphreys 2013) looking at the differential effects of population level PA interventions on social inequalities. They also observed that interventions compared effectiveness by gender followed by age, ethnicity, and socioeconomic status.

Authors' conclusions

Implications for practice.

There is some evidence to support the impact of face‐to‐face interventions to promote PA to older adults but this is limited by the heterogeneity of the studies. Therefore, only limited conclusions can be drawn about the effectiveness of individual components of the interventions as we are unable to demonstrate what the most effective strategies were within the interventions. However, there was some indication that the most effective interventions were those that offered both individual and group support for changing PA levels using a tailored approach. There was limited evidence that such interventions improved quality of life, cost effectiveness or incidence of adverse events. High quality studies investigating the long term effectiveness of face‐to‐face interventions on promoting PA remain a pressing need.

Implications for research.

There is a clear need for future RCTs to build and improve this evidence base by assessing the impact of face‐to‐face PA interventions for at least 12 months and ideally up to 24 months. It is imperative to assess the effect of interventions on participants from varying socioeconomic or ethnic groups, and to gather quality of life, cost effectiveness and adverse event data. In this review we have only been able to describe what was done within the interventions but were unable to unpick what elements worked (were most effective) within the interventions.

What's new

Date	Event	Description
30 August 2013	Amended	Although we were able to find evidence to support the effectiveness of face‐to‐face interventions for promoting physical activity, at least at 12 months, the effectiveness of these interventions were not supported by high quality studies.

Appendices

Appendix 1. Search strategies 2005

MEDLINE (Ovid)

1 exp Exertion/
 2 Physical fitness/
 3 exp "Physical education and training"/
 4 exp Sports/
 5 exp Dancing/
 6 exp Exercise therapy/
 7 (physical$ adj5 (fit$ or train$ or activ$ or endur$)).tw.
 8 (exercis$ adj5 (train$ or physical$ or activ$)).tw.
 9 sport$.tw.
 10 walk$.tw.
 11 bicycle$.tw.
 12 (exercise$ adj aerobic$).tw.
 13 (("lifestyle" or life‐style) adj5 activ$).tw.
 14 (("lifestyle" or life‐style) adj5 physical$).tw.
 15 or/1‐14
 16 Health education/
 17 Patient education/
 18 Primary prevention/
 19 Health promotion/
 20 Behaviour therapy
 21 Cognitive therapy
 22 Primary health care
 23 Workplace/
 24 promot$.tw.
 25 educat$.tw.
 26 program$.tw.
 27 or/16‐26
 28 15 and 27

RCT filter (Dickersin 1995)

EMBASE

1.((((health‐education) or (health‐education‐research)) or ((patient‐education) or (patient‐education‐and‐counseling)) or ((health‐promotion) or (health‐promotion‐international)) or (primary‐health‐care) or ((workplace) or (workplace‐)) or (promot*) or ((promot*) or ((educat*) or ((program*) and ((((exertion) or (fitness) or (fitness‐) or ((fitness) or (fitness‐)) or (exercise) or ((exercise) or (sport) or (walk*)))
 
 2.((research) or (((((random‐controlled) or (random‐sample) or (randomisation) or (randomised) or (randomised‐controlled) or (randomization) or (randomization‐) or (randomizd) or (randomize) or (randomized) or (randomized‐block) or (randomized‐controlled) or (randomized‐controlled‐trial) or (randomized‐control)) or ((double‐blind) or (double‐blind‐procedure)) or ((single‐blind) or (single‐blind‐procedure))) and (ec=human)) or (clinical) or (clin*) or (trial*) or (((clin* near trial*) in ti) and (ec=human)) or (clin*) or (trial*) or (((clin* near trial*) in ab) and (ec=human)) or (sing*) or (doubl*) or (trebl*) or (tripl*) or (blind*) or (mask*) or (((sing* or doubl* or trebl* or tripl*) near (blind* or mask*)) and (ec=human)) or ((placebos) or (placebo‐controlled)) or ((placebo* in ti) and (ec=human)) or ((placebo* in ab) and (ec=human)) or ((random* in ti) and (ec=human)) or ((random in ab) and (ec=human)) or (research)) ec=human)
 
 3.((((studies) or (prospective‐study) or (follow‐up) or (comparative) or (evaluation)) and (ec=human))

CINAHL

1.exact{controlled}
 2.exact{randomized}
 3.exact{random‐assignment}
 4.exact{double‐blind}
 5.exact{single‐blind}
 6.#1 or #2 or #3 or #4 or #5
 7.exact{animal}
 8.exact{human}
 9.#6 not #7
 10.exact{clinical}
 11.(clin* near trial*) in ti
 12.(clin* near trial*) in ab
 13.(singl* or doubl* or trebl* or tripl*) near (blind* or mask*)
 14.(#13 in ti) or (#13 in ab)
 15.placebos
 16.placebo* in ti
 17.placebo* in ab
 18.random* in ti
 19.random* in ab
 20.exact{research‐methodology}
 21.#10 or #11 or #12 or #13 or #14 or #15 or #16 or #17
 22.#18 or #19 or #20
 23.#21 or #22
 24.animal
 25.human
 26.#23 not #24
 27.#26 or #9 or #8 or #25
 28.exact{comparative}
 29.study
 30.#28 and #29
 31.exact{evaluation}
 32.studies
 33.#31 and #32
 34.exact{follow‐up}
 35.exact{propsective}
 36.#35 and #32
 37.control* or prosepctiv* or volunteer*
 38.(#37 in ti) or (#37 in ab)
 39.#38 or #36 or #33 or #30
 40.#39 not #24
 41.#39 or #27 or #9
 42.explode "exertion/"/ all subheadings
 43."physical fitness"
 44.explode "physical education and training"/ all subheadings
 45.explode "sports"/ all subheadings
 46.explode "dancing"/ all subheadings
 47.explode "exercise therapy"/ all subheadings
 48.(physical$ adj5 (fit$ or train$ or activ$ or endur$)).tw.
 49.(exercis$ adj5 (train$ or physical$ or activ$)).tw.
 50.sport$.tw.
 51.walk$.tw.
 52.bicycle$.tw
 53.(exercise$ adj aerobic$).tw.
 54.(("lifestyle" or life‐style) adj5 activ$).tw.
 55.(("lifestyle" or life‐style) adj5 physical$).tw.
 56.#42 or #43 or #44 or #45 or #46 or #47 or #48 or #49 or (exercise$) or (aerobic$) or ("lifestyle") or (activ$) or ("lifestyle") or (life‐style) or (physical$)
 57.health education
 58.patient education
 59.primary prevention
 60.health promotion
 61.behaviour therapy
 62.cognitive therapy
 63.primary health care
 64.workplace
 65.promot$.tw.
 66.educat$.tw.
 67.program$.tw.
 68.#57 or #58 or #59 or #60 or #61 or #62 or #63 or #64 or #65 or #66 or #67
 69.#68 and #56
 70.#69 and #41

