Preventive Medicine 47 (2008) 354–368

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Preventive Medicine
j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / y p m e d

Review

Long-term effectiveness of interventions promoting physical activity:

A systematic review
Falk Müller-Riemenschneider ⁎, Thomas Reinhold, Marc Nocon, Stefan N. Willich
Institute for Social Medicine, Epidemiology, and Health Economics, Charité University Medical Center, 10098 Berlin, Luisenstraße 57, Germany

a r t i c l e i n f o a b s t r a c t

Article history: Background. This systematic review aims to evaluate the long-term effectiveness of physical activity
Available online 15 July 2008 interventions targeted at healthy adults and to identify effective intervention components.
Methods. The systematic search in Pubmed, Embase, the Cochrane Library and Psycinfo identified
Keywords:
literature published in English and German between January 2001 and June 2007. We included randomised
Physical activity
controlled trials investigating physical activity interventions for healthy adults with a minimum study
Exercise
Intervention
duration of 12 months. Two researchers independently assessed publications according to pre-defined
Systematic review inclusion criteria and methodological quality was rated according to the SIGN criteria. Study characteristics
Meta-analysis and outcome measures were extracted, and pooled effect estimates with 95% confidence intervals calculated.
Randomised controlled trials Results. Of 5508 identified publications 25 studies met the inclusion criteria. There was substantial
heterogeneity in study quality, intervention strategies and intervention effects. Compared to no-intervention
and minimal-intervention control, gains in weekly energy expenditure and physical fitness of up to 975 kcal
and 11% were achieved, respectively. Booster interventions were used in 16 studies.
Conclusions. There is evidence for long-term increases in physical activity behaviour and physical fitness.
To improve uptake of physical activity additional tailored exercise prescription strategies seem promising.
Booster interventions such as phone, mail or internet can help to facilitate long-term effectiveness.
© 2008 Elsevier Inc. All rights reserved.

Contents

Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 354
Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355
Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363
Long-term effectiveness of physical activity interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363
Sustainability of intervention effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 364
Intervention effectiveness in specific population groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365
Effectiveness of specific Intervention components . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365
Initial intervention intensity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365
Written exercise prescription . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365
Tailored vs. standard intervention messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365
Effectiveness of maintenance strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365
Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365
Conflict of interest statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367

Background

The positive effects of physical activity on health and mortality

when performed on a regular basis have been well established. In
⁎ Corresponding author.
E-mail address: falk.mueller-riemenschneider@charite.de
addition, physical activity plays an important role in the prevention of
(F. Müller-Riemenschneider). various chronic diseases, such as cardiovascular diseases, ischemic

0091-7435/$ – see front matter © 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.ypmed.2008.07.006
 F. Müller-Riemenschneider et al. / Preventive Medicine 47 (2008) 354–368 355

stroke, hypertension, obesity, diabetes mellitus, osteoporosis, colon reviews specifically investigating the long-term effectiveness of
cancers and fall related injuries (Camacho et al., 1991; Giovannucci et physical activity interventions in a rigorous way are currently not
al., 1995; Hu et al., 2001a; Sesso et al., 2000; Lee et al., 1995; Hu et al., available.
2000; Wannamethee and Shaper 1999; Hu et al., 2001b; Warburton et The present systematic review therefore aims to summarise the
al., 2006a; Wannamethee and Shaper 2001). While health benefits evidence for the long-term effectiveness of physical activity interven-
seem to increase with physical activity levels, already moderate levels tions and to identify efficacious intervention components. In the
have proved to be beneficial. Current guidelines therefore recommend context of this review long-term is defined as a study or follow-up
to achieve a weekly exercise based energy expenditure of about duration of at least 12 months.
1000 kcal (4200 kJ) or to accumulate 30 min of moderate intensity
physical activity over one day on most days of the week (Warburton et Methods
al., 2006a; US Department of Health and Human Services: Healthy
People 2010, 2000; Warburton et al., 2006b; Haskell et al., 2007). The focus of this systematic review is on current literature,
Despite the positive effects associated with moderate levels of published between January 2001 and June 2007. We identified
physical activity, sedentary life style remains a common problem in relevant publications by means of a structured search (see Table 1)
industrialised countries and the overall levels of physical activity of the following databases: Cochrane Library, PubMed, Embase and
continue to be low or even declined in recent years (Owen and PsycInfo. In addition, we conducted a manual search of reference lists
Bauman 1992; Brownson et al., 2005; Lampert et al., 2005). The included in the articles identified as part of the structured database
initiation and maintenance of exercise in adults, adolescents and search described above. Titles and abstracts of identified publications
children are therefore important objectives for the promotion of were screened for relevance by one researcher without restrictions on
health and crucial in the prevention of the increasing burden of study design. Two researchers independently assessed full-texts of
chronic diseases. In view of the public health importance, many included studies with regard to relevance and methodological quality.
countries are aiming to increase the uptake of overall physical activity Disagreements were resolved in discussion. We included studies if
levels and the participation in leisure time activity within the they met the following criteria.
population (Department of Culture Media and Sport & Strategy Unit, Inclusion criteria:
2002; US Department of Health and Human Services: Healthy People
– study design: randomised controlled trials
2010, 2000).
– outcome measures: participation in or level of physical activity or
In these attempts to promote and maintain higher levels of
physical fitness (e.g. proportion of participants meeting recom-
physical activity, a variety of methods have been developed, including
mended targets, energy expenditure, maximum oxygen uptake)
interventions based on informational-, behavioural- and/or environ-
– interventions: exercise programs or interventions aimed to
mental approaches, targeting either the individual, groups of
promote and maintain physical activity regardless of the setting
individuals and/or the whole community. While many approaches
(e.g. worksite, primary health care, community)
proved to be effective and successfully increased physical activity in
the short-term, subjects might fall back into their routine during long-
term interventions or once the intervention period is completed
(Robison and Rogers 1994; Rhodes et al., 1999). Maintenance and
long-term adherence to physical activity, however, is essential to
achieve sustainable public health effects. More recent intervention
studies therefore tried to investigate the long-term maintenance of
increased physical activity levels. To help people exercise continuously
following the initial intervention, booster and reminder strategies via
follow-up workshops, print materials, newsletters, phone or new
information technologies have been developed (Simons-Morton et al.,
2001; Burke et al., 2003; Cox et al., 2003). However, systematic

Table 1
Search strategy

#1 Motor activity (Mesh)

