Physical Activity Interventions in Latin America

Physical Activity Interventions in Latin AmericaA Systematic ReviewChristine M. Hoehner, PhD, MSPH, Jesus Soares, ScD, Diana Parra Perez, CPT, Isabela C. Ribeiro, PhD, MSc,Corinne E. Joshu, MA, MPH, Michael Pratt, MD, MPH, Branka D. Legetic, MD, PhD, MPH,Deborah Carvalho Malta, MD, PhD, Victor R. Matsudo, MD, PhD, Luiz Roberto Ramos, MD, PhD,Eduardo J. Simões, MD, MSc, MPH, Ross C. Brownson, PhD

Background: Recommendations for physical activity in the Guide to Community Preventive Services (theCommunity Guide) have not been systematically examined or applied in developingcountries such as those in Latin America. The aim of this systematic review was to assess thecurrent evidence base concerning interventions to increase physical activity in LatinAmerica using a modified Community Guide process and to develop evidence-basedrecommendations for physical activity interventions.

Methods: In 2006, a literature review of both peer-reviewed and non–peer-reviewed literature inPortuguese, Spanish, and English was carried out to identify physical activity interventionsconducted in community settings in Latin America. Intervention studies were identified bysearching ten databases using 16 search terms related to physical activity, fitness, healthpromotion, and community interventions. All intervention studies related to physicalactivity were summarized into tables. Six reviewers independently classified the interven-tion studies by the categories used in the Community Guide and screened the studies forinclusion in a systematic abstraction process to assess the strength of the evidence. Fivetrained researchers conducted the abstractions.

Results: The literature search identified 903 peer-reviewed articles and 142 Brazilian theses relatedto physical activity, of which 19 were selected for full abstraction. Only for school-basedphysical education classes was the strength of the evidence from Latin America sufficientto support a practice recommendation.

Conclusions: This systematic review highlights the need for rigorous evaluation of promising interven-tions to increase physical activity in Latin America. Implementation and maintenance ofschool physical education programs and policies should be strongly encouraged topromote the health of Latin American children.(Am J Prev Med 2008;34(3):224–233) © 2008 American Journal of Preventive Medicine

Introduction

The majority of low- and middle-income countries1

(hereafter “developing countries”) are experienc-ing a shift from a high prevalence of infectious

diseases to a high prevalence of noncommunicable dis-eases (e.g., cardiovascular disease).2 These shifts are duein part to rapid urbanization and globalization processesin which behaviors, lifestyles, and living situations arechanging at a significant pace. According to the lastWorld Bank report, 56% of all deaths in developingcountries may be attributed to noncommunicable dis-eases,3 and the WHO estimates that by 2020, 80% of alldeaths may be attributed to these diseases.4 The growingburden that chronic disease is placing on developingnations is increasing attention to risk factors such assedentary lifestyles5 and encouraging population-basedstudies of such risk factors in Latin American regions. Forexample, a population-based survey of adults in North-east and Southeast Brazil,6 where approximately 70% of

From the Prevention Research Center, Saint Louis University Schoolof Public Health (Hoehner, Soares, Perez, Joshu, Brownson), St.Louis, Missouri; Physical Activity and Health Branch, Division ofNutrition and Physical Activity (Soares, Ribeiro, Pratt) and Preven-tion Research Centers Program (Simões), Centers for Disease Con-trol and Prevention, Atlanta, Georgia; World Health Organization/Pan American Health Organization Regional Office (Legetic),Washington DC; Division of Situation Analysis and Prevention ofNon-transmissible Diseases, Brazil Ministry of Health (Malta); Centrode Estudos do Laboratório de Aptidão Física de São Caetano de Sul(Matsudo); and Department of Preventive Medicine, UniversidadeFederal de São Paulo (UNIFESP) (Ramos), São Paulo, Brazil

Address correspondence and reprint requests to: Christine Hoeh-ner, PhD, Saint Louis University School of Public Health, SalusCenter, Room 474, 3545 Lafayette Avenue, St. Louis MO 63104.E-mail: [email protected].

The full text of this article is available via AJPM Online atwww.ajpm-online.net; 1 unit of Category-1 CME credit is also avail-able, with details on the website.

224 Am J Prev Med 2008;34(3) 0749-3797/08/$–see front matter© 2008 American Journal of Preventive Medicine • Published by Elsevier Inc. doi:10.1016/j.amepre.2007.11.016

Brazilians live, reported that the prevalence of physicalinactivity (0 days of 30 minutes of leisure-time activityper week) was 87% between 1996 and 1997.

In recent years, increasing attention has been paid tocommunity-based interventions to promote physicalactivity as a critical piece of an overall strategy toincrease health among populations.7 For example, inMay 2004, in response to the increasing global epi-demic of noncommunicable diseases, the WHO re-leased a global strategy on diet and physical activity.8

Bauman et al.7 developed a six-step framework forinternationally disseminating the WHO strategy thatwould promote its implementation. They concludedthat more evaluation as well as the international dis-semination of effective evidence-based interventions topromote physical activity is needed.7 Likewise, the U.S.Task Force on Community Preventive Services recentlypublished the Guide to Community Preventive Services (theCommunity Guide), an evaluation of the effectiveness ofpublic health strategies in 17 areas, including physicalactivity.9 The Community Guide constitutes a highlyvalued and objective evidence-based resource for guid-ing current and future public health activities.9 Thephysical activity interventions reviewed for the Commu-nity Guide include informational, social and behavioral,and environmental and policy approaches to increasephysical activity levels in the community.10,11

Although many promising interventions to promotephysical activity are being carried out in Latin America,12

the types and effectiveness of most interventions in theregion have not been systematically examined. More-over, the application of the methods and findings ofthe Community Guide to developing countries, such asthose in Latin America, is unknown. Namely, severalissues are unclear: (1) Do Latin American interventionscorrespond to categories in the Community Guide?(2) What is the body of evidence when Latin Americaninterventions are subjected to rigorous review criteria?and (3) Are the Community Guide recommendationsgeneralizable to Latin America?

