ReviewEvaluation of physical activity interventions in youth via the Reach, Efficacy/Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework: A systematic review of randomised and non-randomised trials
Introduction
The literature estimates that physical inactivity contributes to 6–10% of the major non-communicable diseases worldwide (i.e., coronary heart disease, type II diabetes, breast and colon cancers) (Lee et al., 2012). In comparison, regular physical activity (PA) confers benefits that extend well beyond physical health and include a better quality of life, reduced stress, improved sleep, and stronger relationships and social connectedness (Das and Horton, 2012). Therefore, PA can be considered a major contributor to overall physical and mental well-being.
The World Health Organization (WHO) guidelines recommend that for optimal health, children and youth (aged 5 to 17 years) should engage in at least 60 min of moderate- to vigorous-intensity physical activity (MVPA) daily (WHO, 2010). However, a synthesis of self-reported global data from WHO Member States estimate that four of every five youth (aged 13–15 years) do not meet the present guidelines (Hallal et al., 2012). Collectively, the established health benefits of regular MVPA and the reported suboptimal activity levels of youth indicate a need for increased participation in PA among this population.
Addressing this need involves a systematic review of the relevant research in order to identify the characteristics of successful interventions designed to promote PA. Several meta-analytic and narrative reviews focus on the efficacy of PA interventions in children and youth, and thereby attempt to provide evidence of a cause and effect relationship between intervention strategies and increased PA levels in participants (Atkin et al., 2011, Cale and Harris, 2006, De Meester et al., 2009, Dudley et al., 2011, Jago and Baranowski, 2004, Lubans et al., 2009b, Metcalf et al., 2012, Salmon et al., 2007, van Sluijs et al., 2007). Although many of these review articles have commented on the potential lack of generalizability of PA interventions in youth (Brown and Summerbell, 2009, Camacho-Miñano et al., 2011, De Meester et al., 2009, Dobbins et al., 2009, Rees et al., 2006, Kriemler et al., 2011, O'Connor et al., 2009, Timperio et al., 2004, van Sluijs et al., 2011), to date, none has specifically addressed the translatability of the research into health promotion practice or its impact on public health. In other words, existing reviews have focused on the internal validity of studies of PA interventions in youth without systematically addressing issues related to external validity.
External validity is defined as the degree to which study findings are generalizable to groups and environments outside the intervention or experimental setting (Gay et al., 2012). To balance the emphasis on internal and external validity, Glasgow et al. (1999) designed an evaluation framework that expands assessments of interventions beyond efficacy. This Reach, Efficacy/Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework has demonstrated utility in evaluating internal and external validity indicators for a number of health behaviour interventions (e.g., nutrition and PA) (Aittasalo et al., 2006, DerAnanian et al., 2012, Dunton et al., 2009, Jenkinson et al., 2012, Nigg et al., 2012), and has been used in reviews of literature to demonstrate the degree to which researchers reported on external validity issues (Akers et al., 2010, Allen et al., 2011, Antikainen and Ellis, 2011, Dzewaltowski et al., 2004, Glasgow et al., 2004, White et al., 2009).
As conceptualized by Glasgow et al., 1999, Glasgow et al., 2004, reach is a measure of participation characterized by the number, proportion and representativeness of individuals willing to participate in the intervention, and efficacy/effectiveness assesses the impact of an intervention on important outcomes (both positive and negative). The term efficacy applies to trials that test the impact of an intervention under optimum conditions, while the term effectiveness applies to trials that are conducted in real-world settings by individuals who are not part of the research staff (Flay, 1986, Glasgow et al., 2003). Adoption reflects the number, proportion and representativeness of settings and intervention agents who are willing to initiate the intervention, and implementation is concerned with the extent to which the intervention was delivered as intended in the real world. Finally, maintenance assesses the degree to which a programme is sustained over time (Glasgow et al., 1999, Glasgow et al., 2004).
The RE-AIM framework has been used to guide PA interventions in youth, and to evaluate reviews of PA interventions in adults; however, there has yet to be a review of PA interventions in youth conducted using the RE-AIM framework. Therefore, the purpose of this article is to present the findings of a RE-AIM review in order to evaluate the internal and external validity of randomised and non-randomised interventions designed to increase PA behaviour in youth. Specifically, the findings include an assessment of PA intervention generalizability to field settings, and consideration of variables that may moderate intervention efficacy/effectiveness, such as resource availability, implementation fidelity and possible incorporation into the daily routine (Glasgow et al., 2003, Glasgow et al., 2004).
Section snippets
Database search and study inclusion
Five electronic databases (Pubmed, Nursing and Allied Health Literature, SPORTDiscus, PsycINFO, and Educational Resources Information Center) were searched for articles written in English and published in peer-reviewed journals from January 2003 to January 2013. For each database, the following search terms were used: (physical activity OR fitness OR exercise OR physical education OR sport OR running) AND (random OR controlled OR trial OR clinical OR intervention) AND (programmes OR strategy OR
Intervention characteristics
Table 1 summarizes the reviewed interventions, and organizes them by design. For the purposes of this review, intervention effects on measured outcomes were recorded as positive when the individual study authors reported a statistically significant change between intervention and control/comparison groups. This liberal summation resulted in considerable variation in both the magnitude and nature of the positive PA effects, which included increases in self-reported leisure time physical activity
Discussion
The RE-AIM reporting criteria were developed to determine both internal and external validity of interventions by addressing five components important for translation of research findings (Glasgow et al., 1999). Based on these criteria, most of the reviewed studies focused on internal validity (e.g., sample size; efficacy; type, frequency, intensity of intervention) rather than on issues of external validity (e.g., the percentage and representativeness of individuals and settings willing to
Conclusions
Numerous systematic reviews have focused on the efficacy of PA interventions in youth; however, many have commented on the potential lack of generalizability of their findings (e.g., Camacho-Miñano et al., 2011, Kriemler et al., 2011, van Sluijs et al., 2011). To address the identified gap between research findings and their application in real-world settings, this review used the RE-AIM framework to expand the assessment of interventions beyond efficacy. To the best of the authors' knowledge,
Conflict of interest statement
The authors declare that there are no conflicts of interest.
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