A systematic review of school-based interventions targeting physical activity and sedentary behaviour among older adolescents

A sys ema ic e iew o school-based in e en ions a ge ing physical ac i i y and seden a y beha iou among olde adolescen s S-T. Hynynen a , M. M. an S alen b , F. F. Snieho a c , V. A aújo-Soa es c , W. Ha deman d , M. J. M. Chinapaw e , T. Vasanka i and N. Hankonen a * a Depa men o Social Resea ch, Uni e si y o Helsinki, Helsinki, Finland; b Depa men o Heal h Sciences, Facul y o Ea h and Li e Sciences and he EMGO Ins i u e o Heal h and Ca e Resea ch, VU Uni e si y Ams e dam, Ams e dam, The Ne he lands; c Ins i u e o Heal h & Socie y, Newcas le Uni e si y, Newcas le upon Tyne, UK; d Beha iou al Science G oup, P ima y Ca e Uni , Uni e si y o Camb idge, Camb idge, UK; e Depa men o Public and Occupa ional Heal h and he EMGO Ins i u e o Heal h and Ca e Resea ch, VU Uni e si y Medical Cen e , Ams e dam, The Ne he lands; UKK Ins i u e o Heal h P omo ion Resea ch, Tampe e, Finland ABSTRACT Lack o physical ac i i y (PA) and high le els o seden a y beha iou (SB) ha e been associa ed wi h heal h p oblems. This sys ema ic e iew e alua es he e ec i eness o school-based in e en ions o inc ease PA and dec ease SB among 15–19-yea -old adolescen s, and examines whe he in e en ion cha ac e is ics (in e en ion leng h, deli e y mode and in e en ion p o ide ) and in e en ion con en (i.e. beha iou change echniques, BCTs) a e ela ed o in e en ion e ec i eness. A sys ema ic sea ch o andomised o clus e andomised con olled ials wi h ou come measu es o PA and/o SB ende ed 10 esul s. Risk o bias was assessed using he Coch ane isk o bias ool. In e en ion con en was coded using Beha iou Change Technique Taxonomy 1. Se en ou o 10 s udies epo ed significan inc eases in PA. E ec s we e gene ally small and sho - e m (Cohen’sd anged om 0.132 o 0.659). Two ou o ou s udies ha measu ed SB epo ed significan educ ions in SB. In e en ions ha inc eased PA included a highe numbe o BCTs, specific BCTs (e.g., goal se ing, ac ion planning and sel -moni o ing), and we e deli e ed by esea ch s a . In e en ion leng h and mode o deli e y we e un ela ed o e ec i eness. Mo e s udies a e needed ha e alua e long- e m in e en ion e ec i eness and a ge SBs among olde adolescen s. ARTICLE HISTORY Recei ed 22 No embe 2014 Accep ed 10 July 2015 KEYWORDS physical ac i i y; seden a y beha iou ; adolescen s; school-based in e en ion; beha iou change echniques In oduc ion Ample e idence exis s o he p o ound benefi s o leading a physically ac i e li e. Regula physical ac i i y (PA) has been associa ed wi h a dec eased isk o physical and men al heal h p oblems, such as obesi y, ca dio ascula disease, ype II diabe es and dep ession © 2015 The Au ho (s). Published by Taylo & F ancis. This is an Open Access a icle dis ibu ed unde he e ms o he C ea i e Commons A ibu ion-NonComme cial-NoDe i a i es License (h p://c ea i ecommons.o g/Licenses/by-nc-nd/4.0/), which pe mi s non-comme cial e-use, dis ibu ion, and ep oduc ion in any medium, p o ided he o iginal wo k is p ope ly ci ed, and is no al e ed, ans o med, o buil upon in any way. CONTACT S-T Hynynen sini.hynynen@kuulas.fi *P esen add ess: School o Social Sciences and Humani ies, Uni e si y o Tampe e, Finland. INTERNATIONAL REVIEW OF SPORT AND EXERCISE PSYCHOLOGY, 2015 VOL. 9, NO. 1, 22–44 h p://dx.doi.o g/10.1080/1750984X.2015.1081706 Downloaded by [Tampe e Uni e si y] a 22:47 08 June 2016 among child en and adolescen s (Biddle, Go ely, & S ensel, 2004; Janssen & LeBlanc, 2010; Penedo & Dahn, 2005). The e idence on he ad e se heal h e ec s o excessi e seden a y beha iou (SB) in you h is inconsis en o da e (Chinapaw, Al enbu g, & B ug, 2015; Chi- napaw, P ope , B ug, an Mechelen, & Singh, 2011). Ye he e is an indica ion ha exces- si e SB is associa ed wi h bo h physical and psychological heal h p oblems such as un a ou able body composi ion, dec eased fi ness, lowe ed sel -es eem and p o-social beha iou and dec eased academic achie emen in school-aged child en and you hs (T emblay e al., 2011a). I non-seden a y li es yle habi s can be ini ia ed in adolescence, his may ha e beneficial p e en i e alue, as he e ec s on mo ali y and mo bidi y among adul s ha e al eady been es ablished (Tho p, Owen, Neuhaus, & Duns an, 2011; Wilmo e al., 2012). To achie e and main ain good heal h, child en and adoles- cen s a e ecommended o engage in a leas 60 minu es o mode a e- o igo ous- in ensi y physical ac i i y (MVPA) each day (Janssen & LeBlanc, 2010; S ong e al., 2005). Howe e , acco ding o he Heal h Beha iou in School-aged Child en s udy 2009–2010, only 15% o 15-yea -old adolescen s me his ecommenda ion globally (Cu ie e al., 2012). The e a e also ecommenda ions o seden a y ime –al hough no as widely ag eed upon as o PA. Fo example, he guidelines o he Canadian Socie y o Exe cise Physiology (CSEP) o dec easing SB in you h s a e ha he goal o minimising he ime spen seden a y can be achie ed by se e al means: in addi ion o limi ing ec ea ional sc een ime, also limi ing seden a y anspo , ex ended si ing ime and