This paper describes: (1) a systematic review of theLatin American literature on strategies for promotingphysical activity in the community and (2) an examina-tion of the Community Guide’s applicability. This reviewincludes the first phase of a project entitled Guide forUseful Interventions for Activity (or GUIA, a term thatmeans “guide” in both Portuguese and Spanish) in Braziland Latin America. The overarching goal of GUIA is todevelop evidence-based strategies for promoting physicalactivity in Brazil and throughout Latin America. Research-ers at Saint Louis University School of Public Health ledthe review, with input provided by a cross-nationaladvisory group composed of members from the CDC,Brazilian Ministry of Health, Universidade Federal deSão Paulo, Centro de Estudos do Laboratório deAptidão Física de São Caetano de Sul (CELAFISCS),and the Pan American Health Organization.

Methods

Overview of the Literature Review

The process of reviewing and critically evaluating the LatinAmerican literature related to physical activity interven-tions involved a two-phased approach of (1) searching peer-reviewed and non–peer-reviewed literature for studies ofthese interventions in community settings (e.g., communities,schools, places of worship, work sites) and (2) systematicallyevaluating the suitability of the design and the quality ofexecution of intervention studies that met criteria for inclu-sion. Both phases were carried out in 2006.

Searching the Literature

In the first phase, peer-reviewed literature and Braziliantheses were searched for studies on physical activity interven-tions. The following databases were systematically searchedfor entries appearing from 1980 to 2006: Biblioteca Virtual deSaúde (which includes LILACS, MEDLINE, MEDCARIB,OPAS/OMS, PAHO, and WHOLIS); SCIELO; PubMed;CAPES (thesis database); and NUTESES (thesis database).Studies of physical activity interventions were identified using16 search terms in Portuguese, Spanish, and English, includ-ing physical activity, physical fitness, cardiorespiratory fitness,aerobic capacity, walking, community intervention, healthpromotion, sport, motor activity, sedentary lifestyle, inactivity,leisure activity, exercise, exercise program, moderate activity,and vigorous activity. Additional English search terms in-cluded Latin America, Brazil, Colombia, Argentina, Chile,Bolivia, Venezuela, Peru, and Mexico. Other articles, govern-ment reports, and theses were located by manually searchingthe reference lists of identified articles. Selected non–peer-reviewed literature was included in the first phase if it couldbe accessed through online databases (Brazilian theses andColombian thesis titles) or personal contacts (via the GUIAadvisory group). While very few non–peer-reviewed sourceshave sufficient detail on the design of interventions and theirevaluation to meet the Community Guide’s criteria for inclu-sion, it was believed that these supplementary sources mightprovide a more complete picture of community interventionsin Latin America.

To assess the state of the evidence concerning physicalactivity interventions, the peer-reviewed articles meeting thesearch criteria were categorized into 11 broad study topics(Table 1), and the relative frequency of articles within eachstudy topic was computed.

Screening and Categorizing Studies

All intervention studies from the peer-reviewed and non–peer-reviewed literature were synthesized by trained research-ers into one-page summary tables in English (available fromfirst author), containing citation, language, study design,country, population, setting, intervention characteristics, out-come measurement, results, and conclusions. Using the syn-thesis tables, six reviewers independently categorized theintervention studies by the 14 Community Guide categories forphysical activity interventions (Appendix A, online at www.ajpm-online.net) and screened the studies for inclusion in afull abstraction process to assess the strength of the evidence.Three reviewers were assigned to each intervention study, anddecisions about categorization and selection of studies were

March 2008 Am J Prev Med 2008;34(3) 225

based on the opinions of a majority of the reviewers or groupconsensus (if there was disagreement among all three review-ers). Interventions were assigned to only one category. Inter-vention studies that met all of the following criteria wereselected for abstraction: (1) assessed an intervention with asignificant focus on physical activity (e.g., not a general healthpromotion intervention); (2) were original investigations ofinterventions selected for evaluation rather than, for exam-ple, guidelines or reviews; (3) evaluated physical activitybehavior or aerobic capacity (maximal oxygen uptake [VO2]or estimate of VO2) as outcomes; (4) compared outcomesamong groups of persons exposed to the intervention withoutcomes among groups of persons not exposed or lessexposed to the intervention; (5) were conducted in a com-munity setting (e.g., not an exercise laboratory or hospitalclinic) and, therefore, were not interventions that usedphysical activity as a therapeutic intervention or for rehabili-tation or that addressed a population group because themembers shared a clinical condition (e.g., heart disease,hypertension, or obesity); (6) did not solely involve one-to-

one advice or counseling in a healthcare setting; and (7) werepublished in a format in which details about the interventionand its execution were available.