PsycLIT

1.exertion
 2.physical‐fitness
 3.exercise
 4.explode exercise
 5.sport
 6.walk*
 7.cycle
 8.#1 or #2 or #3 or #4 or #5 or #6 or #7
 9.health education
 10.patient education
 11.primary prevention
 12.health promotion
 13.behaviour therapy
 14.cognitive therapy
 15.primary health care
 16.workplace
 17.promot$.tw.
 18.educat$.tw.
 19.program$.tw.
 20.#9 or #10 or #11 or #12 or #13 or #14 or #15 or #16 or #17 or #18 or #19
 21.#8 and #20
 22.controlle
 23.randomized
 24.random‐assignment
 25.double‐blind
 26.single‐blind
 27.#22 or #23 or #24 or #25 or #26
 28.animal
 29.human
 30.#27 not #28
 31.clinical
 32.(clin* near trial*) in ti
 33.clin* near trial*) in ab
 34.(singl* or doubl* or trebl* or tripl*) near (blind* or mask*)
 35.(#34 in ti) or (#34 in ab)
 36.placebos
 37.placebo* in ti
 38.placebo* in ab
 39.random* in ti
 40.random* in ab
 41.research‐methodology}
 42.#31 or #32 or #33 or #34 or #35 or #36 or #37 or #38
 43.#39 or #40 or #41
 44.#42 or #43
 45.animal
 46.human
 47.#44 not #45
 48.#47 or #30 or #29 or #46
 49.comparative
 50.study
 51.#49 and #50
 52.evaluation
 53.studies
 54.#52 and #53
 55.follow‐up
 56.propsective
 57.#56 and #53
 58.control* or prosepctiv* or volunteer*
 59.(#58 in ti) or (#58 in ab)
 60.#59 or #57 or #54 or #51
 61.#60 not #45
 62.#60 or #48 or #30
 63.#62 and #21

SPORTDISCUS

1.'physical activity'
 2.exercise
 3.fitness
 4.sedentary
 5.housebound
 6.aerobics or circuits or swimming or aqua or jogging or running or cycling or fitness or yoga or walking or sport
 7.patient education
 8.primary prevention
 9.health promotion
 10.behaviour therapy
 11.cognitive therapy
 12.primary health care
 13.workplace
 14.controlled
 15.randomized
 16.random‐assignment
 17.double‐blind
 18.single‐blind
 19.clinical
 20.placebos
 21.comparative
 22.evaluation
 23.study

SIGLE

1.explode "Exertion/"/ all subheadings
 2."Physical fitness"
 3.explode "Physical education and training"/ all subheadings
 4.explode "Sports"/ all subheadings
 5.explode "Dancing"/ all subheadings
 6.explode "Exercise therapy"/ all subheadings
 7.(physical$ adj5 (fit$ or train$ or activ$ or endur$)).tw.
 8.(exercis$ adj5 (train$ or physical$ or activ$)).tw.
 9.sport$.tw.
 10.walk$.tw.
 11.bicycle$.tw
 12.(exercise$ adj aerobic$).tw.
 13.(("lifestyle" or life‐style) adj5 activ$).tw.
 14.(("lifestyle" or life‐style) adj5 physical$).tw.
 15.#1 or #2 or #3 or #4 or #5 or #6 or #7 or #8 or (exercise$) or (aerobic$) or ("lifestyle") or (activ$) or ("lifestyle") or (life‐style) or (physical$)
 16.Health Education
 17.Patient education
 18.Primary prevention
 19.Health promotion
 20.Behaviour therapy
 21.Cognitive therapy
 22.Primary health care
 23.Workplace
 24.promot$.tw.
 25.educat$.tw.
 26.program$.tw.
 27.#16 or #17 or #18 or #19 or #20 or #21 or #22 or #23 or #24 or #25 or #26
 28.#15 and #27

SCISEARCH

1.((promot$ or uptake or encourag$ or increas$ or start) near (physical adj activity))
 2.(promot$ or uptake or encourag$ or increas$ or start) near exercise
 3.(promot$ or uptake or encourag$ or increas$ or start) near (aerobics or circuits or swimming or aqua$)
 4.(promot$ or uptake or encourag$ or increas$ or start) near (jogging or running or cycling)
 5.(promot$ or uptake or encourag$ or increas$ or start) near ((keep adj fit) or (fitness adj class$) or yoga)
 6.(promot$ or uptake or encourag$ or increas$ or start) near walking
 7.(promot$ or uptake or encourag$ or increas$ or start) near sport$