ime spen indoo s h oughou he day which also may in ol e ime spen in class ooms (T emblay e al., 2011b). In Finland ecen na ional ecommenda ions on he educ ion o seden a y ime explici ly iden i y schools as one o he key se ings (Minis y o Social and Heal h A ai s, 2015). As PA e en dec eases du ing adolescence (Dumi h, Gigan e, Domingues, & Kohl, 2011) and you hs spend a lo o hei ime bo h a home and in school being seden a y ( an S alen e al., 2014; Ve loigne e al., 2012), in e en ions ha aim o p omo e PA and o educe SB among adolescen s a e u gen ly needed. Schools a e a p omising se ing o heal h p omo ion in e en ions aimed a adoles- cen s, since hey each a majo i y o he a ge popula ion. In p e ious s udies, school- based in e en ions ha e been ound o ha e significan e ec s on adolescen s’PA and SB. Howe e , he e ec s ha e been small, sho - e m and ha e la gely di e ed be ween in e en ions (Biddle, O’Connell, & B ai hwai e, 2011; De Mees e , an Len he, Spi aels, Lien, & De Bou daedhuij, 2009; Deme iou & Höne , 2012; Dobbins, De Co by, Robeson, Husson, & Ti ilis, 2009; Lonsdale e al., 2013; Me cal , Henley, & Wilkin, 2012; an Sluijs, McMinn, & G i fin, 2007). Also, e ec s a e mos ly seen in school- ela ed PA while e ec s ou side o his con ex in leisu e ime and commu ing PA a e o en no obse ed o assessed (K iemle e al., 2011). Fu he mo e, age migh mode a e he e ec i eness o school-based in e en ions. Ea lie e iews ha e ended o ei he include a b oad age ange (e.g., 6–18-yea -olds) o ocus on younge age ca ego ies (Sa on, Cislak, Gaspa , & Luszczynska, 2011; an Sluijs e al., 2007). To ou knowledge, no ecen e iew has ocused solely on in e en ions a ge ing olde adolescen s, and e idence in his age g oup is lacking. These p e ious s udies ha e dis ega ded he possibili y ha age g oups di e in de elopmen al s ages and hus equi e di e en in e en ion s a egies. Since olde adolescen s ha e been a less s udied a ge g oup, his e iew ocuses on hem exclusi ely. INTERNATIONAL REVIEW OF SPORT AND EXERCISE PSYCHOLOGY 23 Downloaded by [Tampe e Uni e si y] a 22:47 08 June 2016 The he e ogenei y in e ec i eness o school-based PA in e en ions (see, e.g., K iemle e al., 2011; an Sluijs e al., 2007) may be explained by di e ences in ac o s such as leng h o he in e en ion, mode o deli e y, p o ide o con en o he in e en ion. Ye no s udies so a ha e sys ema ically sough o explain his a iabili y by analysing in e en- ion con en (see Ab aham & Michie, 2008; Michie e al., 2013). Taxonomies o beha iou change echniques (BCTs) allow mo e in-dep h analyses o in e en ions and in e en ion s a egies (Ab aham & Michie, 2008; Michie e al., 2013). Th ee p e ious e iews ha e iden ified he BCTs used in in e en ions a ge ing obesi y- and weigh - ela ed beha iou s among child en and adolescen s (Golley, Hend ie, Sla e , & Co sini, 2011; Hend ie e al., 2012; Ma in, Cha e , & Lo enca o, 2013). In communi y- and school-based in e en ions o a ge obesi y- ela ed beha iou s in 1–18-yea -old child en, h ee BCTs we e associa ed wi h e ec i eness: P o iding gene al in o ma ion on beha iou –heal h links,P omp ing p ac ice, and Planning o social suppo /social changes (Hend ie e al., 2012). In hei e iew on in e en ions ha a ge pa en s o imp o e child en’s weigh - ela ed nu i ion in ake and ac i i y pa e ns, Golley e al. (2011) ound ha e ec i e in e en ions included: P omp ing ba ie iden ifi- ca ion,Res uc u ing he home en i onmen ,P omp ing sel -moni o ing and P omp ing specific goal se ing. In childhood obesi y p e en ion in e en ions, only P omp ing gene - alisa ion o a ge beha iou was shown o be ela ed o in e en ion e ec i eness (Ma in e al., 2013). None o he exis ing e iews has conduc ed a BCT analysis o school-based PA o SB in e en ions among adolescen s aged o e 15 yea s old (e.g., Biddle e al., 2011; Dobbins e al., 2009; an Sluijs e al., 2007). Mo e s udies ha e in es iga ed e ec i e BCTs o inc ease PA among adul popula ions (see, e.g., Ab aham & G aham-Rowe, 2009; Bi d e al., 2013; Michie, Ab aham, Whi ing on, McA ee , & Gup a, 2009; Williams & F ench, 2011). These sys ema ic e iews show ha e ec i e PA in e en ions ha e usually included BCTs linked wi h sel - egula ion, such as sel -moni o ing, goal se ing and ac ion planning. The e is a lack o e idence abou whe he he numbe o BCTs epo ed as being p esen in in e en ions is ela ed o in e en ion e ec i eness. Howe e , a e iew o in e - en ions a ge ing obesi y and weigh - ela ed nu i ion and PA beha iou s in child en bo h in he home and school/communi y se ing (Hend ie e al., 2012) sugges ed ha in e en ions including a highe numbe o BCTs we e associa ed wi h be e ou comes. In addi ion o cha ac e ising in e en ions in e ms o componen BCTs, exis ing e iews o school-based PA in e en ions all sho o analysing whe he in e en ion ou - comes a e influenced by in e en ion leng h, mode o deli e y (e.g., o al communica ion, w i en ma e ial, ideo, in e ac i e compu e p og am, sel -help, indi idual ace- o- ace, g oup ace- o- ace, elephone) o p o ide o deli e y. A sys ema ic e iew o sys ema ic e iews and me a-analyses