Abstracting Studies to Evaluate the Evidence

The abstraction phase of the GUIA project followed theabstraction procedure in the Community Guide13 with somemodifications to streamline the review of articles. Five trainedabstractors, three of whom could read Portuguese or Spanish,participated in the abstractions of articles, reports, and thesesfrom the search of Latin American scientific literature. Twotrained researchers independently abstracted each study andcame to consensus on the suitability of the design and qualityof intervention execution—the two measures by which thestudies were evaluated. Design suitability was coded as great-est, moderate, and least and was determined based on thecriteria described by Briss et al.,14 which are presented inAppendix B, online at www.ajpm-online.net. Based on thenumber of limitations, quality of execution was categorized as

Table 1. Distribution by topic of the peer-reviewed articles that met search criteria

n (%)

Topic FocusTotal(N!903)

Portuguese(n!414)

Spanish(n!333)

English(n!156)

Physical activity interventions Increasing physical activity or aerobic capacity 45 (5.0) 18 (4.3) 7 (2.1) 20 (12.8)Therapeutic interventions Evaluating interventions in which exercise or

physical activity is being used to treat aspecific condition or for rehabilitationpurposes (e.g., diabetes, cardiac disease,obesity).

98 (10.9) 38 (9.2) 55 (16.5) 5 (3.2)

Training studies Effects of specific exercise regimens onhealth parameters (e.g., blood pressure,cholesterol, aerobic capacity, body weight);studies are conducted primarily in alaboratory or research setting.

71 (7.9) 22 (5.3) 38 (11.4) 11 (7.1)

Descriptive studies Reports of the prevalence of physical activitybehaviors or sedentary behavior withoutassociating physical activity with otherhealth outcomes or treating physical activityas a dependent variable.

120 (13.3) 44 (10.6) 51 (15.3) 25 (16.0)

Correlates of physical activity Physical activity, inactivity, or aerobic capacityis treated as the dependent variable,typically in a cross-sectional study.

56 (6.2) 21 (5.1) 27 (8.1) 8 (5.1)

Etiologic studies Physical activity is treated as the independentvariable; outcomes may include heartdisease, cancer, or mortality

86 (9.5) 46 (11.1) 17 (5.1) 23 (14.7)

Measurement of physicalactivity

Measurement properties of various methodsof determining or measuring physicalactivity (e.g., self-report questions,accelerometers, pedometers) forpopulation-based studies

31 (3.4) 7 (1.7) 22 (6.6) 2 (1.3)

Exercise physiology/biomechanics

Laboratory-based studies that examinephysiologic effects of exercise or strength-training protocols; predictors of exercise-related health outcomes; and measurementof aerobic/anaerobic capacity.

215 (23.8) 90 (21.7) 79 (23.7) 46 (29.5)

Other physical activity-related (e.g., review,commentary)

Studies that do not fit other categories 181 (20.0) 128 (30.9) 37 (11.1) 16 (10.3)

Non-Latin American 39a 0a 8a 31a

Unrelated to physical activity 2568a 421a 1105a 1042a

aExcluded from total and denominator.

226 American Journal of Preventive Medicine, Volume 34, Number 3 www.ajpm-online.net

good (0–1 limitations), fair (2–4), or limited (!5).14 Limita-tions were counted in the following nine broad categories, asdescribed elsewhere13: (1) description of the study popula-tion and intervention, (2) sampling, (3) measurement ofexposure, (4) measurement of outcome and independentvariables, (5) confounding bias, (6) data analysis, (7) partic-ipation, (8) comparability and bias, and (9) other biases.

The modified abstraction process for the GUIA projectinvolved two phases. The purpose of Phase 1 was to assessdesign suitability as well as the first five of the nine limitationsrelated to quality of execution. If an intervention had thepotential to achieve strong or sufficient evidence of effective-ness using the Community Guide criteria presented in Appen-dix C, online at www.ajpm-online.net,14 Phase 2 was carriedout to assess the remaining four limitations of quality ofexecution. Following abstraction, the eligibility and categoryassignment of each study, which were initially determinedusing the synthesis tables, were re-evaluated.

Effect size was calculated as the relative, net percent changefrom baseline for participants in both the intervention andcontrol groups for all studies that underwent Phase 2 of theabstraction process. The formula for calculating the net effectvaried depending on the study design (with or without acontrol group and/or pre-intervention measurement of out-

come), as defined previously (Figure 1).10 Net interventioneffects were calculated for all reported measurements ofaerobic capacity and physical activity behavior, for all timeperiods relative to baseline, and for all subgroups (e.g.,gender, country of study). Sufficient and large effect sizes arebased on the quality of the outcomes, magnitude of effectsizes compared with Community Guide results, and the popu-lation reach of the intervention.

Results from the assessments of design suitability, quality ofexecution, and effect size were combined to determinewhether an intervention had strong, sufficient, or insufficientevidence of effectiveness for recommendation on a broadlevel (Appendix C, online at www.ajpm-online.net). It shouldbe noted that insufficient evidence of effectiveness does notequate to evidence of ineffectiveness; instead, it indicates aninadequate number of studies or information for basing arecommendation.15

ResultsSearching the Literature

Of the 3510 (835 Portuguese, 1446 Spanish, and 1229English) peer-reviewed articles that met the search

Net % change from baseline

Bonhauser, 200562

(Chile)

Kain, 200463

(Chile)

Heath, 200267

(U.S./Mexico)

Coleman, 200566

(U.S./Mexico)

Da Cunha, 200260

(Brazil)

