Baker Philip R A, Francis Daniel P, Soares Jesus, Weightman Alison L, Foster Charles
School of Public Health and Social Work, Instiitute of Health and Biomedical Innovation, Queensland University of Technology, KelvinGrove, Australia.
Cochrane Database Syst Rev. 2015 Jan 5;1(1):CD008366. doi: 10.1002/14651858.CD008366.pub3.
BACKGROUND: Multi-strategic community wide interventions for physical activity are increasingly popular but their ability to achieve population level improvements is unknown. OBJECTIVES: To evaluate the effects of community wide, multi-strategic interventions upon population levels of physical activity. SEARCH METHODS: We searched the Cochrane Public Health Group Segment of the Cochrane Register of Studies,The Cochrane Library, MEDLINE, MEDLINE in Process, EMBASE, CINAHL, LILACS, PsycINFO, ASSIA, the British Nursing Index, Chinese CNKI databases, EPPI Centre (DoPHER, TRoPHI), ERIC, HMIC, Sociological Abstracts, SPORT Discus, Transport Database and Web of Science (Science Citation Index, Social Sciences Citation Index, Conference Proceedings Citation Index). We also scanned websites of the EU Platform on Diet, Physical Activity and Health; Health-Evidence.org; the International Union for Health Promotion and Education; the NIHR Coordinating Centre for Health Technology (NCCHTA); the US Centre for Disease Control and Prevention (CDC) and NICE and SIGN guidelines. Reference lists of all relevant systematic reviews, guidelines and primary studies were searched and we contacted experts in the field. The searches were updated to 16 January 2014, unrestricted by language or publication status. SELECTION CRITERIA: Cluster randomised controlled trials, randomised controlled trials, quasi-experimental designs which used a control population for comparison, interrupted time-series studies, and prospective controlled cohort studies were included. Only studies with a minimum six-month follow up from the start of the intervention to measurement of outcomes were included. Community wide interventions had to comprise at least two broad strategies aimed at physical activity for the whole population. Studies which randomised individuals from the same community were excluded. DATA COLLECTION AND ANALYSIS: At least two review authors independently extracted the data and assessed the risk of bias. Each study was assessed for the setting, the number of included components and their intensity. The primary outcome measures were grouped according to whether they were dichotomous (per cent physically active, per cent physically active during leisure time, and per cent physically inactive) or continuous (leisure time physical activity time (time spent)), walking (time spent), energy expenditure (as metabolic equivalents or METS)). For dichotomous measures we calculated the unadjusted and adjusted risk difference, and the unadjusted and adjusted relative risk. For continuous measures we calculated percentage change from baseline, unadjusted and adjusted. MAIN RESULTS: After the selection process had been completed, 33 studies were included. A total of 267 communities were included in the review (populations between 500 and 1.9 million). Of the included studies, 25 were set in high income countries and eight were in low income countries. The interventions varied by the number of strategies included and their intensity. Almost all of the interventions included a component of building partnerships with local governments or non-governmental organisations (NGOs) (29 studies). None of the studies provided results by socio-economic disadvantage or other markers of equity. However, of those included studies undertaken in high income countries, 14 studies were described as being provided to deprived, disadvantaged or low socio-economic communities. Nineteen studies were identified as having a high risk of bias, 10 studies were unclear, and four studies had a low risk of bias. Selection bias was a major concern with these studies, with only five studies using randomisation to allocate communities. Four studies were judged as being at low risk of selection bias although 19 studies were considered to have an unclear risk of bias. Twelve studies had a high risk of detection bias, 13 an unclear risk and four a low risk of bias. Generally, the better designed studies showed no improvement in the primary outcome measure of physical activity at a population level.All four of the newly included, and judged to be at low risk of bias, studies (conducted in Japan, United Kingdom and USA) used randomisation to allocate the intervention to the communities. Three studies used a cluster randomised design and one study used a stepped wedge design. The approach to measuring the primary outcome of physical activity was better in these four studies than in many of the earlier studies. One study obtained objective population representative measurements of physical activity by accelerometers, while the remaining three low-risk studies used validated self-reported measures. The study using accelerometry, conducted in low income, high crime communities of USA, emphasised social marketing, partnership with police and environmental improvements. No change in the seven-day average daily minutes of moderate to vigorous physical activity was observed during the two years of operation. Some program level effect was observed with more people walking in the intervention community, however this result was not evident in the whole community. Similarly, the two studies conducted in the United Kingdom (one in rural villages and the other in urban London; both using communication, partnership and environmental strategies) found no improvement in the mean levels of energy expenditure per person per week, measured from one to four years from baseline. None of the three low risk studies reporting a dichotomous outcome of physical activity found improvements associated with the intervention.Overall, there was a noticeable absence of reporting of benefit in physical activity for community wide interventions in the included studies. However, as a group, the interventions undertaken in China appeared to have the greatest possibility of success with high participation rates reported. Reporting bias was evident with two studies failing to report physical activity measured at follow up. No adverse events were reported.The data pertaining to cost and sustainability of the interventions were limited and varied. AUTHORS' CONCLUSIONS: Although numerous studies have been undertaken, there is a noticeable inconsistency of the findings in the available studies and this is confounded by serious methodological issues within the included studies. The body of evidence in this review does not support the hypothesis that the multi-component community wide interventions studied effectively increased physical activity for the population, although some studies with environmental components observed more people walking.