#2 Exertion (Mesh)
#3 Leisure activities (Mesh)
#4 Exercise therapy (Mesh)
#5 Physical education and training (Mesh)
#6 Physical fitness (Mesh)
#7 Preventive health services (Mesh)
#8 Health promotion (Mesh)
#9 Primary prevention (Mesh)
#10 Behavior therapy (Mesh)
#11 Primary health care (Mesh)
#12 Workplace (Mesh)
#13 Risk-reduction behaviour (Mesh)
#14 Community health services (Mesh)
#15 Health care evaluation mechanisms (Mesh)
#16 Randomized controlled trial (Mesh)
#17 Review literature (Mesh)
#18 #1 or #2 or #3 or #4 or #5 or #6
#19 #7 or #8 or #9 or #10 or #11 or #12 or #13 or #14
#20 #15 or #16 or #17
Fig. 1. Flow-chart of study selection for the systematic review and meta-analysis of the
#21 #18 and #19 and #20
long-term effectiveness of physical activity interventions compared to no-intervention
Mesh: Medical Subject Heading. control, minimal-intervention control and alternative-intervention control.
 356
Table 2
Long-term effectiveness of physical activity interventions

Author Year Study Intervention components Participants (Age, Sex) Follow-up Self-reported Self-reported physical activity Physical fitness
Quality baseline comparability Maintenance physical activity (Energy expenditure)
of groups strategy
Elley et al., (2003) Green prescription (I): Sedentary adults FU: 12 months Targets (2.5 h/wk): TEE (kcal/kg/wk), change
(40–79 yrs). (I: 85%, C: 85%) to BL
High • physician counselling, exercise planning, • I: 23 practices, n = 451 Booster • I: 14.6% (66/451) • I: 9.76 (5.85–13.68)
exercise prescription and phone counselling (57 ± 11, F: 67%)
• newsletters and feedback • C: 23 practices, n = 427 • C: 4.9% (21/427) • C: 0.37 (−3–39–4.14)
(58 ± 12F: 66%)
Control (C): Groups comparable: • BGD: p = 0.003 • BGD: 9.28 (3.96–14.81) =
975 kcal/wk (p = 0.001)
• delayed intervention • Yes
Stewart et al. (2001) Champs II Intervention (I): Healthy sedentary older FU: 12 months (95%) TEE (kcal/wk), change to BL:
adults (65+).
High • staff supported PA planning • I: n = 81 (74 ± 6, F: 69%) Booster • I: 687, p b 0.001

F. Müller-Riemenschneider et al. / Preventive Medicine 47 (2008) 354–368

• print materials and activity log • C: n = 83 (75 ± 6, F: 63%) • C: −10, NS
• 10 group sessions (monthly) Groups comparable: Data for Meta-Analysis⁎:
• regular counselling calls • Yes • I: 374 (SD:260)
Control (C): • C: 292 (SD:244)
• delayed intervention
Hillsdon et al. (2002) All intervention participants: Sedentary adults FU: 12 months % change in EE:
(45–64 yrs). (I1: 32%, I2: 33%, C: 57%)
Good • 30 min primary care based health check • I1: n = 302 (55 ± 6, F: 53%) Booster • I1+2:124 (110–137)
• 6 telephone contacts over 34 weeks • I2: n = 285 (55 ± 6, F: 50%) • C: 113 (95–133), BGD:
3.7, p = 0.39
• exercise logs • C: n = 553 (55± 5, F: 50%) % change in EE by
intervention group:
Direct advice (I1): Groups comparable: • I2: 148 (117–183)
• benefits of PA and risks of inactivity • Yes • I1: 98 (75–125). BGD: 10.2,
p = 0.16
• recommend 30 min walking 5d/wk
Brief negotiation (I2):
• negotiation about positive and negative
outcomes of attempts to increase activity
Control (C):
• repeat health check after 11 months
Napolitano et al. (2006) Choose to move (I1): Healthy sedentary women FU: 12 months PA (min/wk):
(overall: 92.9%)
Good • Standard 12 wk program (AHA) with • I1: n = 93 (47 ± 10) None • I1: 154.48 (SE: 19.51)
changing topics
• booklet and letter • I2: n = 95 (48 ± 11) • I2: 148.87 (SE: 19.13)
Jumpstart (I2): • C: n = 92 (47 ± 11) • C: 139.52 (SE: 19.61)
• BL, 1, 3 and 6 months questionnaire Groups comparable: • BGD: NS
and tailored feedback report addressing
self-efficacy, barriers, benefits, social
support, goal setting and a booklet
Contact control (C): • N.a.
• One mailing including general health
information material
Aittasalo et al. (2004) Counselling (I1): Healthy sedentary FU: 12 months (99%) Targets (moderate: LTPA-EE (kcal/wk): overall
employees (volunteered) 30 min 4d/wk, strenuous: slight increase (p = 0.011)
30 min 2d /wk):
Fair • BL, 8wks, 6 and 12 months. • I1: n = 52 (45 ± 9, F: 61%) Repeat Intervention • Overall slight increase • I1+2 vs. C: −17.9%
(p = 0.049) (−44.4–21.3)
• PA assessment and activity log • I2: n = 51 • I1 vs. I2 8.9% (−30.3−70.2)
(44 ± 10, F: 53%)
 • Individual goal setting and PA planning • C: n = 52 (42 ± 9, F: 54%)
Counselling + fitness test (I2): Groups comparable:
• additional fitness tests BL, 6 and • No
12 months.
• discussion and PA-plan adaptation
Control (C):
• usual care
21
Burke et al. (2003) 16 week intervention for all participants Healthy couples FU: 12 months Targets (30 min 5d/wk), Physical fitness
completers: (75% max heart rate):
Fair High-level (I1): • I1: n = 47 (age M/F: 31/27) (I1: 57%, I3: 42%, C: 72%) • C: 42% (13/31) • Greatest increase and
level in high-level group
• biweekly modules, alternating personal • I2: n = 47 (age M/F: 30/28) None • I1:35% (7/20) • BGD: significant
contact session and mail
Low-level (I2): • C: n = 43 (age M/F: 32/29) • I1: 42% (11/27)
• one initial personal contact session Groups comparable: • BGD: NS
followed by biweekly mail
• Control (C): • No
• no-intervention

