Interventions

Publication Details

Introduction

The summary of the evidence collected in the systematic review is presented in this chapter under the following intervention categories:

  • policy and environment
  • mass media
  • school settings
  • the workplace
  • the community
  • primary health care
  • older adults
  • religious settings.

Although this categorization was chosen to facilitate an analysis by the reader, it should be underlined that interventions are only truly effective when national policies are aligned, coherent and supportive (portfolio approach).

Each category starts with extracts from DPAS, followed by an overview describing the scope of the category, and a summary of the evidence condensed into the following groups:

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Effective interventions: These interventions were based on a formative assessment, with a generally robust experimental design or sufficient sample size, and with significant effects on specified outcome variables. They generally met all or most of the planned objectives and would probably be applicable in other settings (disadvantaged communities and low- and middle-income countries), and demonstrated feasibility and sustainability in their current category. These interventions were most often considered the “example intervention” for the category and specific outcome.

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Moderately effective interventions: These interventions lacked one or more of the critical components listed above, but were sufficiently robust to warrant consideration for application in specific settings or groups and met some, if not all of the planned objectives.

One or two example interventions are then presented. An example intervention is one that serves as an archetype or model for a particular setting; a typical example of good practice that has been shown to be effective with respect to at least one outcome. Example interventions have preferably taken place in disadvantaged communities or in low- or middle income countries, and may be described as feasible or sustainable.

Each category ends with a synopsis of the psychosocial, behavioural, and physical and clinical outcomes and, finally, a summary statement.

Policy and environment

OVERVIEW

“National food and agricultural policies should be consistent with the protection and promotion of public health. Where needed, governments should consider policies that facilitate the adoption of healthy diet.”

“Multisectoral policies are needed to promote physical activity.”

“National and local governments should frame policies and provide incentives to ensure that walking, cycling and other forms of physical activity are accessible and safe; transport policies include nonmotorized modes of transportation; … and sport and recreation facilities embody the concept of sport for all.”

Policies and interventions that modify the physical environment are crucial to making changes to the diet and physical activity patterns of the population. A total of 23 interventions were summarized, with three targeting disadvantaged communities and two in low- or middle-income countries (430).

Included in this category are policies that change the composition of staple foods and that have a direct influence on the nutrient intake of the population. Environmental changes have also been demonstrated in the way stores and restaurants have used point-of-purchase prompts and messaging to encourage shoppers to select healthier food. Further, vending machines have been used to sell healthier snacks and beverages. From a physical activity perspective, environmental policies that impact on people's mode of transport or that increase public space for recreational activities, can also provide health benefits.

Summary of the evidence from the systematic review.

Table

Summary of the evidence from the systematic review.

Outcomes

The majority of dietary studies reported positive behavioural and psychosocial outcomes. Sales of healthier options generally increased in interventions where these options were available and/or were reduced in price (7, 13, 14, 16). Physical and clinical outcomes were rarely reported as many of these interventions target large populations. Only one study reported a clinical change, namely a significant decrease in cholesterol levels in adults (28).

Fourteen of the 23 interventions focused on physical activity alone. The frequency of stair use increased in all interventions that encouraged it (4, 8, 12, 18, 22). All the structural interventions reviewed demonstrated some increase in awareness of the importance of physical activity, intention to become physically active or knowledge regarding physical activity and health (46, 8, 12, 15, 18, 20, 22, 24, 27, 29, 30). All except for one physical activity intervention (18) were moderately effective in terms of changes in physical activity behaviour in the target groups.

Summary statement

Relatively few policy and environmental interventions have been evaluated in peer-reviewed studies. More research is urgently required. The current review showed that policy and environmental interventions create a healthy environment and support individuals to make healthy choices. These interventions can reach large populations. The evidence showed that regulatory policies to support a healthier composition of foods also work. Policies targeting the built environment or a reduction in barriers to physical activity showed positive results. Finally, point-of-decision prompts encouraging the use of stairs proved to be simple but effective policies.

Mass media

OVERVIEW

“Consistent, coherent, simple and clear messages … should be communicated through many channels and in forms appropriate to local culture, age and gender.”