on e ec s o school-based in e en ions a ge ing obesi y- ela ed beha iou s showed ha mo e e ec i e in e en ions gene ally las ed a leas h ee mon hs, i.e. a longe du a ion was epo ed o be mo e e ec i e compa ed o sho e in e en ions (Sa on e al., 2011). A be e unde s anding o whe he he abo e- men ioned cha ac e is ics a e ela ed o in e en ion e ec i eness would enable e i- dence-based decisions du ing in e en ion de elopmen . Ou e iew p o ides anup- o-da e sys ema ic analysis o he e ec i eness o school-based in e en ions a ge ing PA and/o SB among olde adolescen s (aged 15–19 yea s), using an explo a o y na a i e e iew wi h an analysis o in e en ion componen s including BCTs. 24 S-T. HYNYNEN ET AL. Downloaded by [Tampe e Uni e si y] a 22:47 08 June 2016 Re iew ques ions (1) A e school-based in e en ions o inc ease PA and/o educe SB among 15- o 19-yea - olds e ec i e? (2) Does e ec i eness o he in e en ions a y acco ding o a) he leng h o he in e en- ion, b) he mode o deli e y (e.g., o al communica ion, w i en ma e ial, ideo, in e - ac i e compu e p og am, sel -help, indi idual ace- o- ace, g oup ace- o- ace, elephone), and c) he p o ide o he in e en ion (e.g., eache , pee , esea che )? (3) Which BCTs ha e been used in he in e en ions and how is in e en ion con en ela ed o e ec i eness? Me hods The p o ocol o his sys ema ic e iew was published in PROSPERO –In e na ional p o- spec i e egis e o sys ema ic e iews (Hynynen e al., 2013). S udy selec ion and sea ch s a egy A sys ema ic sea ch was conduc ed using he ollowing elec onic da abases o pee - e iewed jou nal a icles and online esea ch egis e s: Medline, Cinahl, Embase, PsycINFO, Coch ane Cen al Regis e o Con olled T ials, Coch ane Da abase o Sys ema ic Re iews, and Coch ane Me hodology Regis e . The sea ch spanned om he yea o he da abase’s incep ion up o and including Feb ua y 2013. Du ing he sea ch we imposed no language es ic ions bu only a icles w i en in English we e included in he e iew. Indi idualised sea ch s a egies o he di e en da abases included combina ions o key wo ds ela ed o PA and SB, school, in e en ion and adolescence (see supplemen al da a). We used a modified e sion o he Coch ane highly sensi i e sea ch s a egy o iden i ying andom- ised ials, whe e he sec ions on complemen a y he apies we e emo ed. The e e ence lis s o s udies ha me he inclusion c i e ia as well as o he ele an e iews we e scanned. The esea che s also sen inqui ies abou ongoing in e en ion s udies ia el- e an ne wo ks, such as scien ific socie ies. Howe e , no addi ional s udies we e iden ified h ough his app oach. Inclusion c i e ia specified andomised o clus e andomised s udies on school-based in e en ions ha a ge ed PA and/o SB among 15- o 19-yea -old adolescen s who a e appa en ly heal hy ( o a mo e de ailed desc ip ion, see Hynynen e al., 2013). Included s udies could also add ess o he heal h beha iou s, bu da a on hese beha iou s we e no ex ac ed. Inclusion c i e ia specified ha in e en ions had o be p ima ily based in schools bu hey migh also include home- o communi y-based componen s. The included s udies epo ed ei he sel - epo ed o objec i ely measu ed (e.g., accele - ome e ) PA o SB o bo h, p esen ing a baseline and a pos -in e en ion measu emen . S udies ha only a ge ed indi iduals a inc eased heal h isk (e.g., obese you hs) we e excluded. We also excluded s udies ha measu ed s uden s’PA du ing physical educa ion (PE) classes only. This s a egy iden ified 8470 e e ences ha we e impo ed in o he Re Wo ks da abase (see Figu e 1). A e excluding duplica es, 5482 e e ences emained. The sc eening o he emaining e e ences was conduc ed in h ee phases by wo esea che s (STH and MVS) INTERNATIONAL REVIEW OF SPORT AND EXERCISE PSYCHOLOGY 25 Downloaded by [Tampe e Uni e si y] a 22:47 08 June 2016 wo king independen ly. Publica ions we e included i eligibili y was unclea . In he fi s phase o sc eening, i les o all e e ences we e e iewed. Du ing his phase 4456 e e - ences we e excluded. In he second phase, abs ac s o he emaining 1026 a icles we e sc eened and 667 a icles excluded. In he hi d phase, ull ex pape s we e ob ained o 359 a icles and eligibili y e iewed in de ail. Any disag eemen s we e esol ed by dis- cussion be ween he wo esea che s. We c ea ed a s anda dised o m o ex ac all ele an de ails o he ial cha ac e is ics (s udy design, numbe o pa icipan s, me hod o andomisa ion, s udy se ing and Figu e 1. Iden ifica ion o he included s udies. 