Appendix 2. Search strategies 2012

CENTRAL

#1MeSH descriptor: [Physical Fitness] this term only
 #2MeSH descriptor: [Physical Exertion] this term only
 #3MeSH descriptor: [Physical Education and Training] explode all trees
 #4MeSH descriptor: [Sports] explode all trees
 #5MeSH descriptor: [Dancing] this term only
 #6MeSH descriptor: [Exercise Therapy] explode all trees
 #7physical* near activ*
 #8physical* near train*
 #9physical* near fit*
 #10exercise* near train*
 #11exercise* near activ*
 #12exercise* near physical*
 #13sport*
 #14walk*
 #15bicycle*
 #16exercise* near aerobic*
 #17((life next style*) near activ*)
 #18life‐style* near activ*
 #19lifestyle* near activ*
 #20((life next style*) near physical*)
 #21life‐style* near physical*
 #22lifestyle* near physical*
 #23#1 or #2 or #3 or #4 or #5 or #6 or #7 or #8 or #9 or #10 or #11
 #24#12 or #13 or #14 or #15 or #16 or #17 or #18 or #19 or #20 or #21 or #22
 #25#23 or #24
 #26MeSH descriptor: [Health Education] this term only
 #27MeSH descriptor: [Patient Education as Topic] this term only
 #28MeSH descriptor: [Primary Prevention] this term only
 #29MeSH descriptor: [Health Promotion] explode all trees
 #30MeSH descriptor: [Behavior Therapy] this term only
 #31MeSH descriptor: [Cognitive Therapy] this term only
 #32MeSH descriptor: [Primary Health Care] this term only
 #33MeSH descriptor: [Workplace] this term only
 #34promot*
 #35educat*
 #36program*
 #37#26 or #27 or #28 or #29 or #30 or #31 or #32 or #33 or #34 or #35 or #36
 #38#25 and #37

MEDLINE Ovid

1. Physical Exertion/
 2. Physical Fitness/
 3. exp "Physical Education and Training"/
 4. exp Sports/
 5. Dancing/
 6. exp Exercise Therapy/
 7. exp Exercise/
 8. (physical$ adj5 (fit$ or train$ or activ$ or endur$ or exertion$)).tw.
 9. (exercis$ adj5 (train$ or physical$ or activ$)).tw.
 10. sport$.tw.
 11. walk$.tw.
 12. bicycle$.tw.
 13. ((exercise$ adj3 aerobic$) or aerobics).tw.
 14. ((lifestyle or life‐style) adj5 activ$).tw.
 15. ((lifestyle or life‐style) adj5 physical$).tw.
 16. or/1‐15
 17. Health Education/
 18. Patient Education as Topic/
 19. Primary Prevention/
 20. exp Health Promotion/
 21. Behavior Therapy/
 22. Cognitive Therapy/
 23. Primary Health Care/
 24. Workplace/
 25. promot$.tw.
 26. educat$.tw.
 27. program$.tw.
 28. or/17‐27
 29. 16 and 28
 30. randomized controlled trial.pt.
 31. controlled clinical trial.pt.
 32. randomized.ab.
 33. placebo.ab.
 34. drug therapy.fs.
 35. randomly.ab.
 36. trial.ab.
 37. groups.ab.
 38. 30 or 31 or 32 or 33 or 34 or 35 or 36 or 37
 39. exp animals/ not humans.sh.
 40. 38 not 39
 41. 29 and 40
 42. (200412$ or 2005$ or 2006$ or 2007$ or 2008$ or 2009$ or 2010$ or 2011$ or 2012$).ed.
 43. 41 and 42

EMBASE Ovid

1. exp exercise/
 2. fitness/
 3. physical education/
 4. exp sport/
 5. dancing/
 6. exp kinesiotherapy/
 7. (physical* adj5 (fit* or train* or activ* or endur* or exert*)).tw.
 8. (exercis* adj5 (train* or physical* or activ*)).tw.
 9. sport*.tw.
 10. walk*.tw.
 11. ((exercise* adj aerobic*) or aerobic*).tw.
 12. ((lifestyle or life‐style) adj5 activ*).tw.
 13. bicycle*.tw.
 14. ((lifestyle or life‐style) adj5 physical*).tw.
 15. or/1‐14
 16. health education/
 17. patient education/
 18. primary prevention/
 19. health promotion/
 20. behavior therapy/
 21. cognitive therapy/
 22. primary health care/
 23. workplace/
 24. promot*.tw.
 25. educat*.tw.
 26. program*.tw.
 27. or/16‐26
 28. 15 and 27
 29. random$.tw.
 30. factorial$.tw.
 31. crossover$.tw.
 32. cross over$.tw.
 33. cross‐over$.tw.
 34. placebo$.tw.
 35. (doubl$ adj blind$).tw.
 36. (singl$ adj blind$).tw.
 37. assign$.tw.
 38. allocat$.tw.
 39. volunteer$.tw.
 40. crossover procedure/
 41. double blind procedure/
 42. randomized controlled trial/
 43. single blind procedure/
 44. 29 or 30 or 31 or 32 or 33 or 34 or 35 or 36 or 37 or 38 or 39 or 40 or 41 or 42 or 43
 45. (animal/ or nonhuman/) not human/
 46. 44 not 45
 47. 28 and 46
 48. (200412* or 2005* or 2006* or 2007* or 2008* or 2009* or 2010* or 2011* or 2012*).dd.
 49. 47 and 48
 50. limit 49 to embase

CINAHL Plus with Full Text EBSCO

S34 S33 Limiters ‐ Exclude MEDLINE records
 S33 S31 and S32
 S32 EM 20041201‐20121010
 S31 S20 and S30
 S30 S21 or S22 or S23 or S24 or S25 or S26 or S27 or S28 or S29
 S29 TX allocat*
 S28 TX control*
 S27 TX assign*
 S26 TX placebo*
 S25 (MH "Placebos")
 S24 TX random*
 S23 TX (clinic* N1 trial?)
 S22 PT clinical trial
 S21 (MH "Clinical Trials+")
 S20 S10 and S19
 S19 S11 or S12 or S13 or S14 or S15 or S16 or S17 or S18
 S18 (TI promot* or educat* or program*) or (AB promot* or educat* or program*)
 S17 (MH "Work Environment")
 S16 (MH "Primary Health Care")
 S15 (MH "Behavior Therapy+")
 S14 (MH "Health Promotion")
 S13 (MH "Preventive Health Care")
 S12 (MH "Patient Education")
 S11 (MH "Health Education")
 S10 S1 or S2 or S3 or S4 or S5 or S6 or S7 or S8 or S9
 S9 (TI sport* or walk* or bicycle* or exercis* or aerobic*) or (AB sport* or walk* or bicycle* or exercis* or aerobic*)
 S8 (TI physical N5 (fit* or train* or activ* or endur* or exert*)) or (AB physcial* N5 (fit* or train* or activ* or endur* or exert*))
 S7 (TI exercis* N5 (train* or physical* or activ*)) or (AB exercis* N5 (train* or physical* or activ*))
 S6 (MH "Exercise+") or (MH "Therapeutic Exercise+")
 S5 (TI (lifestyle* or life‐style*) N5 (activ* or physical*)) or (AB (lifestyle* or life‐style*) N5 (activ* or physical*))
 S4 (MH "Sports+") or (MH "Dancing+")
 S3 (MH "Physical Education and Training")
 S2 (MH "Physical Fitness")
 S1 (MH "Exertion")