M3

Legend: Maximal oxygen uptake

Yards run in 9 minutes

% time in moderate (M) or vigorous (V) activity during PE class (1, 2, and 3 denote specific cohorts)

Estimated caloric expenditure

Number of stages in 20 m shuttle run test

% walking or bicycling to school

% time spent walking during PE classes

boys girls

M1

boysgirls

V1M2V2

% time spent being very active during PE classes

V3

V M

–5 5 15 20 30 40 45 5510 25 35 500 70 180 310–50

Figure 1. Net percentage change in physical activity from baseline for the intervention studies on school-based physicaleducation.Net percentage change was calculated as follows:13

Studies with pre- and post-interventionmeasurements for intervention (I) andcomparison (C) groups

Studies without a comparisongroup

Studies with a comparisongroup but no pre-interventionmeasurements

Ipost " Ipre

Ipre"

Cpost " Cpre

Cpre# 100%

Ipost " Ipre

Ipre# 100%

Ipost " Cpost

Cpost# 100%


criteria, 903 articles were related to physical activity. Ofthese, only 5% (4.3% from Portuguese, 2.1% fromSpanish, and 12.8% from English searches) addressedphysical activity interventions in Latin America, includ-ing one WHO report (Table 1; Figure 2). The search ofBrazilian theses resulted in 16 potential interventionstudies of 142 total physical activity-related theses thatmet the search criteria (Figure 2). Because there was alow yield of Colombian theses addressing physical ac-tivity interventions (n!11) and limited informationavailable (only the titles were available electronically),these theses were excluded from the subsequent liter-ature synthesis.

Screening and Categorizing Intervention Studies

Using the summary synthesis tables, the 61 interventionstudies from the 44 peer-reviewed articles, one report,and 16 Brazilian theses were each categorized by the 14Community Guide intervention categories (Appendix A,online at www.ajpm-online.net)10 and listed in Table 2.The studies were also screened a second time using thelist of selection criteria defined previously. In onereview article,17 six different intervention studies weredescribed, and the reviewers independently categorizedand screened them. On review of the selected studies, itwas found that many did not readily fit within the Com-munity Guide intervention classifications, and thus threenew intervention subcategories were created (AppendixA, online at www.ajpm-online.net). Five studies wereclassified as “delivery of short physical activity–relatedmessages” under the category of “informational ap-proaches to increasing physical activity.”17,20,40 Thirty-three studies were classified as “physical activity classesin community settings” under the category of “behav-ioral and social approaches to increasing physical activ-ity,”17,23–37,41–57 and four studies were classified as“community-wide policies and planning” under thecategory of “environmental and policy approaches toincreasing physical activity.”38,39,58,59

Only 19 of the 61 (31%) intervention studies met allof the criteria for inclusion in the abstraction process.The two criteria most often not met were the onerequiring the outcomes to be physical activity behavioror aerobic capacity (62% of excluded studies) and theone requiring that the interventions be conducted incommunity settings and not for rehabilitative or thera-peutic purposes (38% of excluded studies). Two thirdsof the excluded studies were classified as “physicalactivity classes in community settings” (Table 3).

Abstracting Studies to Evaluate the Evidence

Of the 19 studies that underwent the full abstrac-tion process, nine were conducted in Bra-zil16,17,40,41,44,53,54,60,61; three in Chile46,62,63; two inColombia58,64; and five along the Texas/Mexico bor-der.65–69 Fifteen were peer-reviewed arti-cles17,40,41,46,53,54,58,62–69; three were Brazilian the-ses44,60,61; and one was a WHO report.16 The results ofthe abstraction are presented in Table 2. The Commu-nity Guide results are also presented so that readers cancompare the strength of evidence obtained from theLatin American and U.S. scientific literatures. Onlythose studies under the “physical activity classes incommunity settings” and “school-based physical educa-tion” were eligible for Phase 2 of the abstractionprocess; the other interventions had too few studies toachieve sufficient evidence of effectiveness.

Physical activity classes in community settings. Of thefive studies evaluated that involved classes in commu-nity settings, four were conducted in Brazil41,44,53,54 andone in Chile.46 Three of the Brazilian interventionswere conducted in universities—two as work-site inter-ventions among employees44,53 and the other as aswimming class for elderly women.41 The fourth Brazil-ian intervention was conducted in a church amongwomen aged "50 years.54 The Chilean intervention wasa small pilot intervention of health education andexercise classes for Seventh-Day Adventist and otherwomen in Villarrica County; the exact setting of theintervention was not described. Three studies had thegreatest suitability of study design—two with fair execu-tion41,44 and one with limited execution.54 The remain-ing two studies had the least design suitability—onewith fair46 and one with limited execution.53 Only threestudies reported data on outcomes, including endur-ance capacity as estimated by a step test,54 VO2 max asmeasured by a 6-minute walking test,41 and physicalactivity using an exercise scale from a self-report ques-tionnaire.46 Their net effects were 2%, 34%, and 41%,respectively. According to the Community Guide rules ofevidence (Appendix C, online at www.ajpm-online.net),14 there is insufficient evidence that “physicalactivity classes in community settings” are effective inincreasing levels of physical activity and improvingphysical fitness. The evidence was deemed insufficient

Figure 2. Results from the search of Latin-American peer-reviewed literature and Brazilian theses.aIncludes one WHO report.16


Table 2. Recommendations for physical activity interventions, based on the GUIA and Community Guide10 literature reviews

GUIA in Latin America

Community Guiderecommendations (No. ofqualifyinga studies)