26 S-T. HYNYNEN ET AL. Downloaded by [Tampe e Uni e si y] a 22:47 08 June 2016 coun y), sample cha ac e is ics (inclusion and exclusion c i e ia o pa icipan s, co-mo - bidi ies), de ails o in e en ions (mode o deli e y, p o ide , se ing, ecipien , in ensi y, leng h), pa icipan cha ac e is ics, pa icipan a i ion, physical ac i i y and seden a y beha iou ou come measu es and possible seconda y ou comes. The da a ex ac ion was ca ied ou by one esea che (STH) and e ified by a second (MVS o ano he esea che ). Assessing isk o bias The Coch ane isk o bias ool (Higgins e al., 2011) was used o assessing isk o bias in he included a icles, co e ing he alloca ion p ocedu es, ou come analyses, epo ing and o he possible sou ces o bias. Two esea che s (STH and MC) independen ly assessed he quali y o all s udies ha me he inclusion c i e ia. The ollowing domains we e con- side ed: sequence gene a ion, alloca ion concealmen , blinding o s udy pe sonnel and pa icipan s, incomple e ou come da a, selec i e ou come epo ing, o he possible sou ces o bias, and when ele an clus e ec ui men bias and baseline imbalance bias. Each pape was ca e ully assessed o each domain and judgemen s we e made ega ding po en ial bias, acco ding o h ee ca ego ies: low isk, high isk, o isk unclea . In e - a e eliabili y was calcula ed (a e age pe cen age ag eemen 74%). Coding he beha iou change echniques The BCT coding was conduc ed by wo esea che s (STH and MVS) using Michie e al.’s (2013) beha iou change echnique axonomy (BCTT 1). P io o coding, STH had a ended a BCT aining wo kshop and MVS comple ed a g oup u o ial aining p o- g amme guided by phone. BCTs we e coded sepa a ely o inc easing PA and educing SB. Bo h in e en ion a ms and con ol a ms we e coded o BCTs. All published ma e ials (e.g., in e en ion p o ocols) o he included ials we e used o cha ac e ise in e en ion con en . P io o ex ac ing BCTs om included in e en ion s udies, he wo code s pilo ed consis ency in hei BCT coding by coding h ee in e en ion epo s ha we e no included in he e iew as hey a ge ed a di e en age g oup. All included in e en- ions we e hen coded independen ly. In e - a e eliabili y was assessed and pe cen ag eemen on BCTs p esen in he desc ip ions was high (83.3%). Disc epancies be ween bo h p ima y code s we e discussed and esol ed wi h a hi d esea che (WH) who is a membe o he BCTT 1 eam. Assessing in e en ion and BCT e ec i eness Fo each s udy, in e en ion e ec s (Cohen’sd) o PA and SB we e calcula ed a he fi s ollow-up pos -in e en ion. This was he only ou come measu emen poin a e baseline ha was epo ed in all included s udies. The e o e, we selec ed his poin in ime o compa e he e ec s ac oss s udies. Fo he pu pose o calcula ing e ec sizes, we con- ac ed ou au ho s o u he nume ical da a needed. Th ee esponded and p o ided he eques ed da a. Hal o he s udies epo ed mode a e o igo ous physical ac i i y (MVPA) ou come measu es, which we e used o he e ec size calcula ions when a ail- able. I he s udy p esen ed objec i e measu emen o PA, hose we e used o he INTERNATIONAL REVIEW OF SPORT AND EXERCISE PSYCHOLOGY 27 Downloaded by [Tampe e Uni e si y] a 22:47 08 June 2016 Table 1. S udy cha ac e is ics. S udy Coun y S udy design In e en ion and con ol g oups Numbe o pa icipan s To al a i ion Sex o pa icipan s Mean age o pa icipan s (SD) PA ou comes SB ou comes Assessmen Bayne-Smi h e al. (2004) US CRT 1 IV 1 CON 442 No epo ed Only emale - Sel - epo ed PA no. o sessions pe week No a ge ed o epo ed Baseline, Pos -IV Gomes de Ba os e al. (2009) B azil CRT 1 IV 1 CON 2155 54.1% 55.7% emale 18.4 (SD = 2.3) Sel - epo ed no. o days pe week accumula ing 60 min o MVPA No epo ed Baseline, Pos -IV Hill, Ab aham, and W igh (2007) UK CRT 3 IV 1 CON 620 18.9% 51% emale 16.97 (SD 1.4) Sel - epo ed ‘On a e age o e he las h ee weeks, I ha e exe cised ene ge ically o a leas 30 minu es ____ imes pe week.’ No a ge ed o epo ed Baseline, Pos -IV Lee, Kuo, Fanaw, Pe ng, and Juang (2012) Taiwan CRT 1 IV 1 CON 94 3.2% Only emale 16.2 (SD 0.4) Objec i ely measu ed PA (pedome e ) Change in ae obic walking (s eps/day) No epo ed Baseline, Pos -IV Lubans and Syl a (2006) UK RCT 1 IV 1 CON 78 Pos -IV 0% Follow-up 2.6% 61.5% emale 16.7 (SD 0.5) Sel - epo ed MVPA min/week No epo ed Baseline, Pos -, 3- mon h ollow-up Mau iello e al. (2010) US CRT 1 IV 1 CON 1800 Pos -IV 20.6% Follow-up 34.3% 50.8% emale - Sel - epo ed PA ‘In a ypical week, how many days do you do 60 min o mo e o physical ac i i y?’ Sel - epo ed limi ed TV iewing Baseline, Pos -IV,6- mon h ollow-up, 12-mon h ollow- up Neuma k-Sz aine e al. (2010) US CRT 1 IV 1 CON 356 Pos -IV 3.1% Follow-up 5.6% Only emale - Sel - epo ed MVPA (30-min blocks/day) Sel - epo ed seden a y ac i i y (30-minu e blocks/ day) Baseline, Pos -IV, 9-mon h ollow-up Schofield, Mumme y, and Schofield (2005) Aus alia CRT 2 IV 1 CON 85 Pos -IV 20% Only emale 15.8 (SD 0.8) Objec i ely measu ed PA (pedome e ) 4-d s ep coun No a ge ed o epo ed Baseline, Mid-IV, Pos -IV Singhal, Mis a, Shah, and Gula i (2010) India CRT 1 IV 1 CON 209 Pos -IV 3.8% 40.2% emale IV 16.04 (SD 0.41) CON 16.0 (SD 0.5) Sel - epo ed PA > 4 days in a week Sel - epo ed wa ching TV (4–5 h/day) Baseline, Pos -IV Sloo make , Chinapaw, Seidell, an Mechelen, and Schui (2010) The Ne he - lands RCT 1 IV 1 CON 87 Pos -IV 21.8% Follow-up 9.2% 63.2% emale 15.1 (SD no epo ed) Objec i ely measu ed MVPA (accele ome e ) Objec i ely measu ed seden a y ime Baseline, Pos -IV, 8-mon h ollow-up IV: Sho o in e en ion. CON: Sho o con ol. 28 S-T. HYNYNEN ET AL. Downloaded by [Tampe e Uni e si y] a 22:47 08 June 2016 e ec size calcula ions; in o he cases sel - epo ed ou comes we e add essed. When he e was no MVPA ou come epo ed, we used he closes