PsycINFO

1. exp exercise/
 2. physical fitness/
 3. physical activity/
 4. exp sports/
 5. physical education/
 6. (physical$ adj5 (fit$ or train$ or activ$ or endur$ or exertion$)).tw.
 7. (exercis$ adj5 (train$ or physical$ or activ$)).tw.
 8. sport$.tw.
 9. walk$.tw.
 10. bicycle$.tw.
 11. ((exercise$ adj3 aerobic$) or aerobics).tw.
 12. ((lifestyle or life‐style) adj5 activ$).tw.
 13. ((lifestyle or life‐style) adj5 physical$).tw.
 14. or/1‐13
 15. health education/
 16. client education/
 17. health promotion/
 18. prevention/
 19. primary health care/
 20. behavior therapy/
 21. cognitive therapy/
 22. cognitive behavior therapy/
 23. workplace*.tw.
 24. promot$.tw.
 25. educat$.tw.
 26. program$.tw.
 27. or/15‐26
 28. 14 and 27
 29. random*.tw.
 30. trial.ab.
 31. groups.ab.
 32. factorial$.tw.
 33. crossover$.tw.
 34. cross over$.tw.
 35. cross‐over$.tw.
 36. placebo$.tw.
 37. assign$.tw.
 38. allocat$.tw.
 39. volunteer$.tw.
 40. clinical trials/
 41. (doubl$ adj blind$).tw.
 42. (singl$ adj blind$).tw.
 43. or/29‐42
 44. 28 and 43
 45. (200412* or 2005* or 2006* or 2007* or 2008* or 2009* or 2010* or 2011* or 2012*).up.
 46. 44 and 45

Web of Science

# 20 #19 AND #18
 # 19 TS=(random* or blind* or allocat* or assign* or trial* or placebo* or crossover* or cross‐over*)
 # 18 #17 AND #8
 # 17 #16 OR #15 OR #14 OR #13 OR #12 OR #11 OR #10 OR #9
 # 16 TI=(promot* or educat* or program*)
 # 15 TS=(workplace)
 # 14 TS=(primary health care)
 # 13 TS=(cognitive therap*)
 # 12 TS=((behaviour or behavior) NEAR/2 therap*)
 # 11 TS=(health NEAR/2 promot*)
 # 10 TS=(primary prevent*)
 # 9 TS=((health educat*) or (patient* educat*))
 # 8 #7 OR #6 OR #5 OR #4 OR #3 OR #2 OR #1
 # 7 TS=((lifestyle* or life‐style*) NEAR/5 (activ* or physcial*))
 # 6 TS=((exercis* NEAR/2 aerobic*) or aerobic*)
 # 5 TS=(sport* or danc* or walk* or bicycle*)
 # 4 TS=(physical* educat*)
 # 3 TS=(exercis* NEAR/5 (train* or physical* or activ*))
 # 2 TS=(physical NEAR/5 (fit* or train* or activ* or endur* or exert*))
 # 1 TS=(exercis* therap*)

Data and analyses

Comparison 1. Face‐to‐face interventions versus control.

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Cardiorespiratory fitness: 12 months	2	349	Std. Mean Difference (IV, Random, 95% CI)	0.50 [0.28, 0.71]
2 Dichotomous outcomes: 12 months	3	3277	Odds Ratio (IV, Random, 95% CI)	1.52 [0.88, 2.61]
3 Dichotomous outcomes: 24 months	1	2701	Odds Ratio (IV, Random, 95% CI)	1.19 [1.02, 1.39]
4 Self reported physical activity: 12 months	8	6725	Std. Mean Difference (IV, Random, 95% CI)	0.19 [0.06, 0.31]
5 Self reported physical activity: 24 months	3	4235	Std. Mean Difference (IV, Random, 95% CI)	0.18 [‐0.10, 0.46]

Comparison 2. Face‐to‐face interventions versus control (risk of bias score ≥ 50%).

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Cardiorespiratory fitness: 12 months	1	149	Std. Mean Difference (IV, Random, 95% CI)	0.57 [0.24, 0.89]
2 Dichotomous outcomes: 12 months	1	2853	Odds Ratio (IV, Random, 95% CI)	1.13 [0.96, 1.33]
3 Dichotomous outcomes: 24 months	1	2701	Odds Ratio (IV, Random, 95% CI)	1.19 [1.02, 1.39]
4 Self reported physical activity: 12 months	3	5511	Std. Mean Difference (IV, Random, 95% CI)	0.05 [‐0.05, 0.15]
5 Self reported physical activity: 24 months	1	3691	Std. Mean Difference (IV, Random, 95% CI)	0.01 [‐0.05, 0.08]

Comparison 3. Face‐to‐face interventions versus control (subgroup analysis ‐ self reported physical activity: 12 months).