Recommendations (No. ofstudies included inabstraction)

No. of studiesexcluded fromabstraction

Informational approachesCommunity-wide campaigns Insufficient evidence (n!1)17 117,b Recommended (strong)

(n!10)

“Point-of-decision” prompts Insufficient evidence (n!1)65 0 Recommended (sufficient)(n!6)

Classroom-based health educationfocused on information provision

Insufficient evidence(n!3)16,61,68

118 Insufficient evidence (n!10)

Mass media campaigns Insufficient evidence (n!0) 119 Insufficient evidence (n!3)

Delivery of short physical activity-relatedmessagesc

Insufficient evidence (n!1)40 417,20 —

Behavioral and social approachesIndividually adapted health behavior

changeInsufficient evidence (n!0) 0 Recommended (strong)

(n!18)

Health education with component forturning off TV/video games

Insufficient evidence (n!0) 0 Insufficient evidence (n!3)

College-age physical education/healtheducation


Family-based social support Insufficient evidence (n!0) 0 Insufficient evidence (n!11)

School-based physical education Recommended (strong)(n!5)60,62,63,66,67

121 Recommended (strong)(n!14)

Nonfamily social support Insufficient evidence(n!2)64,69

122 Recommended (strong)(n!9)

Physical activity classes in communitysettingsc

Insufficient evidence(n!5)41,44,46,53,54

2817,23–37,42,43,

45,47–52,55–57––

Environmental and policy approachesCreation of or enhanced access to

places for physical activity combinedwith activities in informationaloutreach

Insufficient evidence (n!0) 117 Recommended (strong)(n!10)

Community-scale urban design andland-use policies and practices

Insufficient evidence (n!0) 0 Recommended (sufficient)(n!12)

Street-scale urban design and land usepolicies and practices

Insufficient evidence (n!0) 0 Recommended (sufficient)(n!6)

Transportation policy and infrastructurechanges


Community-wide policies and planningc Insufficient evidence (n!1)58 338,39,59 —

TOTAL 19 42d 115aQualifying studies included all eligible studies, except those with limited quality of execution.bMultiple intervention studies were described in this review article.17

cNew intervention category identified by the GUIA literature review.dOne of the excluded studies was not an intervention and therefore could not be categorized.


due to: (1) too few studies to meet any of the criteria forsufficient evidence for recommendation (two studieshad limited quality of execution and, of the remainingthree, one was of least design suitability); and (2) onlythree of the five studies reported the necessary out-come measures to calculate net effect changes.

School-based physical education. Of the five school-based physical education intervention studies reviewed,one was conducted in Brazil (children aged 7–10years)60; two in Chile (primary school children and9th-grade classes)62,63; and two in elementary schools onthe U.S.–Mexico border.66,67 All five studies had thegreatest suitability of study design. Three applied agroup-randomized design60,62,66 and two a group non-randomized design.63,67 Three studies had good execu-tion60,62,66 and two had fair execution.63,67

Reported behavioral outcomes were minutes spent inmoderate and vigorous physical activity,67 percentageof children meeting physical activity goals,66 percent-age of children biking or walking to school, estimatedenergy expenditure based on observed physical activitybehavior of children, percentage of children being veryactive during physical education classes, and percent-age of time spent walking during physical educationclasses.60 Three studies also reported aerobic capacityas estimated by VO2 max,62 results from timed runs,66

or endurance capacity as estimated by the shuttle runtest.63

The net effect sizes ranged from –50% for percent-age of female students meeting vigorous activity goals67

to 307% for percentage of time spent walking duringphysical education classes (Figure 1).60 The large rangein net effect sizes was a function of the degree ofchange in the pre- and post-intervention outcomemeasures for both intervention and comparison (ifapplicable) groups and the magnitude of the pre-intervention measure (see Figure 1 footnote). The levelof evidence in support of school-based physical educa-tion as an approach to increasing levels of physicalactivity and improving physical fitness is consistent withthe evidence needed for a strong recommendationusing the Community Guide guidelines (Appendix C,online at www.ajpm-online.net).

Discussion

This systematic literature review represents the firsteffort to adapt an evidence-based review process forcommunity interventions developed in the U.S. (i.e.,the methods of the Community Guide) to Latin America.Importantly, it also reveals key priorities for researchand policy related to physical activity interventions inLatin America. In a region experiencing escalatingrates of obesity and inactivity among urban populationsin particular, there is an opportunity to promote effec-tive community interventions to increase physical activ-ity and prevent noncommunicable diseases.

Several important findings emerged from the GUIAliterature review. Based on rigorous review standards,there is strong evidence in support of school-basedphysical education as a strategy to increase physicalactivity in school children and adolescents. This isparticularly important for developing countries, giventhe rising prevalence of inactivity and overweight in thispopulation and their associated long-term health con-sequences, such as cardiovascular disease, diabetes, andcertain types of cancer.70 In addition, physical activityin adolescence has been identified as a possible predic-tor of levels of physical activity in adulthood.71,72 Today,in Brazil73 and other Latin American countries,74 phys-ical education is mandatory for students in public andprivate elementary, middle, and high schools. Therehas been increased academic and political credibilityfor school physical education in the past decade,75 andyet issues related to salary, work environment, physicalspace, and curriculum structure still persist as barriers,and schools struggle to offer high-quality physical educa-tion.76 Regardless, physical education seems to be aneffective but underused way to promote physical activity.