ou come a ailable (see Table 1). We classified he in e en ions in o e ec i e s. non-e ec i e based on he same PA ou come da a ha we e used in he e ec size calcula ions. E ec i e ials we e defined as hose ha epo ed a significan di e ence (p< .05) be ween in e en ion and con ol g oups’ PA a fi s ollow-up pos -in e en ion. We iden ified which BCTs we e p esen in he e ec i e ials and which BCTs we e p esen in he non-e ec i e ials. We analysed BCT e ec i eness using a me hod modified om one used in Ma in e al.’s(2013) sys ema ic e iew on childhood obesi y p e en ion and managemen in e en ions. E ec i e BCTs we e defined as hose ha we e p esen in a majo i y (> 50%) o he e ec i e ials bu no a all p esen o p esen in only one o he non-e ec i e ials. We also a emp ed o iden i y he BCTs unique o in e en ions ha did no change PA o SB. We illus a ed BCT e ec i eness by calcula ing ‘e ec i eness a ios’o he ela i e weigh o BCTs appea ing in wo o mo e ials. The e ec i eness a io was calcula ed as he a io o he numbe o imes a BCT was p esen in an e ec i e in e en ion di ided by he numbe o imes i was p esen as a componen o all in e en- ions, including he ine ec i e in e en ions. Resul s The sea ch p o ided 5482 eco ds (see Figu e 1) ou o which 13 a icles epo ing 10 unique in e en ion s udies we e iden ified o inclusion in he e iew (Bayne-Smi h e al., 2004; Gomes de Ba os e al., 2009; Hill e al., 2007; Lee e al., 2012; Lubans & Syl a, 2006; Mau iello e al., 2006; Mau iello e al., 2010; Nahas e al., 2009; Neuma k-Sz ai- ne e al., 2010; Neuma k-Sz aine , S o y, Hannan, & Rex, 2003; Schofield e al., 2005; Singhal e al., 2010; Sloo make e al., 2010). S udy cha ac e is ics and pa icipan s Two o he included s udies we e indi idually andomised con olled ials (Lubans & Syl a, 2006; Sloo make e al., 2010) and eigh we e clus e andomised ials (Bayne-Smi h e al., 2004; Gomes de Ba os e al., 2009; Hill e al., 2007; Lee e al., 2012; Mau iello e al., 2010; Neuma k-Sz aine e al., 2010; Schofield e al., 2005; Singhal e al., 2010). The a e age sample size was 593 (SD = 757), anging om 78 o 2155 olde adolescen s. The non- weighed mean a i ion pe cen age (whe e epo ed) a fi s ollow-up pos in e en ion was 16.2% (SD = 16.8%) anging om 0% o 54.1%. Fou in e en ions we e only aimed a emale adolescen s (Bayne-Smi h e al., 2004; Lee e al., 2012; Neuma k-Sz aine e al., 2010; Schofield e al., 2005) and six we e aimed a bo h sexes (Gomes de Ba os e al., 2009; Hill e al., 2007; Mau iello e al., 2010; Singhal e al., 2010; Sloo make e al., 2010). (Fo mo e de ail on s udy cha ac e is ics, see Table 1.) In e en ion and compa ison a ms The 10 s udies compa ed a o al o 13 di e en in e en ion g oups agains 10 con ol g oups. Eigh s udies compa ed one in e en ion g oup agains one con ol g oup (Bayne-Smi h e al., 2004; Gomes de Ba os e al., 2009; Lee e al., 2012; Lubans & Syl a, INTERNATIONAL REVIEW OF SPORT AND EXERCISE PSYCHOLOGY 29 Downloaded by [Tampe e Uni e si y] a 22:47 08 June 2016 2006; Mau iello e al., 2010; Neuma k-Sz aine e al., 2010; Singhal e al., 2010; Sloo make e al., 2010). These in e en ions included a web-based in e en ion o e ing pe sonalised eedback on eadiness o change (Mau iello e al., 2010), a web-based in e en ion coupled wi h he use o accele ome e s (Sloo make e al., 2010), an in e en ion using pedome e s o encou age walking (Lee e al., 2012), an in e en ion a ge ing he school en i onmen and o e ing s uden s PA oppo uni ies (Gomes de Ba os e al., 2009), heal h and exe cise p og ammes (Lubans & Syl a, 2006), a hea heal h p og amme ocusing on igo ous exe cise and o he heal h beha iou s such as die , smoking and s ess (Bayne-Smi h e al., 2004), and an all-gi ls PE cou se a ge ing sel -empowe men , nu i ion and including one-on-one mo i a ional in e iewing sessions (Neuma k-Sz aine e al., 2010) ( o u he in o ma ion see Table 2). One s udy compa ed wo in e en ion g oups agains a con ol g oup (Schofield e al., 2005). In his s udy bo h in e en ion g oups we e o e ed a 12-week PA sel -moni o ing and educa i e p og amme. One in e - en ion g oup was p o ided wi h pedome e s and se daily s ep coun a ge s whe eas he o he g oup se daily ime-based goals o PA in ol emen (Schofield e al., 2005). A final s udy compa ed h ee ypes o heo y-based pe suasi e leafle s o inc ease PA (leafle alone, leafle plus a mo i a ional quiz, and leafle plus implemen a ion in en ion p omp ) agains a no-leafle con ol g oup (Hill e al., 2007). Con ol g oup ea men di - e ed widely in he 10 ials. Whe eas some con ol g oups ecei ed a cogni i e wo d sea ch ask (Hill e al., 2007), o a b ie leafle wi h gene al PA ecommenda ions (Sloo - make e al., 2010), o he s ecei ed he school’s s anda d PE p og amme (Gomes de Ba os e al., 2009). Neuma k-Sz aine e al. (2010) desc ibed also p o iding he con ol g oup wi h an all-gi ls PE class. O e all, con ol g oup in e en ions we e insu ficien ly desc ibed in he s udies o enable coding o BCTs. Risk o bias All s udies excep o one (Sloo make e al., 2010) we e judged o be a high isk o bias in a leas one domain (see Table 3). Howe e , he s udy by