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Delivery: individual	4	5801	Std. Mean Difference (IV, Random, 95% CI)	0.11 [‐0.04, 0.27]
2 Delivery: mixed (individual and group)	4	924	Std. Mean Difference (IV, Random, 95% CI)	0.27 [0.14, 0.40]
3 Implementer: health professional	3	4145	Std. Mean Difference (IV, Random, 95% CI)	0.16 [‐0.15, 0.48]
4 Implementer: non‐health professional	5	2580	Std. Mean Difference (IV, Random, 95% CI)	0.20 [0.06, 0.35]
5 Physical activity type: specified	3	609	Std. Mean Difference (IV, Random, 95% CI)	0.33 [0.17, 0.49]
6 Physical activity type: not specified	5	6116	Std. Mean Difference (IV, Random, 95% CI)	0.12 [‐0.01, 0.25]
7 Prescribed physical activity: supervised	2	445	Std. Mean Difference (IV, Random, 95% CI)	0.33 [0.14, 0.51]
8 Prescribed physical activity: unsupervised	6	6280	Std. Mean Difference (IV, Random, 95% CI)	0.14 [0.01, 0.27]
9 Intervention: includes theory based counselling	4	2274	Std. Mean Difference (IV, Random, 95% CI)	0.21 [‐0.02, 0.44]
10 Intervention: does not include theory based counselling	4	4451	Std. Mean Difference (IV, Random, 95% CI)	0.18 [‐0.01, 0.37]

3.8. Analysis.

Comparison 3 Face‐to‐face interventions versus control (subgroup analysis ‐ self reported physical activity: 12 months), Outcome 8 Prescribed physical activity: unsupervised.

Characteristics of studies

Characteristics of included studies [ordered by study ID]

Aittasalo 2004.

Methods
Participants	Workplace employees from nine different sites
Interventions	The participant’s current LTPA was assessed by a trained nurse and an individual goal for PA was set. All participants were given a supplementary leaflet about PA, developed for the contemplation and preparation stages, plus a written weekly PA plan and a self monitoring PA diary for the next follow‐up visit. At the follow‐up visits (after 8 weeks, 6 and 12 months) progress was reviewed and, if necessary, modified. During all the visits, emphasis was put on strengthening the participant’s positive impressions of their capability to follow the plan (self‐efficacy). Three fitness test were also administered at baseline, 6 and 12 months.
Outcomes	Self‐reported PA
Notes
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Not stated
Allocation concealment (selection bias)	Unclear risk	Not stated
Blinding of participants and personnel (performance bias) All outcomes	Unclear risk	Clear presentation of participant numbers at each stage of trial
Blinding of outcome assessment (detection bias) All outcomes	Unclear risk	Not stated
Incomplete outcome data (attrition bias) All outcomes	Low risk	All outcomes reported
Selective reporting (reporting bias)	Low risk	All outcomes stated were analysed
Other bias	Low risk	Validated outcome measures

Calfas 2000.

Methods
Participants	Primary care patients
Interventions	Participants received a 15 week cognitive behavioural education course, which comprised 15 x 50 minute lectures followed by 15 x 110 minute laboratory experiences that were led by peer health facilitators and included practice of behavioural management strategies as homework. Participants received two course credits and could attend two supervised exercise sessions per week. All participants received monthly follow‐up phone calls and monthly written materials for 15 months.
Outcomes	Self‐reported PA
Notes
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Not stated
Allocation concealment (selection bias)	Unclear risk	Not stated
Blinding of participants and personnel (performance bias) All outcomes	Low risk	Clear presentation of participant numbers at each stage of trial
Blinding of outcome assessment (detection bias) All outcomes	Unclear risk	Not stated
Incomplete outcome data (attrition bias) All outcomes	Low risk	All outcomes reported
Selective reporting (reporting bias)	Low risk	All outcomes stated were analysed
Other bias	Unclear risk	Validated outcome measures

Cunningham 1987.

Methods
Participants	Retirees from community centre
Interventions	Participants received 3 group exercise sessions per week and were encouraged to do one additional home based session
Outcomes	Self‐reported PA Cardio‐respiratory fitness
Notes
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Not stated
Allocation concealment (selection bias)	Unclear risk	Not stated
Blinding of participants and personnel (performance bias) All outcomes	High risk	Participant numbers were not clearly reported
Blinding of outcome assessment (detection bias) All outcomes	Unclear risk	Not blinded
Incomplete outcome data (attrition bias) All outcomes	Unclear risk	All outcomes reported
Selective reporting (reporting bias)	Low risk	All outcomes stated were analysed
Other bias	Unclear risk	Fitness assessment reliability reported

Grandes 2011.

Methods
Participants	Primary care patients
Interventions	Physician delivered brief advice and educational materials within a 15 minute intervention, plus an individualised PA plan. The intervention was supported by web based software to prompt and guide the physician and patient session
Outcomes	Self‐reported PA
Notes
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Authors reported a total of 70 family physicians as allocation units from 13 health centres that were randomised before patient recruitment, in a 1:1 ratio using computer generated random numbers provided by a central site. Baseline characteristics of these participants were balanced between both comparison groups with regard to the primary and secondary outcomes, as well as to the majority of sociodemographic and risk factors
Allocation concealment (selection bias)	High risk	Randomisation of physicians before patient recruitment prevented concealment of the patient enrolment process
Blinding of participants and personnel (performance bias) All outcomes	Low risk	Clear presentation of participant numbers at each stage of trial
Blinding of outcome assessment (detection bias) All outcomes	Low risk	Trained nurses working in exercise laboratories who performed baseline and follow‐up measurements at 6, 12 and 24 months were blinded to the allocation group of the participants
Incomplete outcome data (attrition bias) All outcomes	Low risk	All outcomes reported
Selective reporting (reporting bias)	Unclear risk	All outcomes stated were analysed
Other bias	Low risk	Validated outcome measures

Harland 1999.