“Simple, direct messages need to be communicated on the quantity and quality of physical activity sufficient to provide sustainable health benefits.”

Mass media campaigns use paid and non-paid forms of media to increase knowledge and change attitudes and behaviours towards diet and physical activity. These interventions commonly employ television and radio, as well as print media, and are often associated with community-based activities that run in parallel. Twenty-four interventions were summarized, including two targeting disadvantaged communities and three in low- or middle-income countries (3164).

Summary of the evidence from the systematic review.

Table

Summary of the evidence from the systematic review.

Outcomes

Fifteen of the 24 interventions reported psychosocial improvements, mostly in awareness of the campaign (31, 32, 3647, 52, 53, 55, 57, 62, 63).

Half of the interventions reported positive changes in behaviour (32, 33, 3639, 4147, 50, 5255, 57, 62, 63).

Four of the five interventions that reported on physical and clinical changes showed improvements (33, 40, 47, 48, 62).

Outcomes were often related to exposure, such that increased exposure to the campaign translated into greater positive changes (36, 46).

Positive changes were reported in high, low- and middle-income countries.

Summary statement

Since there have been few evaluations of mass media campaigns against chronic NCDs, more evidence is required on their effectiveness in a variety of settings and life cycle phases. Further research is needed to determine whether changes made as a result of such campaigns are sustained post-intervention. The limited knowledge base and data available make comparative analyses and cost-effectiveness research difficult. However, there is sufficient evidence to recommend multi-component mass media campaigns on a population basis in the settings which have been tested.

Characteristics of mass media campaigns for physical activity that have been successful in changing awareness and behaviour include the use of a simple message with frequent exposure. Those that are most likely to be successful are accompanied by appropriate “upstream” policy support and “downstream” community-based activities, and usually involve a community participation approach.

School settings

OVERVIEW

“Of particular concern are unhealthy diets, inadequate physical activity and energy imbalances in children and adolescents.”

“School policies and programmes should support the adoption of healthy diets and physical activity. Schools influence the lives of most children in all countries.”

The largest number of studies evaluated was on school-based interventions. One hundred and seven peer-reviewed articles provided information on 55 interventions, mostly from North America (65, 108). Minimal research came from low- or middle-income countries, although 14 interventions targeted disadvantaged communities within high-income countries. Common among the reviewed studies were comprehensive, multi-component programmes with interventions targeting the school environment and its food services and classroom curriculum. Many interventions combined diet and physical activity, and encouraged parental involvement

Summary of the evidence from the systematic review.

Table

Summary of the evidence from the systematic review.

Outcomes

Nearly all the school-based studies showed positive psychosocial and behavioural outcomes. However, only a few measured clinical outcomes.

Positive psychosocial changes were reported for 28 interventions (65, 66, 68, 71, 72, 78, 81-84, 87, 88, 91, 92, 98-104, 106-108, 110, 111, 113, 115, 118, 120, 122, 123, 124-129, 133, 138, 139, 141, 145-147, 150, 153, 160, 154-158,164, 166,168).

Behaviour was positively improved in 49 of the interventions, ranging from an increase in fruit and vegetable consumption to the number of minutes of physical activity (65-67, 70, 71, 77, 79, 80, 82, 85-88, 91-93, 95-97, 100-105, 108, 109, 118, 117, 120, 122, 123, 126-129, 134, 136-139, 141, 149, 150, 153-155, 158, 167, 170, 171).

15 interventions reported positive phisical and clinical changes (71, 85, 88, 90, 100-103, 109,110, 120, 122, 123, 127, 128, 134, 149, 166, 170, 171) and 6 reported no changes (98, 108, 144, 146, 147, 151, 152, 165, 172).

Summary statement

School-based interventions show consistent improvements in knowledge and attitudes, behaviour and, when tested, physical and clinical outcomes. There is strong evidence to show that schools should include a diet and physical activity component in the curriculum taught by trained teachers; ensure parental involvement; provide a supportive environment; include a food service with healthy choices; and offer a physical activity programme. However there is lack of cost-effectiveness research in this area.

The workplace

OVERVIEW

“National and local governments should frame policies and provide incentives to ensure that … labour and workplace policies encourage physical activity.”

