Policy brief on promoting physical activity among adolescents.

Regular physical activity (PA) is an underlying factor since childhood and adolescence for having a healthy and active future for life. The aim of this stud y was to review the evidence on increasing the youth PA to develop the national program at country level. At first, the databases were searched using the sensitive keywords, and systematic reviews of the relevant databases were extracted. The studies were evaluated in terms of relevance and methodological quality for effective interventions that were detected. These cases were also identified in the effective interventions: disadvantages, benefits, costs, methods, and limitations of early studies, which were based on systematic review of the studies. Three interventions were identified as physical education curriculum reform, the creation of extra-curricular activities, as well as approaches to environmental and social support. Evidences showed that the relative impact of these interventions were not high. Thus, a combination of all three options of integrated approach is recommended for reducing the sedentary lifestyle of youths.

INTRODUCTION

In spite of the public awareness about the health benefits of physical activity (PA) for youths, still there are barriers for an active lifestyle in many communities. The purpose of this study was to develop a national program to increase the PA in adolescents. Indeed, the obtained data from National School-Based Surveillance of Students’ High Risk Behaviors indicated the decrease in PA is a serious problem and an action must be done.[1] As a result, some interventions should be chosen for implementation. Those interventions should be approved by using the best available evidences and they should also be practical. Due to the nature of the PA, it is necessary to consider the beneficiary of various interventions to make the final choice. In the literature of evidence informed policy making, for these cases, the recommendation of formulated policy brief (PB) have been suggested. PB is a new approach in producing and presenting the evidences for decision makers and policymakers and is consisted of a compilation of systematic reviews and local evidences.[2] Explaining the position of PB and the manner of its formulation is shown in another article, but according to the author's knowledge, this is the first published PB in the peer review journals as the result of the conducted studies in Iran. For the formulation of PB and due to this fact that the respondent groups are the decision makers, the article format is slightly different.

Initially, the problem was introduced and then the global and local evidences have been reviewed. In order to decide the level of performance, those interventions have been targeted which there were good evidences for their effectiveness. It means that there were a set of synthesized evidences for their effectiveness. However, when introducing this option to the decision makers, various aspects of the intervention were offered to make better decisions. The introduction of policy options has been mentioned in this article.

Introducing the problem

Around the world, wide ranges of interventions and major policies have been performed for increasing the physical activity in children and adolescents.[3-5] However, despite that, still no agreement exists for a certain type of intervention.[67] Today, lack of physical activity is one of the dilemmas of modern life and the importance of this problem is more in adolescents’ age group and many of the beliefs and behavior habits can be formed and stabilized in the period of adolescence.[8-12] In our country, the problem of sedentary lifestyle adolescents is among the priority issues of the healthcare system.[1314] Therefore, collecting the documentation, timely planning, and implementation of active interventions for adolescents can have a great influence in reducing the disease burden and population health in the long run. On the other hand, the local evidence in PA interventions was not enough and has some shortcomings.[15-17] At the level of global evidence, the findings show that some interventions have been effective and others have been ineffective.[18-23] The “Healthy people 2020” program also reflects a multiple approach to promote physical activity in children and adolescents.[24] However, there is always a gap to prevent intervention recommendation in order to be defined in various settings. In fact, the differences in the structure of study (type of study, how to evaluate outcomes) and in addition, various aspects of the PA issue in different communities have impact on items such as culture, religion, ethnicity, facilities, and resources.[625] Since most of the adolescents spend a significant amount of time in school, therefore the use of school-based interventions is considered as an effective approach to increase the physical activity.[1826] This can be a range of activities during the school time, before or after it, and the school is the focal point of these activities. Hence, this document was prepared to provide evidence-based policy options including barriers, facilitators, and resources for Iranian adolescents to promote physical activity. Therefore, the policy makers can make more confident decisions and have better choices for planning interventions.

METHODS

This review took place without time limit until September 2011, in order to receive the systematic reviews published in English. In the searching strategy, three points were considered as follows:

(1) The target population (children, adolescents), (2) Intervention (education, behavior change and changing facilities) and (3) Behavior or consequences of the assessed cases (physical activity, health promotion outcomes).

Three types of databases were searched including:

Databases of systematic reviews: Health Systems Evidence (McMaster University) - health-evidence.ca- Cochrane Library- Health Information Research Unit (HIRU) - Rapid Evidence Assessment (REA).

Policy Brief (BP) databases: COHRED- EVIPNET Africa- Global and Social Policy program- Global Health Council- Health Action International- Health Systems Evidence, McMaster University- Management Sciences for Health (MSH)- Supporting Policy relevant Reviews and Trials (SUPPORT) Summaries- World Bank: Health Results Innovation Trust Fund (HRITF)

General databases: Pub med- Google Scholar- Magiran- Iranmedex -SID (three last databases are in Farsi).