Methods
Participants	Primary care patients
Interventions	All participants completed a baseline assessment of self‐reported PA, physical measures and cycle ergometer fitness test. They received feedback on their results, brief advice about their present level of PA and comparison to recommended levels, plus written health information, 19 leaflets about local PA facilities and activities. In addition, each participant was allocated to one of four intervention groups: (i) one motivational interview; (ii) one motivational interview plus vouchers for free use of local facilities; (iii) 6 motivational interviews over 12 weeks; and (iv) 6 motivational interviews over 12 weeks plus vouchers.
Outcomes	Self‐reported PA
Notes
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	After their baseline assessment, participants were randomised in blocks of 10. They chose blind from a set of 10 randomly ordered cards corresponding to intervention or control groups and were allocated to the group drawn. Baseline characteristics were evenly distributed in control and intervention groups
Allocation concealment (selection bias)	Unclear risk	Not stated
Blinding of participants and personnel (performance bias) All outcomes	Low risk	Participant numbers were clearly reported
Blinding of outcome assessment (detection bias) All outcomes	Low risk	Assessors were blinded to the allocation group of the participants
Incomplete outcome data (attrition bias) All outcomes	Unclear risk	All outcomes reported
Selective reporting (reporting bias)	Unclear risk	All outcomes stated were analysed
Other bias	Low risk	ITT but the outcome measure used by Harland 1999 did not report any measurement metrics and was adapted from a national survey tool

Hillsdon 2002.

Methods
Participants	Primary care patients
Interventions	Participants received brief negotiation plus follow‐up phone calls, or direct advice plus phone calls
Outcomes	Self‐reported PA
Notes
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Randomisation performed by independently in monthly batches which produced balanced groups at baseline
Allocation concealment (selection bias)	Low risk	Not stated
Blinding of participants and personnel (performance bias) All outcomes	Low risk	Participant numbers were clearly reported
Blinding of outcome assessment (detection bias) All outcomes	High risk	Assessor knew allocation status
Incomplete outcome data (attrition bias) All outcomes	Low risk	All outcomes reported
Selective reporting (reporting bias)	Low risk	All outcomes stated were analysed
Other bias	Low risk	Validated outcome measures, ITT

Katz 2008.

Methods
Participants	Primary care patients
Interventions	Participants received five sessions of the Pressure Systems Model. This comprised tailored counselling based on motivational interviewing plus handout materials addressing barriers to PA
Outcomes	Self‐reported PA
Notes
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Not stated but no significant (P > 0.05) differences were observed in gender, illness/injury/disability and PA between the intervention and control sites at baseline. However, marital status, race and education level differed significantly (P < 0.05) between the intervention and control sites at baseline
Allocation concealment (selection bias)	Unclear risk	Not stated
Blinding of participants and personnel (performance bias) All outcomes	Unclear risk	Not stated
Blinding of outcome assessment (detection bias) All outcomes	Unclear risk	Not stated
Incomplete outcome data (attrition bias) All outcomes	Unclear risk	All outcomes reported
Selective reporting (reporting bias)	High risk	All outcomes stated were analysed
Other bias	High risk	Validated outcome measures

King 1991.

Methods
Participants	Inactive community older volunteers aged 50‐65 years
Interventions	Participants received baseline physiological assessments and then were prescribed group based training at high intensity plus written information, PA logs and phone calls. They attedned local exercise classes at least three times per week for 12 months. Telephone calls were made once a week for the first four weeks, twice a week for the next four weeks and then once a month for 12 months.
Outcomes	Cardio‐respiratory fitness
Notes
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Participants were randomly assigned to one of the four exercise training conditions using a computerised version of the Efron procedure
Allocation concealment (selection bias)	High risk	Not stated
Blinding of participants and personnel (performance bias) All outcomes	Low risk	Clear presentation of participant numbers at each stage of trial
Blinding of outcome assessment (detection bias) All outcomes	Low risk	Assessment staff were blind to the results of the subjects' previous visits
Incomplete outcome data (attrition bias) All outcomes	High risk	All outcomes reported
Selective reporting (reporting bias)	Low risk	All outcomes stated were analysed
Other bias	Low risk	Validated outcome measures

Kriska 1986.

Methods
Participants	Older women
Interventions	Participants received a baseline physical assessment, eight week walking training programme with organised walks and then a choice of group or independent walking. Participants monitored their walking with monthly logs and were also offered social meetings. Participants also received follow‐up phone calls, cards, and incentives to maintain compliance.
Outcomes	Self‐reported PA
Notes
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Not stated
Allocation concealment (selection bias)	Unclear risk	Not stated
Blinding of participants and personnel (performance bias) All outcomes	Unclear risk	Not stated
Blinding of outcome assessment (detection bias) All outcomes	High risk	Not stated
Incomplete outcome data (attrition bias) All outcomes	Unclear risk	Does not describe dropout numbers
Selective reporting (reporting bias)	Unclear risk	Some outcomes were analysed
Other bias	Low risk	Validated outcome measures

Stewart 2001.

Methods
Participants	Health maintenance organisation members
Interventions	Participants received social cognitive theory based counselling to develop and maintain their own PA routine using locally available resources. They also attended informational meetings, individual planning sessions, monthly group workshops that were augmented by PA diaries, telephone calls, newsletters, and functional fitness assessments. Participants were strongly encouraged to attend the first two of 10 workshops where a walking clinic was offered.
Outcomes	Self‐reported PA
Notes
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Not stated but none of the measures differed significantly at baseline
Allocation concealment (selection bias)	Unclear risk	Not stated
Blinding of participants and personnel (performance bias) All outcomes	Low risk	Clear presentation of participant numbers at each stage of trial
Blinding of outcome assessment (detection bias) All outcomes	High risk	Not stated
Incomplete outcome data (attrition bias) All outcomes	Unclear risk	All outcomes reported but as graphs
Selective reporting (reporting bias)	Unclear risk	All outcomes stated were analysed
Other bias	Low risk	Validated outcome measures

Characteristics of excluded studies [ordered by study ID]