Another key finding from the literature review wasthe identification of three new intervention categoriesthat were not part of the Community Guide : community-wide policy and planning, the delivery of short physicalactivity-related messages, and physical activity classes incommunity settings. Although evidence was insufficientto assess the effectiveness of these interventions, theyrepresent promising interventions for further evalua-

Table 3. Reasons for excluding studies from the abstraction phase

Inclusion criteria not metNo. of excluded studies(n!42)

No. of excluded physical activityclasses studies (n!28)

Assessed an intervention with a significant focus on physicalactivity

2 0

Original investigations of interventions selected for evaluation 3 0Evaluated physical activity or aerobic capacity as outcomes 26 17Compared exposed vs not/less exposed 8 4Conducted in a community setting and not for therapeutic or

rehabilitative purposes among a clinical population16 14

Not one-on-one advice or counseling in healthcare setting 2 2Published in format in which details about the intervention

and its execution were available6 1


tion in Latin America. For example, the VIDA CHILEprogram, organized by over 13 regions and overseen bymore than two dozen Chilean organizations, is a na-tional program that uses a variety of strategies topromote physical activity for improved health andquality of life for all Chileans.39 In Bogotá, Colombia,the Ciclovia-Recreovia58 and Cicloruta programs77 arecommunity-wide programs that promote recreationalactivity and active transportation for the citizens byencouraging the use of the public space (parks, ave-nues, and bicycle paths). In addition, several Academiadas Cidades (city gyms) have been organized andpromoted in Recife, Aracaju, and Belo Horizonte,Brazil, as has a comprehensive physical activity promo-tion program in Curitiba (CuritibAtiva), also in Bra-zil.78 These locally funded interventions combine manyaspects of physical activity classes and community-widepolicy and planning to increase physical activity.

The paucity of literature describing evaluations ofcommunity-level physical activity interventions in LatinAmerica was another important finding from this sys-tematic review. Only 15 of over 900 (#2%) peer-reviewed articles related to physical activity addressedinterventions in Latin American community settingsthat were evaluated using physical activity outcomes.Clearly, there is a need to publish and disseminateresults from evaluated interventions to provide theminimum number of studies necessary for buildingevidence about their effectiveness. In reality, there is noshortage of interventions being conducted in LatinAmerica. In particular, the widely implemented AgitaSão Paulo intervention has shown promise as an effec-tive community-wide campaign to increase physicalactivity in communities.79 Although 50 community-levelphysical activity interventions in Latin America wererecently highlighted in the Best Practices for PhysicalActivity Promotion Around the World,12 only two withpublished, peer-reviewed evaluations were eligible forthis systematic review.17,58

Finally, this review emphasizes the need for improv-ing the methodologic rigor or reporting of evaluationsof interventions in Latin America. Nearly two thirds(63%) of the abstracted studies had limitations relatedto sampling, including failure to describe the eligibilitycriteria, sampling frame, or recruitment strategies, aswell as use of volunteer samples. For these studies, theimpact of the intervention was measured among theparticipants in the program and not the community atlarge—limiting an understanding of the population-wide impact of the program. Another limitation thatappeared in 53% of the studies was a failure to measurethe exposure or to cite the measurement properties ofthe exposure measures. Examples of exposure mea-surement might be class attendance among study par-ticipants, awareness of the intervention message oractivities, or other process evaluation measures. Thelast two commonly cited limitations were related to

confounding bias (failing to show similarities and dif-ferences between study groups at baseline or not con-trolling for differences; 42% of studies) and limiteddescriptions of the study population and intervention(37% of studies). Enhancements across these method-ologic areas will make it possible to determine whetherchanges in behavior are clearly attributable to theintervention as well as to assess the impact of theintervention on a community level.

This literature review has several strengths: This wasthe first study to adapt the Community Guide process toa developing region, and it may encourage similarreviews in Latin America and other parts of the world.These systematic reviews are valuable for three reasons:(1) practitioners and policymakers value scientificknowledge as a basis for decision making; (2) thescientific literature on a given topic is often vast,uneven in quality, and inaccessible to busy practitio-ners; and (3) an experienced and objective panel ofexperts is seldom locally available to public healthofficials on a wide range of topics.9 The systematicnature and transparency of this well-accepted reviewprocess and the breadth of literature that was searchedsupport the robustness of the conclusions from theGUIA literature search. Moreover, the results werereviewed and endorsed by a cross-national advisoryteam. This suggests that the Community Guide process isfeasible and valuable for developing countries in LatinAmerica and possibly beyond.

Some limitations of this review should also be noted.The search was limited to intervention studies in whichthe results were published (e.g., thesis, journal article,report) and could be identified via searchable data-bases or recommended by the advisory team. Moreover,the reviewed masters and doctoral theses were limitedto Brazilian and a sample of Colombian theses thatwere readily available using databases on the Internetor through professional contacts. Although for theCommunity Guide there was no searching of theses, theymay be a valuable source for identifying studies fromLatin America, where peer-reviewed publications in thearea of physical activity interventions are less common.Another limitation was that the abstraction process wasslightly streamlined, and thus not all of the method-ologic limitations were documented, specifically forinterventions with few candidate studies.