F. Müller-Riemenschneider et al. / Preventive Medicine 47 (2008) 354–368

Campbell et al. (2002) PA as part of multi component worksite Female rural workers. FU: 18 months (75.6%) Frequency of PA TEE (MET):
health promotion program (frequency/wk)
Fair Intervention (I): • I: 4 worksites, n = 362 Repeat Intervention • I: 1.6 ± 2.0 I: 4.9 ± 7.7
(17% N 50 yrs)
• individualised health messages • C: 5 worksites, n = 298 • C: 1.5 ± 1.6 C: 4.1 ± 5.7
(e.g. feedback, strategies for change, (20% N 50 yrs)
community resource) after baseline and
6 months
• lay helpers support Groups comparable: • BGD: p = 0.51 BGD: p = 0.46
Control (C): • No
• after 6 months one magazine
Eiben and Lissner (2006) Health Hunters (I): Healthy sedentary women FU: 12 months Change in self-reported Change in time on
(18–28yrs) (I: 78%, C: 73%) EE (kcal/wk) treadmill (min)
Fair • BL examination and PA counselling • I: n = 18 Booster • I: 1464 ± 96) • I: 0.7 ± 0.4
• Individualised support package including • C: n = 22 • C: 200 ± 383) • C: −0.3 ± 0.4
informational and self-help material
focussing on PA, diet and weight control
• Continuous contact: personal, e-mail Groups comparable: • BGD: p = 0.03 • BGD: p = 0.08
and phone
Control (C): • No
• Delayed intervention
Yancey et al. (2006) Intervention (I): Healthy afro-american FU: 12 months Self-reported PA: Change in 1 mile walk
women (overall: N 70%) time (min)
Fair • 8 weekly (120 min) group sessions related • I: n = 188 (45 ± 11) Gym • BGD: NS • I: 1.9 (n = 72)
to exercise skills training and dietary advice
• Free gym membership for participant and • C: n = 178 (47 ± 11) • C: 2.3 (n = 61)
one other person
• Incentives: pedometers, exercise bands etc. Groups comparable: • BGD: p = 0.1
Control (C): • Yes
• 8 weekly sessions focussing on general
health
• Delayed free gym membership

Studies comparing intervention vs. no-intervention control.

PA: physical activity, M: male, F: female, FU: follow-up, BL: baseline, BGD: between group difference, NS: not significant, MWT: minute walk test, AHA: American Heart Association, n.a: not available, SE: standard error, LTPA: leisure time
physical activity, TEE: total energy expenditure, EE: energy expenditure, MET: metabolic equivalents, ⁎ data not from original publication but previous systematic review.

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Table 3

F. Müller-Riemenschneider et al. / Preventive Medicine 47 (2008) 354–368

Long-term effectiveness of physical activity interventions. Studies comparing intervention vs. minimal-intervention control

Author Year Study Intervention components Participants (Age, Sex) Baseline comparability of Follow-up Maintenance PA-maintenance Energy Physical Fitness
Quality groups strategy Expenditure
Petrella et al. (2003) All participants: Healthy older adults (65+) FU: 12 months (86%) Compliance (I1: ≥3 sessions/wk VO2max (ml/kg/min):
at target heart rate, C: according to
ACSM recommendations):
High • physician counselling (ACSM) • I1: n = 131 (74 ± 4, F: 50%) Repeat Intervention • I1: 71% (93/131) • I1: 24.9 ± 1.3 (+15%)
• list of exercise facilities • C: n = 110 (73 ± 6, F: 46%) • C: 56% (62/110) • C: 22.8 ± 0.9 (+3%)
• repeat visits at 3, 6 and 12 months Groups comparable: • BGD: p b 0.05 • BGD: p b 0.001
STEP prescription group (I1): • yes
• prescribed exercise intensity
(75% of VO2max) and adjustment at
FU-visits
• activity logs (including heart rate)
Guidelines group (C):
• guidelines on physical activity
• activity log (no heart rate)
Marcus et al. (2007a) Motivationally tailored internet (I1): Healthy sedentary adults (18+ yrs) FU: 12 months (87%) Targets (30 min 5d/wk) VO2 (ml/kg⁎min)
High • Program website with information, • I1: n = 81 (F: 82%, 45 ± 9) Booster • I1: 39.5% • I1: 26.1 ± 6.9
goal setting tools and links
• Regular e-mail prompts over 12 months • I2: n = 86 (F: 84%, 45 ± 10) • I2: 32.6% • I2: 26.2 ± 6.9
• Monthly online questionnaires, tailored • C: n = 82 (F: 83%, 46 ± 9) • C: 30.5% • C: 25.7 ± 6.0
feedback and activity logs, financial
incentives
Motivationally tailored print (I2): Groups comparable: • BGD:p = 0.45 • BGD: p = 0.31
• Same intervention components via • Yes
print mail
Standard internet (C):
• Identical questionnaire and activity logs
• Links to 6 standard PA websites
Dubbert et al. (2002) All participants: Sedentary older adults (60-80yrs) FU: 12 months Walking for exercise (min/wk), Physical fitness (6 MWT), overall:
in stable health. (I1: 85%, I2: 71%, C: 85%) Overall:
Good • activity counselling • I1:: n = 69 (69 ± 5) Booster • 87.2 ± 99.4, p = 0.0001 • 1504 (301) feet, p = 0.0001 (BGD:
(video, nurse advice and goal setting) NS)
• walking diaries/incentives • I2: n = 73 (68 ± 4) • I2: N I1 and C (p = 0.002)
Personal phone calls (I1): • C: n = 70 (69 ± 5)
• 20 counselling calls over 12 months • Overall: 2 /179 female
Automated phone calls (I2): Groups comparable:
• 10 counselling and 10 automated calls •No
Control (C):
• no phone calls
Resnicow et al. (2005) Tailored (I1): Healthy adults (randomised per church): FU: 12 month (86%) Any PA (min/wk):
Good • culturally tailored materials • C: n = 267 (46 ± 13, F: 74%) Bbooster • C: 826 (SE: 53.6)
• exercise video and exercise guide • I1: n = 355 (46 ± 13, F: 76%) • I1: 928 (SE: 47.8)
• walking recommended, pedometer • I2: n = 304 (47 ± 14, F: 78%) • I2: 936 (SE: 50.7)
• audiocassette to accompany exercise Groups comparable: • BGD: I1 and I2 increased
significantly more than C,
I1 vs. I2: NS
• newsletters • Yes
Tailored + phone (I2):
• 4 additional phone counselling calls by
psychologists (2 calls addressing PA)
Standard (C):
• Standard material
Bock et al. (2001) Intervention materials following BL, Healthy sedentary adults FU: 12 months (63%) Targets (30 min 5d/wk):
1, 3 and 6 months questionnaires
Fair Intervention (I): • Overall: n = 194 (44 ± 11, F: 76%) Repeat Intervention • I: 42% (26/61)
• Individualised counselling messages Groups comparable: • C: 25% (15/59)
(benefits/barriers, rewards etc.)

F. Müller-Riemenschneider et al. / Preventive Medicine 47 (2008) 354–368

• stage specific self-help manuals • n.a. • BGD: p b 0.05
Standard (C):
• 4 standard booklets (AHA)
Lowther et al. (2002) According to preference participants Disadvantaged sedentary adults FU: 12 months LTPA (min/wk):
were allocated into two separate RCTs (FA: 25%, FC: 39%,
EC: 55%, CE: 41%)
Fair All participants: • FA: n = 40 (32 ± 13, F: 40%) Repeat Intervention • FA: 281 ± 100
• ask questions relating to the study or PA • FC: n = 41(40 ± 15, F: 37%) • FC: 317 ± 159
• print materials and exercise vouchers • EC: n = 40 (45 ± 19, F: 28%) • EC: 314 ± 160
• questionnaire (4 wks, 3, 6 and • CE: n = 34 (53 ± 16, F: 21%) • CE: 248 ± 158
12 months)
• re-interventions after 3 months Groups comparable: Change to FU:
1. Fitness assessment (FA): • No • Only EC increased PA
significantly
• standardised FA protocol vs. no-FA (FC)
2. Exercise consultation (EC):
•standardised EC (30 min) vs. no-EC (CE)

PA: physical activity, FU: follow-up, BL: baseline, AHA: American Heart Association, M: male, F: female, BGD: between group difference, NS: not significant, TEE: total energy expenditure, EE: energy expenditure, ACSM: American College of
Sports Medicine, wk: week, LTPA: leisure time physical activity.