Sloo make e al. (2010) also had domains o unclea isk o bias. Sequence gene a ion was inadequa ely desc ibed in eigh ou o 10 s udy epo s. None o he s udies epo ed p ope blinding o pa icipan s o s udy g oup alloca ion. Ou comes Fi e s udies a ge ed only PA o PA and SB ou comes (Hill e al., 2007; Lee e al., 2012; Lubans & Syl a, 2006; Schofield e al., 2005; Sloo make e al., 2010). The fi e o he s udies a ge ed o he ou comes as well, such as hea heal h knowledge and die a y beha iou s (Bayne-Smi h e al., 2004; Gomes de Ba os e al., 2009; Mau iello e al., 2010; Neuma k-Sz aine e al., 2010; Singhal e al., 2010). Fi e s udies assessed ou come measu es only a baseline and a he end o he in e en ion pe iod (Bayne-Smi h e al., 2004; Gomes de Ba os e al., 2009; Lee e al., 2012; Schofield e al., 2005; Singhal e al., 2010). Hill e al. (2007) assessed ou comes h ee weeks pos -in e en ion. Th ee s udies assessed ou comes bo h pos -in e en ion and a ew mon hs pos -in e en ion (Lubans & Syl a, 2006; Neuma k-Sz aine e al., 2010; Sloo make e al., 2010). Mau iello e al. 30 S-T. HYNYNEN ET AL. Downloaded by [Tampe e Uni e si y] a 22:47 08 June 2016 la ge, epo ed using mo e BCTs han he non-e ec i e in e en ions, and specifically eigh BCTs: In o ma ion abou social and en i onmen al consequences,G aded asks,Sel - moni o ing o beha iou ,Feedback on beha iou ,P oblem sol ing,Goal se ing (beha iou ), Ac ion planning and Social suppo . Ou o he ou s udies ha measu ed SB, only wo had significan e ec s on he beha iou . No s udies we e ound ha ocused solely on SB. Due o his lack o e idence, i is di ficul o d aw conclusions on wha in e en ion elemen s o BCTs we e ela ed o e ec i eness in ega ds o SB. Ou e iew sugges s ha in e en ions a ge ing mul iple heal h beha iou s a e less e ec i e in p omo ing PA among olde adolescen s han ones ocusing solely on PA o PA and SB, which is also suppo ed by ea lie e idence (C u zen e al., 2010). P e ious e iews ha e sugges ed ha when app op ia ely ained, a wide ange o p o ide s can deli e e ec i e heal h beha iou in e en ions (G ea es e al., 2011; Pe e s, Kok, Ten Dam, Buijs, & Paulussen, 2009). On he con a y, we ound ha in e en ions deli e ed by esea ch s a we e mo e e ec i e han hose deli e ed by school s a o o he p o i- de s. This finding esembles he basic di e ence be ween e ficacy and e ec i eness ials, and may be mo e a ma e o fideli y o deli e y –o aining – a he han a ma e o he pe son p o iding he in e en ion. While o he e iews ha e shown ha longe du a ion o school-based PA in e en ions was associa ed wi h e ec i eness (Dobbins e al., 2009; Sa on e al., 2011), we did no find a ela ionship be ween in e en ion leng h and sho - e m e ec i eness. I is possible ha he ela ionship be ween in e en ion leng h and PA ou comes was influenced by o he in e en ion cha ac e is ics no analysed in ou e iew such as in e en ion in ensi y: sho bu e y in ensi e in e en ions may be mo e e ec i e han longe in e en ions wi h less con ac . Finally, in line wi h p e ious e i- dence (G ea es e al., 2011), he e was no clea associa ion be ween mode o in e en ion deli e y and e ec i eness. In line wi h some (A e y, Flynn, an We sch, Snieho a, & T enell, 2012; Hend ie e al., 2012) and in con as o o he e iews (Ab aham & G aham Rowe, 2009; Domb owski e al., 2013), we ound ha e ec i e PA in e en ions included mo e BCTs han non-e ec- i e in e en ions. This may be ei he a ma e o non-e ec i e in e en ions ac ually using ewe echniques o change beha iou , o o no epo ing wha was done, indica ing less p ecision in bo h planning and epo ing he in e en ion. The specific BCTs iden ified o be ela ed wi h in e en ion e ec i eness esona e wi h he findings o p e ious e iews wi h adul popula ions (A e y e al., 2012; Michie e al., 2009; Williams & F ench, 2011), whe e BCTs ela ed o sel - egula ion ha e been shown o be e ec i e in changing PA. Based on ou e iew, his applies also among olde adolescen s: Goal se ing and Ac ion planning we e echniques emphasised in e ec i e ials, and complemen ing BCTs such as Sel -moni o ing o beha iou ,Feedback on beha iou and P oblem sol ing we e unique o e ec i e ials. In hei e iew on obesi y p e en ion in e en ions o child en, Hend ie e al. (2012) ound ha p o iding in o ma ion on beha iou –heal h links was ela ed o in e en ion e ec i eness. Qui e simila ly, we ound In o ma ion abou social and en i onmen al conse- quences o be a echnique uniquely p esen in he e ec i e ials. Wha should be no ed is ha his BCT is coded whene e he in o ma ion p o ided is unspecified in he in e en- ion desc ip ion (Michie e al., 2013). The e o e i is possible ha he in o ma ion p o ided in he in e en ions was no ac ually abou social and en i onmen al consequences, bu a he abou heal h consequences o emo ional consequences, o a combina ion o hese. INTERNATIONAL REVIEW OF SPORT AND EXERCISE PSYCHOLOGY 37 Downloaded by [Tampe e Uni e si y] a 22:47 08 June 2016 In e es ingly, Beha iou al p ac ice/ ehea sal was a echnique p esen mainly in non- e ec i e in e en ions. In a p e ious e iew o PA in e en ions among obese adul s (Olande e al., 