In addition, the variety of outcomes measured lim-ited our ability to calculate a summary net effect forschool-based physical education. Also, although it wasdetermined that the process and intervention catego-ries from the Community Guide can be applied to LatinAmerica studies, whether the recommendations forphysical activity interventions in the U.S. may be gen-eralizable to Latin America was not assessed; this will beaddressed in the later phases of the GUIA project.Finally, it is important to emphasize that the reviewedinterventions were conducted in a variety of countries,


including the U.S.–Mexico border. As is the case withthe Community Guide, it is not known whether interven-tions may be effective in a single subpopulation, city,region, or country within Latin America.

In summary, this systematic review was the first toapply the Community Guide process of evaluatingcommunity-level strategies to interventions in a devel-oping region. Two findings from this review should behighlighted: (1) the need for rigorous evaluation ofpromising physical activity interventions in developingcountries, as recommended by others,80 coupled withthe reporting of such evaluations in peer-reviewedarticles, and (2) strong evidence of the effectiveness ofschool-based physical education programs in LatinAmerica. Clearly, the implementation and mainte-nance of quality school physical education programsand policies should be strongly encouraged to promotethe health of Latin America children. It is hoped thatthe findings from this review will be used to improveevaluation methodology, eventually leading to moreevidence-based policies and programs, which will inturn contribute to positive changes in physical activityamong Latin American populations.

This study was funded through the Centers for DiseaseControl and Prevention contract U48/DP000060-01 (Preven-tion Research Centers Program). The authors are gratefulfor the valuable input of Pedro Hallal, Julia Nogueira, andMarcia Munk and for the administrative support of BrendaMcDaniel, Mary Adams, Katie Duggan, Madalena Soares, andDiva Brunieri.

No financial disclosures were reported by the authors ofthis paper.

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Appendix A. Description of the Community Guide and New GUIA Intervention Categories

Intervention Description

InformationalCommunity-wide campaigns1 ● These campaigns involve many community sectors in highly visible, broad-based,

multicomponent approaches to increasing physical activity. Most campaigns alsoaddress cardiovascular risk factors other than inactivity.

● Campaign messages are directed to large audiences through a variety of channels(e.g., TV, radio, newspapers).

● The campaigns include such components as support and self-help groups; counselingon physical activity; risk factor screening and education at work sites, schools, andcommunity health fairs; community events; and creation of walking trails.

“Point-of-decision” prompts1 ● Signs are placed next to elevators and escalators to motivate people to use nearbystairs for health benefits or weight loss.

● All interventions are single component, with placement of signs the only activity.Classroom-based health

education focused oninformation provision1

● These programs consist of health education classes in elementary, middle, or highschools whose goal is to help students develop the skills they need to make rationaldecisions about adopting healthier behaviors.

● Class content is usually multicomponent, with teachers educating students aboutaspects of physical inactivity, nutrition, smoking, alcohol, and drug misuse.

● Behavioral skills components (e.g., role play, goal setting, contingency planning) canalso be part of the classes.

● Spending additional time in physical activity is not usually part of the curriculum.Mass media campaigns1 ● These are single-component campaigns that are designed to increase knowledge

about physical activity, influence attitudes and beliefs, and change behavior bytransmitting messages through newspaper, radio, TV, and billboards, singly or incombination.

● Paid advertisements, donated time and space for promotions, and news or lifestylefeatures are used.

● These interventions do not include other components such as support groups, riskfactor screening and education, or community events.

Delivery of short messagesrelated to physical activity*

● These interventions involve short physical activity-related educational andmotivational messages (about 5 minutes) delivered to a specific population on aroutine basis.

● Settings for this intervention included work sites, senior centers, and communitycenters.

● They are distinct from the “mass media campaigns” interventions in that a healtheducator delivers the short messages verbally to a targeted population in a groupsetting.

Behavioral and social approachesIndividually adapted change in

health behavior1● These programs are tailored to participants’ specific interests, preferences, and

readiness to change, teaching specific behavioral skills that enable participants tomake moderate-intensity physical activity part of their daily routines.

● The behavioral skills taught include setting goals for physical activity and monitoringone’s progress toward those goals, building social support for new behavioralpatterns, reinforcing new behaviors through self-reward and positive self-talk,structured problem solving to help maintain behavior change, and preventing relapseinto sedentary behaviors.

● Participants can engage in activities that are planned (e.g., daily scheduled walk) orunplanned (e.g., taking the stairs when the opportunity arises).

● The interventions are delivered to people either in group settings or by mail,telephone, or directed media.

● Programs typically involve recruiting volunteers who selected physical activity goalsand worked in groups to achieve those goals. Group members providecompanionship and support for one another.

● Study staff also provide encouragement in the form of phone calls to check onparticipants’ progress and to encourage them to continue, and by leading formalgroup discussions about negative views of exercise and other barriers to change.

Social support interventions incommunity settings1

● These interventions build, strengthen, and maintain social networks that supportincreases in physical activity.

● New social networks can be created or existing networks can be used in socialsettings outside the family, such as the workplace. The interventions typically involveparticipants setting up a buddy system and making contracts to guarantee that bothbuddies will be active, or they form walking groups or other groups to providecompanionship and support while being physically active.

● The programs typically involve recruiting volunteers who selected physical activitygoals and worked in groups to achieve those goals.

233.e1 American Journal of Preventive Medicine, Volume 34, Number 3

Appendix A. (continued)


● Study staff also provide encouragement in the form of phone calls to check onparticipants’ progress and to encourage them to continue, and by leading formalgroup discussion about negative views of exercise and other barriers to change.

Health education withcomponent for turning offTV/video games1

● These health education classes, based in elementary school classrooms, encouragestudents to spend less time watching TV and playing video games.