The 38 workplace interventions reviewed included five that targeted disadvantaged communities (172-221). The majority of these interventions took place within North America, with a few based in Europe, and only one in a low- or middle-income country. Interventions were primarily multi-component and activities included environmental changes, food service changes, information campaigns, physical activity programmes and the adoption of healthy policies.

Summary of the evidence from the systematic review.

Table

Summary of the evidence from the systematic review.

Outcomes

Nineteen interventions had positive psychosocial changes in the areas of knowledge, attitudes and/or self-efficacy (120, 122, 123, 172, 178-180, 183-185, 190, 196, 199, 200, 206, 208, 210, 212, 220).

Positive behavioural changes were reported in 25 studies (172, 173, 176, 178, 180, 183-185, 187-189, 197-199, 202, 204, 206, 208, 210, 211, 212, 214, 216, 217, 219).

Physical and clinical changes were largely not evaluated, although 15 interventions demonstrated at least moderate improvements in BMI, blood pressure, and/or serum cholesterol (172, 178, 182, 184, 185, 188, 194, 195, 204-207, 209-211, 219).

Summary statement

The workplace is an ideal venue to offer employees structured and planned activities to improve their health. Since many workplaces provide meals, snacks and/or beverages, these can be optimized by providing healthy options at lowest prices in vending machines or in the available food service facilities. Additionally, physical activity programmes that are accessible and sustainable can be introduced at low cost to the organization to provide maximum health benefits for employees. Evidence consistently indicates that including workers in programme planning and implementation brings positive outcomes.

The community

OVERVIEW

“Strategies should be geared to changing social norms and improving community understanding and acceptance of the need to integrate physical activity into everyday life.”

Community-level interventions target communities, neighbourhoods, families, parents, couples and disadvantaged populations. Sixty-five interventions were reviewed with more then 20 focusing on disadvantaged communities and three from low- or middle-income countries (222-282). Many of the interventions were adult classes with curriculum on diet and physical activity focusing on knowledge, attitude and behaviour change. These classes sometimes targeted chronic NCD high-risk groups, such as those predisposed to type 2 diabetes or cardiovascular diseases. There were also a number of computer- or web-based programmes focused on weight loss or walking. Additionally, some interventions offered individual counselling followed by group sessions and/or telephone counselling with information distributed through the mail.

Summary of the evidence from the systematic review.

Table

Summary of the evidence from the systematic review.

Outcomes

Seventeen interventions reported positive psychosocial changes, including knowledge, attitudes, and self-efficacy to change behaviour (222, 223, 226, 228, 232, 234,235, 237, 241, 246, 257, 259, 280, 283, 295).

Positive behaviour changes were observed in one or more areas in 41 interventions, including decreased consumption of total and saturated fats, increased consumption of fruits and vegetables and increased number of minutes of physical activity (222-228, 230, 231, 233-236, 238, 240, 241, 249, 250, 255, 257, 259, 260, 262, 264, 266, 274, 276, 278, 281, 283, 286-289, 294, 296,). Seven interventions reported no improvements in behaviour (229, 242, 248, 254, 272, 273, 292).

Summary statement

As with school-based interventions, the most successful community interventions generally comprised many different activities and usually included both diet and physical activity components. The majority had a strong educational component, were theory-based and focused on facilitating changes in behaviour. To date, however, few interventions have been evaluated in terms of cost-effectiveness and sustainability. The Internet and electronic communication provide the potential to create and sustain “virtual” communities of persons with common interests, challenges and needs.

Primary health care

OVERVIEW

“Prevention is a critical element of health services. Routine contacts with health-service staff should include practical advice to patients and families on the benefits of healthy diets and increased levels of physical activity, combined with support to help patients initiate and maintain healthy behaviours.”

“Routine enquiries as to key dietary habits and physical activity, combined with simple information and skill-building to change behaviour, taking a life-course approach, can reach a large part of the population and be a cost-effective intervention.”

Sixty-seven manuscripts on 29 primary health care interventions were reviewed, all of which were from high-income countries (298-367). Five interventions focused on disadvantaged communities. The intensity of interventions ranged from minimal, where printed materials were made available, to intense, where participants lived at a facility and had a regulated activity schedule.