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Table 4
Long-term effectiveness of physical activity interventions. Studies comparing intervention vs. alternative-intervention control

Author Year Intervention components Participants Baseline Follow-up Maintenance PA-maintenance Energy Expenditure Physical Fitness
Study Quality comparability of groups strategy
Cox et al. (2003) Intervention components for all groups: Sedentary healthy women FU: 18 months (CBM: 100%, Retention to exercise Change in energy expenditure VO2max (ml/kg/min), change at
(40–65 yrs). CBV: 64%, HBM: 63%, HBV: program at 18 months FU: (kJ/kg/day):: 18 months:

F. Müller-Riemenschneider et al. / Preventive Medicine 47 (2008) 354–368

60%)
High • stage matched information on heart rate CB-moderate: Booster CB: 81% (52/64) CB: 3.1 (0.8–5.5) Moderate: 2.0 (−1.9–5.9)%
measurement and activity log n = 31(48 ± 5)
• exercise preparation and safety CB-vigorous: HB: 61% (38/62) HB: 2.5 (−0.1–5.1) Vigorous: 2.8 (0.01–5.6)%
n = 33 (48 ± 5)
• 30 min walking and aerobics activity HB-moderate: BGD: both p b 0.05. BGD: NS BGD and from BL: NS
classes with gradual increase during initiation n = 32 (48 ± 6)
• moderate: 40–55% of Heart Rate reserve HB-vigorous: Significant only for CB-vigorous:
n = 30 (49 ± 6) 6.0 (1.3–10.7)
• vigorous: 65–80% of Heart Rate reserve Groups comparable:
Centre-based (CB): Yes
• 3 supervised sessions/wk over 6 months
Home-based (CB):
• 10 supervised training sessions over 5 wks
• followed by 3 unsupervised sessions/wk
(print material, video and audio support)
All participants were HB from month 6–18:
• 6 phone calls over 12 months
Duncan et al. All participants were assessed at baseline, 6 and Sedentary adults FU: 24 months Adherence: Change in VO2max (L/min):
(2005) 24 months. Participants in counselling conditions (30–69yrs). (69.5%, BGD: NS)
received: individual walking prescription
(training heart rate zones based on
treadmill tests)
High b moderate-intensity–low frequency (LowF): • HardI-HIF: Booster ModI: 65.8% (132/200) HardI-HIF: 0.10 ± 0.21, significant
45–55% of HRres 3–4d/wk n = 102 (age F/M: compared to BL, Advice and
47 ± 8/52 ± 10) ModI-LowF
bmoderate-intensity–high frequency (Mod–HiF: • ModI-HIF: n = 107 HardI: 57.8% (115/199) ModI-HIF: 0.07 ± 0.20, significant
45–55% of HRres 5-7d/wk (age F/M: 48 ± 8/49 ± 8) compared to BL
bhard intensity-low frequency (Hi-LowF): 65–75% • HI-LowF: n = 97 BGD p b 0.03 HardI-LowF: 0.06 ± 0.20,
of HRres 3-4d/wk (age F/M: 47 ± 8/52 ± 10) significant compared to BL
bhard-intensity-High frequency (HardI-HiF): • M-LowF: n = 93 ModI-LowF: 0.03 ± 0.17, NS
65–75% of HRres 5-7d/wk (age F/M: 47 ± 8/49 ± 8)
group counselling sessions (11 over first 6 months • C: n = 93 (age F/M: Physician advice: 0.04 ± 0.25, NS
and 6 over 47 ± 8/51 ± 11)
remaining 18 months)
heart rate monitor and activity logs Groups comparable:
PA-advice: • Yes
• 90 min quarterly group session, print materials
(AHA booklets)
Simons-Morton Measurement and reinforcement of intervention Healthy inactive adults (35– FU: 24 months (91.4% Targets (moderate:
et al. (2001) at BL, 6, 12 and 24 months. 75yrs) (PAR), 77.6% (VO2max) 30 min 5d/wk, vigorous:
30 min 3d/wk), (F):
High Physician advice (A): Ass: n = 293 (age F/M: Booster Co: 25.7% (28/109) VO2max (ml/min),
52 ± 9/52 ± 10, F: 51%)
assessment and exercise goal setting Co: n = 289 (age F/M: Ass: 9.9% (12/121) BGD at FU, (F):
52 ± 9/52 ± 9, F: 45%)
health educator provided print material and A: n = 292 (age F/M: A: 14.3% (17/119) Ass vs. A 80.7 ml/min
available for related questions 51 ± 10/50 ± 10, F: 46%) (8.1–153.2, p = 0.02)
Assistance (Ass): Groups comparable: Co vs. Ass p = 0.005, Co vs. A 73.9 ml/min
other comparisons NS. (0.9–147, p = 0.046)
additional counselling by health educator Yes Men (M): Ass vs. Co -6.7 ml/min
(40 min) (−80.9–67.5, p = 0.99)
phone contact (one week after baseline) Co: 18.5% (28/151) Men (M):
monthly newsletters and step counter Ass: 29.9% (46/154) • Ass vs. A 49.5 (−44.6–143.6,
p = 0.66)
exercise log and weekly interactive mails A: 16.4% (24/146) • Co vs. A 15.3 (−81.1–111.7, p = 0.99)
Counselling (Co): Ass vs. A p = 0.02, other • Ass vs. Co −34.2(−130.1–61.6,
comparisons NS p = 0.92
• initially additional biweekly than monthly
telephone counselling (at agreed frequencies

