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.
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VOL. 9, NO. 1, 22–44
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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
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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.
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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
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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.
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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
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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.
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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
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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.
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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
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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.
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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
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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. Funding
o Fuse om he B i ish Hea Founda ion, Cance Resea ch UK, Economic and Social
Resea ch Council, Medical Resea ch Council, and he Na ional Ins i u e o Heal h Resea ch,
unde he auspices o he UK Clinical Resea ch Collabo a ion.
Supplemen al da a
Supplemen al da a o his a icle can be accessed 10.1080/1750984X.2015.1081706.
40 S-T. HYNYNEN ET AL.
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No e
1. P omp ing p ac ice is a BCT in he CALO-RE axonomy; a efined axonomy o beha iou change
echniques o help people change hei physical ac i i y and heal hy ea ing beha iou (see
Michie e al. 2011)
Re e ences
Ab aham, C., & G aham-Rowe, E. (2009). A e wo ksi e in e en ions e ec i e in inc easing physical
ac i i y? A sys ema ic e iew and me a-analysis. Heal h Psychology Re iew,3(1), 108–144.
Ab aham, C., & Michie, S. (2008). A axonomy o beha io change echniques used in in e en ions.
Heal h Psychology,27(3), 379–387.
A e y, L., Flynn, D., an We sch, A., Snieho a, F. F., & T enell, M. I. (2012). Changing physical ac i i y
beha io in ype 2 diabe es a sys ema ic e iew and me a-analysis o beha io al in e en ions.
Diabe es Ca e,35(12), 2681–2689.
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