The used key words were as follows (although searching with the key words was performed by the specific strategies in each database):

(adolescent OR young people OR child * OR pediatric * OR student) AND (school) AND (physical activity OR exercise OR sport OR cycling OR walk * OR physical education OR television viewing OR TV viewing OR sedentary) AND (intervention OR effectiveness OR promotion OR initiative * OR behavior change OR policy OR strategies OR health education)

The study inclusion criteria were included: (1) Children, adolescents (up to 19 years), (2) One or more subsequent interventions used to improve physical activity with or without considering the health consequences, (3) The main focus of interventions was on school (school based), respectively. However, the intervention also could be combined with multi-level actions, including family or community support. Those interventions were not considered, which were based solely on family, community or clinical settings, and (4) The main purpose of the intervention was not to change in specific diseases or health problems (such as obesity, skeletal problems, or…).

The results of this searching were included 640 systematic reviews. Titles and abstracts were reviewed independently by two browsers. Thirty articles met the inclusion criteria, which the full text of all of the articles were studied by three browsers. After the assessment with the ‘Critical Appraisal Skills Programme’ (CASP) critical appraisal tool, 17 articles were remained which had the minimum quality required for their inclusion. Finally, all the interventions used for the improvement of the physical activity were identified by three researchers independently after careful and complete study of the text articles. Then, by holding a meeting and exchanging the ideas between the research team members, the general classification of the existing interventions were performed with consensus.

Policy options

The first policy option (PA curriculum reforms) is the curriculum change in PA strategy with increasing the duration and intensity of physical activity to improve the quantity and quality of education and physical activities,[27] which has been considered in the secondary and high schools of the country. Educational provision of these classes can be a combination of the followings: physical activity programs, programs to reduce the time spent for watching television and sedentary activities along with teaching healthy eating and non-tobacco use.[28] New educational approaches based on behavioral theories are well known (such as health promotion model (HPM) and social cognitive theory).[29] Training aids can be used in most types of traditional methods (education using leaflets and brochures) and modern methods (CD or instructional video and internet applications).[1930] The second policy option (creation of extracurricular activities) includes the followings: entertainment programs (in the form of games and enjoyment), holding regular competitions and summer camps (such as hiking, biking, etc). Strategies employing short physical breaks (on average 10 minutes) have been fixed as a part of this program in addition to the existing curriculum.[3132] The final policy option (environmental approaches and social support) is included a range of strategies for capacity building, providing sports facilities and other cooperation from the community and families.[3334] Considering the available resources, it will be possible to exploit one or more interventions. Policy options for promoting physical activity and the implementing strategies of three alternative policy options are shown in Tables 1,2.

Table 1

Policy options for promoting physical activity, their description, and attributes

Table 2

Implementation characteristics of policy options for improving physical activity

DISCUSSION

This PB was developed with three policy options based on the evidences collected by searching in existing reviews. The global evidences showed that altogether, implementing of interventions and school-based multilevel can promote physical activity including training programs, physical activity (with the family and community support) and also may be effective to some extent in improving the adolescent health and fitness indicators.[5182943-45] However, it should be noted that reviews of the initial studies due to the heterogeneity, i.e., different types and quality of studies and implementing a variety of interventions, did not have a quantitative assessment (meta-analysis) of the used interventions. Their conclusion was based on the aggregate findings of the studies. These findings also showed that there are still shortcomings and gap, such as lack of the interventions effectiveness on different social – economic groups, ethnicities and separate programs for boys and girls. However, it was emphasized that the national associations and research organizations have the priority in promoting the PA. They should identify the financial resources and existing facilities for a long term monitoring program implementation.[51846] In searching local evidences, single studies showed the positive effects of multi-level interventions the same as the global evidences, but in neither of them there were comprehensive documentation for providing scientific evidences.[1347-50] There were numerous challenges in the field of financial resources, human resources and equipments. Severe weaknesses in inter-sectoral cooperation give rise to these problems. Finally, by considering the existing documents and aggregating the results of the interventions with appropriate quality and effectiveness, three available policy options were prepared. It seems that implementing the combination of policy options can be more effective.

However, it should be noted that implementing the proposed interventions have their own specific circumstances. The results can be effective only by respecting the limitations, resources and facilities. Therefore, since the possibilities and potential of different regions of the country is different, implementing a similar policy for all areas is not possible (e.g., using the pedometer, providing specific sports equipment and the usage of sports halls or equipped athletic places). This is recommended that the aspects of work to be measured by organizing a meeting with attending the planners and experts in order to prepare an equivalent program. Finally, it is expected that developing operational plans with using a combination of the three policy options will be instrumental in promoting physical activity in the secondary and high school students (ages 12 to 18 years) of the country.