F. Müller-Riemenschneider et al. / Preventive Medicine 47 (2008) 354–368

during second year)
• weekly behavioural skill classes
Lamb et al. Advice (C): Sedentary adults FU: 12-month Targets (30 min 5d/wk): VO2max, (L/min)):
(2002) (40–70yrs) (C: 72%, I: 73%)
Good • one standardised PA group session in the I: n = 129 Booster I: 31% (40/129) C: 2.47 ± 0.39
primary care setting (physiotherapist led)
• print materials C: n = 131 C: 26% (34/131) I: 2.49 ± 0.46
• Advice and walks (I): mean age: 51 ± 8 (F: 51.2%) BGD: 6% (−5–16.4) Change to BL:
• lay led walks program Groups comparable: C: +0.08
• print material about local walking routes n.a. I: + 0.05
BGD: 0.03 (− 0.02–0.08)
Pahor et al. Physical activity intervention (I): Healthy sedentary FU: 12 months Frequency of moderate PA EE in moderate intensity PA Change in 400 m-walk speed
(2006) adults (70–89yrs) (I: 94%, C: 73%) (per wk) (kcal/wk) favoured Intervention group
Good Individual 45 min training, initially centre I: n = 213 (F: 69%) Booster I: 5.1 ± 4.0 • I: 1001 ± 1084
(3/wk) than home-based sessions
Monthly phone calls and optional continuing C: n = 211 (F: 69%) C: 3.5 ± 5.2 • C: 710 ± 978
centre-based sessions
Successful Aging intervention (C): Overall mean age: 77 BGD: p = 0.002 • BGD: p = 0.002
Health education and attention Groups comparable:
26 weekly than monthly group sessions Yes
5–10 min light stretching during sessions
Phone reminders
Rovniak et al. Both groups:
(2005)
Fair Baseline orientation session, walking Sedentary women FU: 12 months Walking (min/wk)
prescription (no HR), interactive e-mail (20–54yrs) (79%)
exchange (activity logs)
High theoretical fidelity to SCT (I): I: n = 30 Booster I: 51.7 ± 76.9
Brief skills training (modelling session) C: n = 31 C: 24.2 ± 39.0
Free stopwatch (feedback, goal setting) Mean age: 40 ± 9 BGD: NS
List of local walking routes Groups comparable:
Low theoretical fidelity (C): n.a.
As described above
Albright et al. All Participants: Healthy low-income women FU: 12 months Targets (30 min 5d/wk): EE post class to FU:
(2005) (79%)

(continued on next page)

(continued

361
 362
Table 4 (continued)
Author Year Intervention components Participants Baseline Follow-up Maintenance PA-maintenance Energy Expenditure Physical Fitness
Study Quality comparability of groups strategy
Fair 8 h skill-building classes and feedback on I1: n = 37 (32 ± 11) Booster I1: 35% I1: − 1014 kcal/wk
laboratory parameters
Mail (I1): I2: n = 35 (33 ± 9) I2: 49% I1: + 0.6 (315 kcal/wk)
print material (AHA) Groups comparable: BGD: NS BGD and BL to FU: p b 0.05
monthly newsletters and pedometers n.a.
Mail + phone (I2):

F. Müller-Riemenschneider et al. / Preventive Medicine 47 (2008) 354–368

additional stage specific phone counselling
(14 sessions, 10–15 min) and activity logs
Castro et al. Following a 12 months home-based Sedentary healthy FU: month 12 to 24 Maintenance (Hi: 3/wk, Lo:
(2001) intervention (High (Hi) and Low (Lo) intensity) adults (50–65yrs) (n.a.) 5/wk):
randomisation to
Fair Mail (I1): • I1: Hi (n = 39), Lo (n = 33) Booster At 24 months FU:
monthly educational mailings (12 in total) • I2: Hi (n = 36), Lo (n = 32) Hi: 2.19 (73%) (55/75)
including self assessment
Mail + phone (I2): • Overall F: 43% Lo: 2.85 (57%) (35/65)
15 additional monthly counselling calls Groups comparable: BGD and 12 to 24 months:
p b 0.05
• Yes
Jimmy and Primary care based PA scheme. Sedentary primary care FU: 14 months Targets (moderate: 30 min
Martin (2005) patients. (I1: 84%, I2: 80%) 7d/wk, vigorous: 20 min 3/wk):
Fair Feedback (I1): I1: n = 92 (50 ± 18, F: 58%) None I1: 47% (36/77)
stage matched feedback to level of PA I2: n = 69 (47 ± 17, F: 57%) I2: 47% (26/55)
Advice plus (I2): Groups comparable: BGD: NS
additional stage matched print materials • n.a.
physician advice to increase PA
optional (18€): one to one counselling
Nies and All groups: Healthy sedentary women FU: 12 months PA (min walked/wk) Walk test (min/1mile) Overall
Partridge (2006) (30–60yrs) (overall: 81%) improvement BGD: NS
Fair • Baseline assessment, walk test and I1: n = 90 None I1: 69.8 ± 52.8
recommendations to walk 90 min/wk
Phone counselling (I1): I2: n = 80 I2: 66.4 ± 55.6
16 phone calls (15 min each) over 24 weeks C: n = 83 C: 67.5 ± 66.6
related to exercise benefits and efficacy, goal
setting, social support and relapse prevention
Brief phone call (I2): Groups comparable: BGD: NS
16 phone calls (2–5 min each) over 24 wks n.a.
inquiring about PA behaviour
Video education control (C):
20 min video at BL about benefits of PA