背景:针对身体活动的多策略社区范围干预措施越来越普遍,但其能否在人群层面实现改善尚不清楚。 目的:评估社区范围的多策略干预措施对人群身体活动水平的影响。 检索方法:我们检索了Cochrane研究注册库中的Cochrane公共卫生组部分、Cochrane图书馆、MEDLINE、MEDLINE在研数据库、EMBASE、CINAHL、LILACS、PsycINFO、ASSIA、英国护理索引、中国知网数据库、EPPI中心(DoPHER、TRoPHI)、ERIC、HMIC、社会学文摘、SPORT Discus、交通数据库和科学网(科学引文索引、社会科学引文索引、会议论文引文索引)。我们还浏览了欧盟饮食、身体活动与健康平台、Health-Evidence.org、国际健康促进与教育联盟、英国国家卫生研究院健康技术协调中心(NCCHTA)、美国疾病控制与预防中心(CDC)以及英国国家卫生与临床优化研究所(NICE)和苏格兰院校指南网络(SIGN)指南的网站。检索了所有相关系统评价、指南和原始研究的参考文献列表,并联系了该领域的专家。检索更新至2014年1月16日,不受语言或出版状态限制。 选择标准:纳入整群随机对照试验、随机对照试验、使用对照人群进行比较的准实验设计、中断时间序列研究以及前瞻性对照队列研究。仅纳入从干预开始到结局测量至少有六个月随访的研究。社区范围干预必须包括至少两种针对全体人群身体活动的广泛策略。排除将同一社区个体进行随机分组的研究。 数据收集与分析:至少两名综述作者独立提取数据并评估偏倚风险。对每项研究的背景、纳入组成部分的数量及其强度进行评估。主要结局指标根据其是二分法(身体活动者百分比、休闲时间身体活动者百分比、身体不活动者百分比)还是连续性指标(休闲时间身体活动时间(花费时间)、步行时间(花费时间)、能量消耗(以代谢当量或梅脱表示))进行分组。对于二分法指标,我们计算未调整和调整后的风险差以及未调整和调整后的相对风险。对于连续性指标,我们计算相对于基线的百分比变化,未调整和调整后的。 主要结果:选择过程完成后,纳入33项研究。本综述共纳入267个社区(人口在500至190万之间)。纳入的研究中,25项在高收入国家开展,8项在低收入国家开展。干预措施因纳入策略的数量及其强度而异。几乎所有干预措施都包括与地方政府或非政府组织建立伙伴关系的组成部分(29项研究)。没有研究按社会经济劣势或其他公平指标提供结果。然而,在高收入国家开展的纳入研究中,14项研究被描述为针对贫困、弱势或社会经济地位低的社区。19项研究被确定存在高偏倚风险,10项研究不清楚,4项研究存在低偏倚风险。选择偏倚是这些研究的主要关注点,只有5项研究使用随机化分配社区。4项研究被判定选择偏倚风险低,尽管19项研究被认为偏倚风险不清楚。12项研究存在高检测偏倚风险,13项研究不清楚,4项研究存在低偏倚风险。总体而言,设计较好的研究在人群层面身体活动的主要结局指标上未显示出改善。新纳入的且被判定为低偏倚风险的所有4项研究(在日本、英国和美国开展)均使用随机化将干预措施分配到社区。3项研究采用整群随机设计,1项研究采用阶梯楔形设计。这4项研究中测量身体活动主要结局的方法比许多早期研究更好。1项研究通过加速度计获得了客观的人群代表性身体活动测量值,其余3项低风险研究使用了经过验证的自我报告测量方法。在美国低收入、高犯罪社区开展的使用加速度计的研究强调社会营销、与警方的伙伴关系以及环境改善。在运营的两年期间,未观察到中度至剧烈身体活动的七天平均每日分钟数有变化。在干预社区观察到有更多人步行的一些项目层面效应,然而在整个社区中这一结果并不明显。同样,在英国开展的两项研究(一项在乡村,另一项在伦敦市区;均采用沟通、伙伴关系和环境策略)发现,从基线起一至四年测量的每人每周平均能量消耗水平没有改善。报告身体活动二分法结局的3项低风险研究中,没有一项发现干预措施带来改善。总体而言,纳入研究中明显缺乏关于社区范围干预措施在身体活动方面益处的报告。然而,作为一个整体,在中国开展的干预措施似乎成功可能性最大,报告的参与率较高。两项研究未报告随访时测量的身体活动情况,存在报告偏倚。未报告不良事件。与干预措施成本和可持续性相关的数据有限且各不相同。 作者结论:尽管已开展了大量研究,但现有研究结果存在明显不一致性,且纳入研究中存在的严重方法学问题使其更加复杂。本综述中的证据不支持所研究的多成分社区范围干预措施能有效增加人群身体活动这一假设,尽管一些包含环境成分的研究观察到有更多人步行。
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