Study	Reason for exclusion
Aggarwal 2010	Multiple risk factor intervention
Aittasalo 2006	Less than 12 months follow‐up
Akiyama 2007	Less than 12 months follow‐up
Albright 2005	No appropriate control or intervention group
Albright 2012	No appropriate control or intervention group
Andersen 2012	Less than 12 months follow‐up
Anderson 2005	No appropriate control or intervention group
Armit 2005	Less than 12 months follow‐up
Armit 2009	Less than 12 months follow‐up
Baker 2008	No appropriate control or intervention group
Baker 2008a	No appropriate control or intervention group
Baker 2011	Less than 12 months follow‐up
Baruth 2010	More than 20% loss to follow‐up
Baruth 2010a	No appropriate control or intervention group
Bennett 2008	Less than 12 months follow‐up
Berlant 2004	No appropriate control or intervention group
Bowen 2006	No appropriate control or intervention group
Buman 2011	No appropriate control or intervention group
Caperchione 2006	No appropriate control or intervention group
Carr 2012	Less than 12 months intervention
Carroll 2010	Less than 12 months intervention
Castro 2011	Remote and web 2.0 intervention
Cheung 2008	Less than 12 months intervention
Connell 2009	Insufficient data
Cox 2006	Study aim irrelevant
Cox 2008	Study aim irrelevant
Cox 2011	Study aim irrelevant
Cox 2011a	Study aim irrelevant
Crain 2010	Remote and web 2.0 intervention
de Vreede 2007	Less than 12 months follow‐up
Dorgo 2009	Less than 12 months follow‐up
Dorgo 2011	Less than 12 months follow‐up
Dubbert 2002	Less than 12 months follow‐up
Duncan 2005	No appropriate control or intervention group
Duru 2010	Less than 12 months follow‐up
Elley 2003	Remote and web 2.0 intervention
Elley 2004	Remote and web 2.0 intervention
Elley 2011	Remote and web 2.0 intervention
Estabrooks 2011	Less than 12 months follow‐up
Evers 2012	Less than 12 months follow‐up
Farmandbar 2012	Insufficient data
Ferney 2009	Less than 12 months follow‐up
Findorff 2007	Inappropriate primary outcome
Finni 2011	No appropriate control or intervention group
Fitzsimons 2008	No appropriate control or intervention group
Fitzsimons 2012	No appropriate control or intervention group
Fortier 2007	Less than 12 months follow‐up
Fortier 2007a	Less than 12 months follow‐up
Fortier 2011	Less than 12 months follow‐up
Fortier 2011a	Less than 12 months follow‐up
Freene 2011	No appropriate control or intervention group
French 2011	Less than 12 months follow‐up
Froehlich‐Grobe 2012	More than 10% of participants with a pre‐existing medical condition
Fujita 2003	Less than 12 months follow‐up
Fukuoka 2011	No appropriate control or intervention group
Gine‐Garriga 2009	More than 10% of participants with a pre‐existing medical condition
Godin 2010	Less than 12 months follow‐up
Goldstein 1999	Less than 12 months follow‐up
Greaney 2008	Multiple risk factor intervention
Green 2002	Less than 12 months follow‐up
Hardcastle 2012	Non‐randomised study
Hardeman 2011	Remote and web 2.0 intervention
Harrison 2005	More than 10% of participants with a pre‐existing medical condition
Havenar 2007	More than 20% loss to follow‐up
Heesch 2004	Face‐to‐face versus remote and web 2.0 interventions
Herrera‐Sanchez 2006	Multiple risk factor intervention
Hind 2010	Less than 12 months follow‐up
Hosper 2008	Non‐randomised study
Hovell 2008	Multiple risk factor intervention
Hughes 2009	Less than 12 months follow‐up
Inoue 2003	Less than 12 months follow‐up
Isaacs 2007	Less than 12 months follow‐up
Jimmy 2005	Non‐randomised study
Jolly 2009	Less than 12 months follow‐up
Juneau 1987	Less than 12 months follow‐up
Kerse 2005	Remote and web 2.0 intervention
King 1988	Less than 12 months follow‐up
King 2006	No appropriate control or intervention group
King 2007	Remote and web 2.0 intervention
Kinmonth 2008	Remote and web 2.0 intervention
Kolt 2007	Remote and web 2.0 intervention
Kolt 2009	No appropriate control or intervention group
Kolt 2012	No appropriate control or intervention group
Kriska 2012	Study aim irrelevant
Lamb 2002	No appropriate control or intervention group
Lawton 2008	Remote and web 2.0 intervention
Lawton 2009	Remote and web 2.0 intervention
LeCheminant 2011	Less than 12 months follow‐up
Leung 2012	No appropriate control or intervention group
Lombard 1995	Less than 12 months follow‐up
Macmillan 2011	Less than 12 months follow‐up
Marcus 2007	No appropriate control or intervention group
Marcus 2007a	No appropriate control or intervention group
Marcus 2007b	Remote and web 2.0 intervention
Marcus 2007c	Remote and web 2.0 intervention
Marshall 2003	Less than 12 months follow‐up
Marshall 2004	Less than 12 months follow‐up
Martinson 2008	Remote and web 2.0 intervention
Martinson 2010	Remote and web 2.0 intervention
McAuley 2007	No appropriate control or intervention group
McAuley 2012	Remote and web 2.0 intervention
McEachan 2011	No appropriate control or intervention group
McGowan 2009	Less than 12 months follow‐up
McGowan 2009a	Less than 12 months follow‐up
McMurdo 2010	Less than 12 months follow‐up
Merom 2007	Less than 12 months follow‐up
Muda 2006	Less than 12 months follow‐up
Murphy 2010	More than 10% of participants with a pre‐existing medical condition
Napolitano 2006	Remote and web 2.0 intervention
Napolitano 2010	Remote and web 2.0 intervention
Newton 2004	Less than 12 months follow‐up
Nichols 2000	Less than 12 months follow‐up
Nies 2006	No appropriate control or intervention group
Norris 2000	Less than 12 months follow‐up
Norton 2011	Non‐randomised study
Opdenacker 2008	More than 20% loss to follow‐up
Opdenacker 2011	More than 20% loss to follow‐up
Oppert 2007	Less than 12 months follow‐up
Paasche‐Orlow 2012	No appropriate control or intervention group
Papandonatos 2012	Remote and web 2.0 intervention
Peels 2012	Remote and web 2.0 intervention
Pekmezi 2009	Less than 12 months follow‐up
Pekmezi 2010	No appropriate control or intervention group
Petrella 2003	No appropriate control or intervention group
Petrella 2006	More than 20% loss to follow‐up
Petrella 2010	No appropriate control or intervention group
Pinto 2002	Less than 12 months follow‐up
Pinto 2005	Less than 12 months follow‐up
Plotnikoff 2007	More than 20% loss to follow‐up
Plotnikoff 2010	More than 20% loss to follow‐up
Poulsen 2007	More than 20% loss to follow‐up
Prestwich 2012	Less than 12 months follow‐up
Ransdell 2004	Less than 12 months follow‐up
Reed 2008	Less than 12 months follow‐up
Reid 1979	Less than 12 months follow‐up
Resnick 2002	Less than 12 months follow‐up
Rose 2007	Remote and web 2.0 intervention
Sarkisian 2010	No appropriate control or intervention group
Schneider 2011	No appropriate control or intervention group
Sevick 2007	Remote and web 2.0 intervention
Sheeran 2012	Less than 12 months follow‐up
Sherwood 2008	Remote and web 2.0 intervention
Simons‐Morton 2001	No appropriate control or intervention group
Skar 2011	Less than 12 months follow‐up
Slootmaker 2005	Less than 12 months follow‐up
Smith 2000	Less than 12 months follow‐up
Sorensen 2007	Less than 12 months follow‐up
Sorensen 2008	Less than 12 months follow‐up
Spittaels 2007	Less than 12 months follow‐up
Spittaels 2007a	Less than 12 months follow‐up
Steele 2007	Less than 12 months follow‐up
Steele 2009	Less than 12 months follow‐up
Stevens 1998	Less than 12 months follow‐up
Talbot 2010	Less than 12 months follow‐up
Talbot 2011	Less than 12 months follow‐up
Tan 2006	Less than 12 months follow‐up
Taylor 2005	Less than 12 months follow‐up
Thogersen‐Ntoumani 2010	Less than 12 months follow‐up
Thomas 2012	No appropriate control or intervention group
Vainionpää 2007	Study aim irrelevant
van Sluijs 2006	Less than 12 months follow‐up
van Stralen 2008	Remote and web 2.0 intervention
van Stralen 2009	Remote and web 2.0 intervention
van Stralen 2009a	Remote and web 2.0 intervention
van Stralen 2010	Remote and web 2.0 intervention
van Stralen 2011	Remote and web 2.0 intervention
Visek 2011	Less than 12 months follow‐up
von Thiele 2008	Study aim irrelevant
Wadsworth 2010	Less than 12 months follow‐up
Wanner 2009	No appropriate control or intervention group
Wanner 2010	No appropriate control or intervention group
Watkinson 2010	Less than 12 months follow‐up
Whitehead 2007	Less than 12 months follow‐up
Wilcox 2007	More than 20% loss to follow‐up
Williams 2004	Remote and web 2.0 intervention
Williams 2006	Remote and web 2.0 intervention
Williams 2011	No appropriate control or intervention group
Wilson 2009	Less than 12 months follow‐up