PA: physical activity, FU: follow-up, BL: baseline, HRres: heart rate reserve, AHA: American Heart Association, M: male, F: female, BGD: between group difference, NS: not significant, TEE: total energy expenditure, EE: energy expenditure, PAR:
physical activity recall questionnaire, wk: week.
 F. Müller-Riemenschneider et al. / Preventive Medicine 47 (2008) 354–368
– duration of the intervention/follow-up at least 12 months
– target population: healthy adults N18 years of age
– publication language: English or German
Exclusion criteria:
– physical activity interventions targeting populations with diag-
nosed diseases or selected on the basis of risk factor clustering
– level of physical activity or physical fitness not stated as outcome in
title or abstract
– size of intervention groups: b10 participants
Data extraction of all included studies was performed by one
researcher and cross-checked by a second researcher. Included studies
were classified according to their control group into three categories:
1. no-intervention control: studies which clearly describe a no-
intervention control or a usual care group. 2. minimal-intervention
control: studies which include control groups consisting of the
provision of standard information-(material) or single and clearly
circumscribed intervention sessions. 3. alternative-intervention con-
trol: studies which compare different intervention strategies which
were more comprehensive than those described above. The metho-
dological quality of included studies was evaluated using standardised
quality checklists employed by the German Institute for Documenta-
tion and Information. Depending on their risk of bias studies were
then rated according to the grading system developed by the Scottish
Intercollegiate Guidelines Network Group (SIGN) as high (minimal
risk of bias), good (moderate risk of bias) and fair (high risk of bias)
methodological quality (Harbour and Miller 2001).
We estimated pooled effects using Review Manager 4.2 separately
for studies presenting appropriate dichotomous and continuous
outcome measures. We included studies rated with good and high
methodological quality to minimise heterogeneity. Dichotomous
outcome measures reflected the proportion of participants meeting
recommended targets of physical activity as specified in the study and
were presented as odds ratios and 95% confidence intervals. To
estimate the pooled effect and 95% confidence intervals of continuous
outcome measures we calculated the Standardised Mean Difference
(SMD), using measures of physical fitness, energy expenditure and
time spent for physical activity. All analyses were conducted using a
random effects model. Sensitivity analyses were conducted by
including methodologically less rigorous studies, excluding outliers
and using fixed effect models.
Results
Our literature search identified 5508 references and we assessed
the full-text of 156 documents. Twenty-five studies met all selection
criteria and were included in this review (see Fig. 1).
The main reasons for exclusion of studies from this review were:
• non randomised study design
• participants selected on the basis of underlying disease or risk
factors
• not relevant to the research question
• outcome not level of physical activity but mediators or possible
surrogates of physical activity
Twenty-five RCTs investigated 39 intervention strategies to
promote physical activity behaviour. In the majority of studies walking
was the main physical activity component targeted by the interven-
tion. Nine studies compared physical activity interventions to a no-
intervention control group (Elley et al., 2003; Stewart et al., 2001;
Hillsdon et al., 2002; Napolitano et al., 2006; Aittasalo et al., 2004;
Burke et al., 2003; Campbell et al., 2002; Eiben and Lissner, 2006;
Yancey et al., 2006), 6 studies included a minimal-intervention control
(Petrella et al., 2003; Marcus et al., 2007a; Dubbert et al., 2002;
Resnicow et al., 2005; Bock et al., 2001; Lowther et al., 2002; Nies and
363
Partridge 2006) and 10 studies (Cox et al., 2003; Duncan et al., 2005;
Simons-Morton et al., 2001; Lamb et al., 2002; Pahor et al., 2006;
Rovniak et al., 2005; Albright et al., 2005; Castro et al., 2001; Jimmy
and Martin 2005; Nies and Partridge 2006) compared different
intervention strategies but did not include a no-intervention control
group (see Tables 2–4). Overall, only 7 studies could be rated as high-
quality studies (Cox et al., 2003; Duncan et al., 2005; Elley et al., 2003;
Petrella et al., 2003; Simons-Morton et al., 2001; Stewart et al., 2001;
Marcus et al., 2007a) and 6 further studies as good-quality (Dubbert et
al., 2002; Hillsdon et al., 2002; Lamb et al., 2002; Resnicow et al., 2005;
Napolitano et al., 2006; Pahor et al., 2006). Common methodological
limitations were differences in baseline characteristics between
intervention groups, high attrition rates or inadequate presentation
of investigated outcome parameters. Detailed descriptions of study
characteristics, intervention components and outcomes are presented
in Tables 2–4. Included studies reported a variety of outcome
measures and even when reporting the same outcome (e.g. proportion
of participants meeting recommended physical activity targets) they
used different definitions. Due to limited methodological quality or a
lack of appropriately reported outcome measures, only 9 studies were
found suitable for meta-analysis.
Long-term effectiveness of physical activity interventions
Compared to no-intervention or minimal-intervention control 10
out of 15 studies found at least some evidence for positive
intervention effects (see Tables 2–3). Especially 4 high and good-
quality studies (Elley et al., 2003; Stewart et al., 2001; Petrella et al.,
2003; Resnicow et al., 2005) provided strong evidence for increases in
physical activity behaviour. They reported increases in weekly energy
expenditure of up to 975 kcal and physical fitness of up to 11%
compared to control groups. Similarly, none of the studies reported
unfavourable effects of the interventions on the level of physical
activity. However, physical activity behaviour varied substantially
between studies. Thus, the proportion of intervention participants
meeting recommended physical activity targets or adhering to
physical activity prescriptions ranged between 4.6% and to 81%.
Estimated pooled effects were consistent with these findings and
found significant increases in the proportion of participants meeting
recommended physical activity targets. Respective odds ratios to meet
physical activity targets were 3.31 (1.99–5.52) and 1.52 (1.07–2.14)
compared to no-intervention and minimal-intervention control, respec-
tively (see Fig. 2). Fig. 3 present pooled estimates of continuous outcome
measures, which also indicated significant increases in self-reported
energy expenditure and physical fitness associated with the interven-
tions. Results of meta-analyses were robust to sensitivity analyses.
Table 4 lists 10 identified studies which compared different
intervention strategies but did not include a no- or minimal-
intervention control group. Of these, four studies compared interven-
tion strategies to physician/health care professional advice (Duncan et
al., 2005; Lamb et al., 2002; Simons-Morton et al., 2001; Nies and
Partridge 2006). Three of these studies tested more than one
intervention strategy (Duncan et al., 2005; Simons-Morton et al.,
2001; Nies and Partridge 2006). Whereas none of the four studies
reported consistently positive effects across intervention groups, all
except one fair-quality study (Nies and Partridge 2006) found some
evidence for the long-term effectiveness of interventions compared to
advice only (Duncan et al., 2005; Lamb et al., 2002; Simons-Morton et
al., 2001) (see Table 4). Estimated pooled effects were consistent with
these findings and found increases in the proportion of participants
meeting recommended targets and physical fitness (see Figs. 2 and 3).
Pooled effects were robust to sensitivity analyses. The six remaining
studies (Cox et al., 2003; Pahor et al., 2006; Rovniak et al., 2005;
Albright et al., 2005; Castro et al., 2001; Jimmy and Martin 2005)
compared a variety of different intervention strategies to promote
physical activity behaviour. Of these, only 1 study reported clearly
364 F. Müller-Riemenschneider et al. / Preventive Medicine 47 (2008) 354–368

Fig. 2. Meta-analysis of the long-term effectiveness of physical activity interventions compared to no-intervention control, minimal-intervention control and health care staff advice
control, for studies reporting the proportion of participants meeting study specific physical activity targets.

positive intervention effects compared to an alternative intervention
(Pahor et al., 2006), whereas additional intervention effects in the
remaining studies were less strong (see Table 4).
Sustainability of intervention effects
Maximum study duration was 24 months. Nine methodologically
reliable studies reported physical activity or cardiorespiratory fitness
at different time points up to 24 months after intervention onset
(Simons-Morton et al., 2001; Duncan et al., 2005; Cox et al., 2003;
Marcus et al., 2007a; Napolitano et al., 2006; Petrella et al., 2003;
Dubbert et al., 2002; Pahor et al., 2006). Although a moderate decline
of physical activity behaviour and physical fitness between early and
late follow-up could frequently be observed, reported intervention
effects were mostly stable. Only one high-quality study (Petrella et al.,
2003) reported a continuous increase of the intervention effect up to
the 12 month follow-up. In contrast, two studies (Marcus et al., 2007a;
Napolitano et al., 2006) found no significant intervention effects at