Summary of the evidence from the systematic review.

Table

Summary of the evidence from the systematic review.

Outcomes

Significant improvements in psychosocial variables were reported in five interventions (301, 303, 307, 312, 313, 320, 331-333, 335, 340, 341, 362, 361, 364, 366).

Eighteen interventions reported positive behaviour changes, i.e. eating more fruit and vegetables, eating less fat, and/or increasing physical activity (301-304, 307, 312-315, 317, 318, 320, 321, 328-333, 335, 340, 341-343, 345, 346, 348, 353-362, 364-367,).

Physical and clinical changes were positive in 10 interventions (298, 299, 302, 307, 317, 320, 321, 330-333, 337, 340-345, 350, 351, 353, 356, 362, 365-367).

Summary statement

Interventions in the primary health care setting vary greatly in their intensity and thus in their effectiveness. Minimal contact interventions, such as health checks, single visit counselling or information distribution have typically not been effective. However, individual responses may vary depending on stage of “readiness”. In conclusion, this setting is effective at modifying risk factors with moderately intense interventions that provide chronic NCD consultations with follow-up by trained personnel and targeted information. The potential of this setting in low- or middle-income countries is largely unknown.

Older adults

OVERVIEW

“… maintaining the health and functional capacity of the increasing elderly population will be a crucial factor in reducing the demand for, and cost of, health services.”

“A life-course perspective is essential for the prevention and control of noncommunicable diseases. This approach … encourages a healthy diet and regular physical activity from youth into old age.”

Seventeen interventions specifically targeted older adults, with three focusing on those in disadvantaged communities and three from low- or middle-income countries (308-381). The majority of interventions focused on physical activity. They ranged from health promotion classes, to home- and community-based physical activity classes, distribution of health information and increased exposure to fresh fruit and vegetables.

Summary of the evidence from the systematic review.

Table

Summary of the evidence from the systematic review.

Outcomes

Of the four interventions that measured psychosocial changes, two home-based programmes saw no improvement, one group programme saw an increase in quality of life and one Internet-based programme saw a decrease in perceived barriers (306, 368, 369, 375, 379, 383).

Nine interventions saw favourable increases in physical activity behaviour, and both diet-related interventions saw improvements (370, 382, 383).

Eight interventions reported physical and clinical changes, including improvements in blood pressure and fitness (306, 368, 369, 371-374, 376, 378, 381-383).

Summary statement

Maintaining and/or improving diet and physical activity among older adults can significantly improve overall health and quality of life in a globally aging population. Group physical activity programmes reported improvements in psychosocial outcomes. Interventions were effective across contexts. More long-term research is necessary to see changes in rates of chronic NCD morbidity and mortality. Programmes for older adults must reduce barriers by addressing accessibility, for example through home delivery of fruit and vegetables, or by conducting physical activity programmes at venues where older adults regularly meet.

Religious settings

OVERVIEW

“Consistent, coherent, simple and clear messages should be prepared and conveyed … through several channels and in forms appropriate to local culture, age and gender. Behaviour can be influenced especially in … religious institutions.”

Of the 10 interventions in the religious category, all but one were based in the United States of America (384-389). The majority of programmes were based in African-American congregations in disadvantaged communities. Programmes ranged from focusing on a healthy lifestyle, to increasing consumption of fruit and vegetables, weight loss, type 2 diabetes and cancer prevention.

Summary of the evidence from the systematic review.

Table

Summary of the evidence from the systematic review.

Outcomes

Five interventions reported favourable increases in knowledge, stage of change and/or self-efficacy (387, 389, 390, 393-395).

Seven interventions reported significant positive behaviour changes in physical activity or consumption of fruit and vegetables (384, 396, 390, 385, 391, 392, 394).

Positive physical and clinical changes were reported in one intervention (396).

Summary statement

While the number of interventions in religious settings is small, there is consistent evidence of positive psychosocial, behavioural and physical changes. Using the existing social structure of a religious community appears to facilitate adoption of changes towards a healthy lifestyle, especially in disadvantaged communities. There are also great advantages in terms of cost of this type of study since the spiritual members themselves may take responsibility for the intervention within the ambit of the religious environment.