Characteristics of ongoing studies [ordered by study ID]

Iliffe 2010.

Trial name or title	ProAct 65+ trial
Methods	Pragmatic 3 arm parallel design cluster controlled trial
Participants	Older adults aged 65 years and over
Interventions	Class based exercise (FAME), home based exercise (OEP) and usual care
Outcomes	Achievement of recommended PA targets
Starting date	2010
Contact information	Professor S Iliffe, Department of Primary Care & Population Health, University College London, Rowland Hill St, London NW3 2PF, UK. s.iliffe@pcps.ucl.ac.uk
Notes

Wilson 2010.

Trial name or title	"Positive Action for Today's Health" (PATH) trial
Methods	Cluster randomised controlled trial (three communities matched on census tract information ‐ crime, PA, ethnic minorities, and income)
Participants	Adults aged 18 year or older who are residents of three communities
Interventions	The three communities have been randomised to receive one of the three interventions: an intervention that combines a police‐patrolled‐walking program with a social marketing intervention, a police‐patrolled walking program only, or no‐walking related intervention (general health education only)
Outcomes	Objective assessment of PA using Actical min MVPA/day, assessed at 12, 18 and 24 months
Starting date	2010
Contact information	Professor D Wilson, Department of Psychology, University of South Carolina, Columbia, SC 29208, United States. wilsondk@mailbox.sc.edu
Notes

Differences between protocol and review

Study selection

The six month follow‐up period was extended to 12 months in response to the recommendations from the previous versions of this review, which called for better study quality with longer follow‐up periods (Foster 2005a).

Data extraction

The identified authors undertaking this task were modified.

Assessing the risk of bias

The identified authors undertaking this task were modified and the criteria for completing this task were explicitly identified.

Unit of analysis

The method for dealing with multiple intervention arms in a study was changed and these arms were not compared to a split control group. Instead, the relevant intervention arms were combined for comparison against the existing control group using established approaches (Higgins 2011).

Subgroup analysis

The following refinements were made to the subgroup analysis based on the data that were available in the identified studies.

1. The inclusion of a comparison of group versus individual versus mixed (group and individual) was removed from the primary outcome measures section and more appropriately included as a subgroup analysis. This comparison also became a secondary rather than a primary objective.

2. The prescription of the intervention was changed to focus on whether the type of PA was specified, and if theory based counselling was included.

3. The intensity of the intervention delivery was changed to focus on whether the PA participation was directly supervised.

Sensitivity analysis

The threshold for 'low' risk was specified as meeting at least 50% of the applicable risk of bias criteria.

Contributions of authors

All named authors contributed to the conceptual planning of this suite of reviews to update the previously completed Cochrane review assessing 'Interventions for promoting physical activity' (Foster 2005a). This manuscript was initially drafted by Justin Richards and Charlie Foster. Editorial contributions were received from Margaret Thorogood and Melvyn Hillsdon.

Sources of support

Internal sources

• British Heart Foundation Core Grant (021/P&C/Core/2010/HPRG), UK.

External sources

• NIHR Cochrane Incentive Scheme 2012, UK.

Declarations of interest

Melvyn Hillsdon has received a research council grant to investigate the feasibility of a primary care PA intervention. This was not a study of outcomes and therefore had no bearing on this review. He has been a member of a NICE programme development group on walking and cycling and was paid for travel expenses.

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