Fig. 3. Meta-analysis of the long-term effectiveness of physical activity interventions compared to no-intervention control, for studies reporting continuous outcome measures.
 F. Müller-Riemenschneider et al. / Preventive Medicine 47 (2008) 354–368
12 month follow-up after observing statistical significant effects at 3
and 6 months, respectively. In one of these studies Napolitano et al.
(2006) reported that this lack of a significant intervention effect was
due to an unexpected increase of physical activity in participants of
the alternative-intervention control groups.
Intervention effectiveness in specific population groups
Three studies, including 2 high-quality studies, investigated the
effectiveness of physical activity interventions exclusively among
older participants (60+ years) compared to no-intervention or
minimal-intervention control (Dubbert et al., 2002; Petrella et al.,
2003; Stewart et al., 2001). One additional study compared a physical
activity intervention designed for older participants to an alternative-
intervention control group (Pahor et al., 2006). All studies found
significant increases in physical activity associated with the interven-
tion. In addition, Elley et al. (2003) included participants aged 40–
79 years (mean age 57 years) and also observed significant increases in
physical activity behaviour.
One study of high and 3 of good methodological quality
investigated intervention effectiveness compared to no- and mini-
mal-intervention control exclusively in middle aged adults (b60 years
of age) (Marcus et al., 2007a; Napolitano et al., 2006; Hillsdon et al.,
2002; Resnicow et al., 2005). Three studies reported at least some
evidence for intervention effectiveness while one found no favourable
intervention effect compared to control group. Elley et al. (2003)
reported clear evidence for intervention effectiveness compared to
no-intervention control, study participation was not restricted to
middle aged adults, however. Compared to health care staff/physician
advice three studies reported positive intervention effects in some
groups (Duncan et al., 2005; Simons-Morton et al., 2001; Lamb et al.,
2002). Two studies also included older adults, however.
Resnicow et al. (2005), Albright et al. (2005), Lowther et al. (2002)
and Yancey et al. (2006) targeted disadvantaged population groups.
While two studies found evidence for intervention effectiveness
compared to no- and minimal-intervention control (Resnicow et al.,
2005; Yancey et al., 2006), the remaining 2 studies did not find
evidence of favourable intervention effects. These studies were not
suitable for meta-analysis.
Effectiveness of specific Intervention components
In the majority of studies, interventions consisted of a combination
of different intervention components and only infrequently investi-
gated specific intervention components (see Table 2–4).
Initial intervention intensity
One fair-quality study specifically compared different intensities of
the initial intervention strategy (Burke et al., 2003) and observed no
differences in intervention effectiveness. Cox et al. (2003) compared
strategies of centre-based and home-based interventions during the
initial six months of the study. Both groups were home-based
thereafter. While exercise retention rates were higher in the centre-
based group, increases in energy expenditure or physical fitness did
not differ significantly.
Written exercise prescription
Three high-quality studies provided exercise prescriptions in
addition to other intervention strategies, e.g. exercise counselling,
planning and activity logs (Duncan et al., 2005; Elley et al., 2003;
Petrella et al., 2003). Two studies included exercise testing to write
prescriptions according to target heart rate zones (Petrella et al., 2003;
Duncan et al., 2005). While Elley et al. (2003) and Petrella et al. (2003)
found significant increases in physical activity behaviour and physical
365
fitness compared to minimal-intervention control, Duncan et al.
(2005) only found increases in physical fitness compared to physician
advice when prescribing high-intensity and high-frequency exercise.
In contrast, no significant intervention effects were found in two
studies investigating fitness assessments without exercise prescrip-
tion strategies (Aittasalo et al., 2004; Lowther et al., 2002).
Tailored vs. standard intervention messages
Six studies specifically compared tailored to standard materials,
phone calls, internet strategies or feedback protocols (Dubbert et al.,
2002; Napolitano et al., 2006; Marcus et al., 2007a; Nies and Partridge
2006; Bock et al., 2001; Rovniak et al., 2005). Results were conflicting
and did not provide strong evidence for favourable outcomes of
tailored compared to standard interventions. One study (Resnicow et
al., 2005) found evidence for the effectiveness of culturally tailored
strategies, however.
Effectiveness of maintenance strategies
Tables 2–4 show that studies frequently used methods to reinforce
the initial intervention strategy. While various studies compared
different maintenance strategies, none of the included studies
specifically investigated the effectiveness of interventions with and
without reinforcement strategy.
With regard to these maintenance strategies, studies were defined
as:
– those including no maintenance strategy to reinforce the initial
intervention.
– those repeating (in the same or similar way) the initial interven-
tion during the follow-up period.
– those using booster strategies during the follow-up period (e.g.
mailed reminder, phone call, e-mail, internet, or group sessions
and workshops) to reinforce the initial intervention.
Four studies did not use any maintenance strategies, although in
some cases baseline interventions lasted for up to 6 months (Burke et
al., 2003; Jimmy and Martin 2005; Napolitano et al., 2006; Nies and
Partridge 2006). Of these, 3 studies reported no differences in physical
activity behaviour at the end of follow-up between intervention and
control group, and only one fair-quality study (Bock et al., 2001) found
favourable intervention effects.
Five studies evaluated 7 repeat intervention strategies to increase
maintenance of physical activity behaviour. Of these, one high-quality
study (Petrella et al., 2003) reported strong evidence of intervention
effectiveness. Four interventions found no (Aittasalo et al., 2004;
Campbell et al., 2002; Lowther et al., 2002) and two interventions found
some evidence of effectiveness (Bock et al., 2001; Lowther et al., 2002).
The 16 remaining studies assessed 23 booster strategies (see Tables
2–4). Two high-quality studies provided strong evidence of effective-
ness compared to no-intervention control (Duncan et al., 2005; Elley
et al., 2003; Stewart et al., 2001), and 4 high-quality studies observed
some evidence of effectiveness compared to minimal- or alternative-
interventions (Cox et al., 2003; Simons-Morton et al., 2001; Marcus et
al., 2007a; Duncan et al., 2005). Among the remaining studies only one
found no positive effect compared to control group (Hillsdon et al.,
2002) and three studies found no effect compared to alternative
booster interventions (Hillsdon et al., 2002; Resnicow et al., 2005;
Rovniak et al., 2005).
Discussion
Our systematic review provides evidence for the effectiveness of
physical activity interventions to increase levels of physical activity
over 12 to 24 months. Compared to no-intervention control and to
minimal-intervention, increases in self-reported weekly energy
366 F. Müller-Riemenschneider et al. / Preventive Medicine 47 (2008) 354–368
expenditure 12 months after intervention onset were almost
1000 kcal. These gains in weekly energy expenditure are consistent
with current physical activity recommendations to achieve mean-
ingful health benefits (Warburton et al., 2006a; Warburton et al.,
2006b; Haskell et al., 2007). There was also evidence of substantial
increases in physical fitness associated with physical activity inter-
ventions. Immediate increases in physical activity or fitness were
frequently followed by a moderate decline of the intervention effects
over time. With regard to specific population groups, the evidence for
the long-term effectiveness of physical activity interventions seemed
to be somewhat stronger for older compared to middle aged adults. In
addition, there was some evidence that current comprehensive
interventions can be more effective in the long-term to increase
levels of physical activity behaviour than physician or health care staff
advice only (Fig. 4). However, these results where less conclusive and
warrant further investigation.