2013), qui e o he con a y, P omp ing p ac ice 1 was ela ed o la ges e ec s o PA. I is possible ha p omp ing beha iou al p ac ice ou side o in e en ion sessions is ela ed o e ec i eness whe eas p ac ice wi hin he sessions is a ypical elemen o non-e ec i e in e en ions. This is suppo ed by ou finding ha se ing G aded asks was a BCT p esen uniquely in e ec i e in e en ions. We ound li le e idence o in e en ion echniques ocusing on he en i onmen le el o beha iou change, such as Res uc u ing he physical en i onmen . Nei he ha e p e ious e iews on PA in e en ions (see, e.g., G ea es e al., 2011; Michie e al., 2009) shown hese echniques o be ela ed o e ec i eness. Res uc u ing he physical en i onmen was p esen in only h ee in e en ions, wo o which we e e ec i e and one non-e ec i e. The lack o en i onmen -le el echniques may be a ma e o financial esou ces. Ini ia ing majo changes in he school’s physical en i onmen wi hou p e ious e idence o i ac u- ally being e ec i e in suppo ing and inc easing s uden s’PA migh be oo isky and cos ly. Se e al dis inc en i onmen al changes, such as p o iding oppo uni ies o PA by di ec mone a y in es men s in schools’PA equipmen , o e ing s uden s ee oppo u- ni ies o s uc u ed PA and o ganising collec i e supe ised PA e en s, we e hea ily emphasised in he in e en ion by Gomes de Ba os e al. (2009). Howe e , in he BCT Tax- onomy 1 all o hese di e en ac ions a e coded unde one echnique: Res uc u ing he physical en i onmen . We ecommend ha his echnique is unpacked in mo e de ail in u u e de elopmen s o he axonomy, so ha s udies can in es iga e he ela i e e ec- i eness o he abo e app oaches. Ou o he ou s udies ha measu ed seden a y beha iou , only wo significan ly dec eased SB. Based on only wo s udies i is di ficul o d aw eliable conclusions on wha elemen s we e ela ed o e ec i eness. No ably, none o he ials measu ing SB ea ed i as a sepa a e beha iou , bu a he as an indica o o insu ficien PA le els. SB was measu ed objec i ely in only one o he s udies (Sloo make e al., 2010). The o he s elied on sel - epo ed SB o en indica ed by ime spen on he compu e , iewing ele ision o playing boa d games. The s udies p o ided no desc ip ions o in e en ion s a egies aimed specifically a changing SB, which made i impossible o iden i y he BCTs e ec i e in educing SB, and make a dis inc ion wi h PA. The BCTs and al e a ions in he school con ex ha may need o occu in o de o dec ease adolescen s’SB may be qui e di e en om he s a egies needed o enhance PA. Ul ima ely, an in e en ion ocusing on PA may no a ec SB (e.g., i he ocus o he in e en ion is on inc easing he in ensi y o he PA). Con e sely, an SB in e en ion may no a ec heal h-enhancing MVPA i adolescen s a e encou aged o subs i u e si ing wi h s anding o ligh -in ensi y PA. I is e iden ha mo e s udies a e needed ha a ge in e en ion s a egies o specifically dec ease SB. Fu he mo e, in o de o eliably iden i y he BCTs associa ed wi h PA and SB in e en- ion e ec i eness, he BCTs used in con ol g oups, i.e. s anda d ca e, should be desc ibed in in e en ion epo s and coded. Especially when he in e en ion is deli e ed du ing he PE class, i is di ficul o d aw conclusions on e ec i e BCTs wi hou knowing which BCTs a e also pa o s anda d ca e. Con ol g oup ea men di e ed widely in he 10 ials and was al oge he insu ficien ly desc ibed in he s udies. Neuma k-Sz aine e al. (2010) desc ibed p o iding he con ol g oup wi h an all-gi ls PE class wi h mos ly inac i e pa - icipan s. I is possible ha his alone is qui e a powe ul in e en ion, de ia ing om 38 S-T. HYNYNEN ET AL. Downloaded by [Tampe e Uni e si y] a 22:47 08 June 2016 he s anda d mixed-gende PE, and may explain he lack o s a is ically significan di e - ences in PA be ween in e en ion and con ol g oups pos -in e en ion. We ecommend ha u u e s udies epo BCTs used in bo h in e en ion and con ol g oups. I is no able ha ou ou o 10 in e en ions a ge ed emales exclusi ely. Gi ls a e indeed mo e in need o PA-p omo ing in e en ions, as hey engage on a e age in less MVPA han boys (Sallis, P ochaska, & Taylo , 2000). Howe e , boys gene ally spend mo e ime on sc een-based beha iou s. P e ious s udies ha e shown ha school-based PA in e en ions wo k be e o gi ls han boys (Yildi im e al., 2011), which may be in pa due o gi ls’low baseline MVPA le els. The limi a ions o ou e iew a e influenced by he numbe and quali y o he s udies included. In gene al, he me hodological quali y o he included s udies was weak, wi h ela- i ely small sample sizes and a high isk o bias. Only h ee s udies epo ed objec i e measu emen o PA (accele ome y, pedome e s) and one s udy (Sloo make e al., 2010) objec i ely assessed SB, posing a majo eliabili y p oblem. Ou o he se en s udies ha we classified as e ec i e in inc easing PA, ou elied solely on sel - epo measu es. Since sel - epo can be influenced by ecall bias and social desi abili y bias, hese findings need o be confi med by objec i e measu es. Ano he majo limi a ion in his a ea, as no ed in ea lie sys ema ic e iews as well (e.g., an Sluijs e al., 2007), is he lack o long- e m ollow-ups