Compared to previous systematic reviews the evidence for the
long-term effectiveness of physical activity interventions has thereby
increased considerably (Hillsdon et al., 2005; Lawlor and Hanratty
2001; Petrella and Lattanzio 2002; Eakin et al., 2004; Marcus et al.,
2006; Foster et al., 2005). However, this evidence of effectiveness is
mainly attributable to three high-quality studies that used written
prescription of exercise as an intervention component in addition to
physician advice, counselling and provision of information material.
Elley et al. (2003) and Petrella et al. (2003) reported the most
substantial increases in physical activity compared to no-intervention
or minimal-intervention control, and Duncan et al. (2005) observed
increases in physical fitness compared to a physician advice group at
24 months follow-up.
Considering tailored strategies, intervention effectiveness seems to
improve when messages and materials are culturally adapted to the
needs of specific population groups. Our study also confirms findings
Fig. 4. Meta-analysis of the long-term effectiveness of physical activity interventions compared to minimal-intervention control and health care staff advice control, for studies
reporting continuous outcome measures.
of a recently published review of walking interventions which
reported “tailoring” to be one general component of effective
interventions (Ogilvie et al., 2007). The evidence is limited to tailored
exercise prescription or tailored counselling, however. There was no
conclusive evidence that individually tailored intervention materials,
phone calls, internet strategies or feedback protocols are more
effective than standard approaches to maintain physical activity
behaviour in the long-term.
The majority of studies used strategies to maintain increased levels
of physical activity in the long-term. These generally consisted of
repeat interventions or booster strategies in the format of mail, phone,
internet, group sessions or combinations. Although none of the
identified studies specifically investigated the additional benefit of
maintenance strategies compared to none or to repeat intervention,
the overall evidence seemed more consistent for studies using booster
strategies.
Uncertainty remains, however, in respect to the most effective and
efficient delivery mode of booster messages. Most commonly print
material or phone reminders were used. Only one study (Marcus et al.,
2007b) directly compared these delivery modalities. The authors
reported superior long-term effectiveness associated with delivery of
print material. However, because this study was published after the
end of our search strategy it did not meet the inclusion criteria of the
present review and was not formally assessed. Three included studies
attempted to identify the additional benefit of phone interventions
(phone plus mail) over mail only (Albright et al., 2005; Castro et al.,
2001; Resnicow et al., 2005). In addition Simons-Morton et al. (2001)
used regular additional phone counselling compared to an interactive
mail exchange. Overall, results were inconclusive and did not provide
sufficient evidence for an additional effect of phone reminders. The
mode of phone contract was further investigated by Dubbert et al.
(2002) and Hillsdon et al. (2002). They observed that automated
 F. Müller-Riemenschneider et al. / Preventive Medicine 47 (2008) 354–368
phone calls achieved similar maintenance rates as personal phone
calls and that advice giving during counselling calls was less effective
than brief negotiation. These strategies, however, require confirma-
tion in more rigorous studies. New information technologies have
frequently been used in recent years as a mode for the delivery of
booster messages. Only Marcus et al. (2007a) specifically investigated
the internet as a delivery tool and reported that tailored internet
strategies were as effective as tailored print strategies in promoting
physical activity behaviour. They didn't compare this strategy to a no-
intervention control group, though. Conversely, a recent review by
Vandelanotte et al. (2007) did not identify strong evidence for the
long-term effectiveness of internet strategies. Although it might be
possible to deliver internet messages at considerably lower costs than
traditional print or phone messages, it has to be kept in mind,
however, that certain important population groups will inevitably be
missed using this approach.
Numerous other intervention components are nowadays fre-
quently used to increase promotion of physical activity. Studies
often use and combine approaches such as goal setting, problem
solving, self-monitoring, exercise planning and incentives as well as
provision of activity logs, pedometers and heart rate monitors. While
these strategies have not been specifically assessed in any of the
included studies, they have been used in different combinations in
studies providing strongest evidence for intervention effectiveness.
Considering public health consequences, presented results require
further discussion. While interventions were effective to increase
physical activity behaviour, comprehensive and well conducted
studies were necessary to achieve these effects. This has also been
reported in the above mentioned review by Ogilvie et al. (2007). Even
in the study by Elley et al. (2003), which reported most substantial
intervention effects, only 15% of the participants were actually
meeting recommended targets at the end of the study period.
While reported gains in physical activity can be considered a success,
it still leaves a substantial proportion of the population not being
sufficiently active. Furthermore, participants in the majority of studies
volunteered and were motivated to increase their level of physical
activity. Generalisability is therefore limited. Future strategies to
reach the whole population and to motivate those not responding at
present will therefore be necessary to achieve greater public health
effects.
Regarding the results of this systematic review some limitations
should be noted. Firstly, although we conducted a highly sensitive and
comprehensive search strategy and handsearch, publication bias
cannot be entirely excluded. Secondly, the assessment of single
intervention components was limited. This however, was due to a lack
of appropriate studies investigating these issues and should be
included in future research. Thirdly, pooled effect estimates were
frequently based on a limited number of studies. However, this
approach was chosen to increase reliability of pooled effect estimates.
Fourthly, the selection criteria exclude intervention strategies which
might less frequently be investigated in RCTs, such as environmental
changes, interventions targeting active transport or community-
interventions. The fact that we were not able to identify randomised
studies using these approaches should be considered when interpret-
ing the results of our systematic review. Finally, because studies had a
maximum duration of 24 months, the sustainability of observed
effects remains unknown. Especially when considering the observed
decline of physical activity over time it could be argued that increases
in physical activity will be difficult to maintain as long as environ-
mental factors are not targeted concurrently.
In conclusion, there is evidence for the long-term effectiveness of
physical activity interventions in healthy adults. Increases in physical
activity can meet recommended targets necessary for meaningful
health benefits. Comprehensive and high-quality interventions, using
additional exercise prescriptions and booster strategies achieved most
substantial long-term increases in physical activity behaviour. Con-
367
sidering the delivery mode of booster strategies, it seems that new
information technologies can be equally effective as print materials,
possibly at considerably lower costs. Due to the increased complexity
of effective interventions, additional cost-effectiveness analyses of
physical activity interventions are warranted to assess the feasibility
of these strategies on a broad population basis. Further, there is a need
for methodologically rigorous studies to investigate the sustainability
of current physical activity interventions.
Conflict of interest statement
All authors declare that they have no conflict of interest.
Acknowledgments
We would like to thank Dr. Klaus Linde for his helpful advice and
constructive criticism with regard to execution and presentation of
this Systematic Review and Meta-Analysis.
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