and, consequen ly, a lack o e idence ega ding long- e m e ec i eness. Thi dly, deli e ing in e en ions only o olun ee pa icipan s exp essing heigh ened in e - es in he p og amme (Lubans & Syl a, 2006; Mau iello e al., 2010) e sus, o example, ec ui ing all s uden s om a gi en class oom possesses a h ea o posi i ely biased esul s. I is qui e e iden ha indi iduals who seek o pa icipa e in a PA in e en ion a e mo e mo i a ed o inc ease hei le el o PA han hei age coho in gene al. Also, because sel - epo ed PA was he main ou come measu e in mos s udies, i is possible ha ailu e o blind pa icipan s o alloca ion migh ha e esul ed in di e en ial e ec s o social desi abili y bias be ween in e en ion and con ol g oup pa icipan s. The e was an appa en lack o quali y in epo ing he s udies. Some o he s udies we e so supe ficially desc ibed ha i was di ficul o d aw conclusions on in e en ion elemen s ela ed o e ec- i eness; om some i was di ficul o e en ell who deli e ed he in e en ion. Howe e , he in e - a e eliabili y o he code s was adequa e. Finally, due o he small numbe o included s udies and he he e ogenei y o he ou come measu es, we we e no able o conduc a me a-analysis. Hence, i should be aken in o accoun ha he conclusions on associa ions and ela ionships be ween in e en ion componen s and in e en ion e ec i e- ness p esen ed in his e iew a e based on a small numbe o s udies and desc ip i e a he han quan i a i e analysis. The sca ci y o epo ed s udies in his age g oup and he ac ha only h ee non-e ec i e s udies we e ound in he li e a u e sea ch also aises a se ious ques- ion o possible isk o publica ion bias in his esea ch field. Due o hese ac o s, he con- clusions d awn om his e iew ega ding BCT e ec i eness a e en a i e. This s udy has se e al implica ions o u u e esea ch and p ac ice. We ecommend ha u u e in e en ion s udies use objec i e measu es o PA and SB alongside sel - epo measu es and use la ge enough sample sizes o allow o mul i-le el analyses o accoun o clus e ing wi hin classes and schools. Fu he mo e, u u e ials should include long- e m ollow-ups and mo e p ecise desc ip ions o in e en ion con en in e ms o BCTs. The ad an ages o school-based PA and SB in e en ions include a cap i e audience and wide each o he a ge g oup. As he e is a ma ked d op in PA le els du ing INTERNATIONAL REVIEW OF SPORT AND EXERCISE PSYCHOLOGY 39 Downloaded by [Tampe e Uni e si y] a 22:47 08 June 2016 adolescence, and a high le el o SB, his age g oup is an especially impo an a ge o public heal h e o s. Ou e iew may help e o s o de elop mo e e ec i e in e en ions in his unde - esea ched age g oup, ha ing iden ified ac o s associa ed wi h e ec i eness and c ucial gaps in esea ch ha me i a en ion in u u e s udies. Fi s , o u u e in e en- ion de elope s, we would poin ou he majo lack o school-based in e en ion s udies o dec ease SB in his age g oup. Fu u e s udies ough o acknowledge ha PA and SB a e di e en a ge beha iou s ha equi e di e en in e en ion s a egies. In ou e iew, we iden ified p omising BCTs ha seem o be e ec i e a leas in he sho e m in school-based in e en ions o p omo e PA among olde adolescen s. I should be no ed ha in e en ions should no be deemed e ec i e based on s a is ical significance only, bu one should also examine whe he he changes ha e public heal h o clinical signifi- cance. Few o he o iginal s udies made an explici judgemen , o assessed cos -e ec i e- ness. Since ou e iew ound ha in e en ions deli e ed ia esea ch s a we e mo e e ec i e han hose deli e ed by school s a o o he p o ide s, we sugges ha in u u e esea ch ca e ul p ocess e alua ion (Moo e e al., 2015) is conduc ed o examine accep abili y and fideli y o he in e en ion and o unde s and whe he public heal h in e en ions can be olled ou success ully wi hou esea che deli e y. In addi ion, in e - en ion de elope s should ca e ully selec BCTs and o he elemen s ha would inc ease main enance o PA o e he long e m, as so a no s udy has been able o demons a e ha hei school-based in e en ion ha e long-las ing e ec s on olde adolescen s’PA. Since ou e iew shows a lack o e idence in his a ge audience and beha iou , we sugges ha de elope s look in o o he a eas o beha iou al science esea ch whe e BCTs aimed a main aining beha iou a e being es ed. In conclusion, his e iew ound ha he e is limi ed e idence on how o bes p omo e PA and educe SB among olde adolescen s in school-based in e en ions in he long e m. The me hod we used o analyse he con en o in e en ions was help ul in iden i ying e ec i e elemen s, which will benefi u u e in e en ion de elopmen wo k, ul ima ely imp o ing adolescen ac i i y beha iou s. Disclosu e s a emen No po en ial conflic o in e es was epo ed by he au ho s. Funding The fi s au ho S-T. Hynynen was suppo ed by he Minis y o Educa ion and Cul u e [g an numbe 34/626/2012], and he Minis y o Social A ai s and Heal h [g an numbe : 201310238]; Finland. F. F. Snieho a is unded by Fuse, he UK Clinical Resea ch Collabo a ion Cen e o Excellence o T ansla ional Resea ch in Public Heal h. 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