● Students are taught techniques or strategies to help achieve these goals, such aslimiting access to TV and video games.

● All classes include a “TV turnoff challenge” encouraging students not to watch TVfor a specified number of days.

● Classes do not specifically encourage physical activity as an alternative to watching TVand playing video games.

● Parental involvement is prominent, and all households are given monitors forautomatically monitoring TV use.

College-age physical education(PE)/health education1

● This intervention uses didactic and behavioral education to increase and retainphysical activity levels among college students and to help students develop lifelongexercise habits.

● The PE classes may or may not be offered by PE or wellness departments at collegesand universities but must include supervised activity in the class.

● Classes include both lectures and laboratory-type activities.● Students engage in supervised physical activity, develop goals and activity plans, and

write term papers based on their experience.● Social support is also built into these programs.

Family-based social support1 ● These interventions help families of those trying to increase physical activity (parents,siblings, or partners) to encourage this effort by modeling healthy behavior and bybeing supportive of exercise.

● Intervention components – which may include goal setting, problem solving,contracts to exercise among family members, and other techniques for promotingphysical activity – are often delivered in conjunction with other school-basedactivities, such as PE or health education.

● Family involvement may be promoted through take-home packets, reward systems,and family record keeping.

● Some programs, such as CATCH, also include family-oriented special events.School-based physical education1 ● These programs modify school-based PE classes by increasing the amount of time

students spend in PE class, the amount of time they are active during PE classes, orthe amount of moderate or vigorous physical activity in which they engage during PEclasses.

● Most increase the amount of physical activity during already scheduled PE classes bychanging the activities taught or modifying the rules of the game so that students aremore active.

● Health education is often part of the program as well.Physical activity classes in

community settings*● These interventions are regular, structured exercise group classes that involve some

educational component.● They may be implemented in work sites and community centers.● They are different from “classroom-based health education” interventions because

they are not restricted to elementary, middle, or high school students. In addition,participation in physical activity is part of the intervention.

● They are different from the “individually adapted health behavior change”interventions because they lack an individualized goal-setting or tailoring component.

● They are distinct from the “social support interventions in community settings”because their primary purpose is not to build, strengthen, and maintain socialnetworks through activities such as buddy systems or walking groups.

Environmental and policyapproaches

Creation of or enhanced accessto places for physical activitycombined with informationaloutreach activities1

● These multicomponent interventions involve the efforts of businesses, coalitions,agencies, and communities to create or provide access to places where people can bephysically active.

● Creating walking trails or providing access to fitness equipment in nearby fitness orcommunity centers can increase the opportunities for people to be more active.

● In addition to promoting access, many include training people to use weights andaerobic fitness equipment; teaching about healthy behaviors; creating health andfitness programs and support or buddy systems; and providing seminars, counseling,risk screening, health forums and workshops, and referrals to physicians oradditional services.

Am J Prev Med 2008;34(3) 233.e2

Appendix A. (continued)


Community-scale urban designand land use policies andpractices to promote physicalactivity2

● These interventions commonly strive to create more livable communities.● The interventions use policy instruments such as zoning regulations and building

codes, and environmental changes brought about by governmental policies orbuilders’ practices. The latter include policies encouraging transit-orienteddevelopment and policies addressing street layouts, the density of development, andthe locating of more stores, jobs, and schools within walking distance of wherepeople live.

● The review was restricted to those studies reporting physical activity outcomes, mostlywalking or biking for transportation, but also total physical activity and outdooractive play.

Street-scale urban design andland use policies and practicesto increase physical activity2

● These interventions use policy instruments and practices to support physical activityin small geographic areas, generally limited to a few blocks. These policies andpractices include features such as improved street lighting or infrastructure projectsthat increase the ease and safety of crossing streets, ensure the continuity ofsidewalks, introduce or enhance traffic calming such as center islands or raisedcrosswalks, or enhance the aesthetics of the street area, such as landscaping.

● The review was restricted to those studies reporting physical activity (walking,bicycling, and outdoor play) outcomes.

● These interventions involve the efforts of urban planners, architects, engineers,developers, and public health professionals who were instrumental in creating orproviding more safe, secure, and enjoyable streets and sidewalks for walking andbiking.

Transportation and travelpolicies and practices2

● Interventions to promote physical activity, including interventions that strive toimprove access to walkways for pedestrians increase access to light rail and otherforms of mass transit, increase the safety of pedestrians and cyclists, reduce the use ofcars, and improve air quality.

● The review was restricted to studies reporting physical activity (walking or bicycling)outcomes.

● The interventions use policy and environmental changes such as creating and/orenhancing bike lanes, requiring sidewalks, subsidizing transit passes, providingincentives for car/van pooling, increasing the cost of parking, and adding bicycleracks on buses.

Community-wide policies andplanning*

● These interventions involve community-wide efforts to promote physical activity (allforms) through policy agendas, guidelines, incentives, policies that reduceenvironmental or institutional barriers to physical activity, and media campaigns.

● They are comparable to the informational community-wide campaigns, in that theyinvolve many community sectors in broad-based, multicomponent approaches toincrease physical activity. The primary distinction, however, is that these interventionsinvolve more than providing information to motivate people to change theirbehavior and to maintain that change over time; they require community-level policychanges.

● Although these interventions may include aspects of the other environmental andpolicy interventions to increase physical activity, they are distinct in that they seek toincrease all forms of physical activity and often consist of a combination of thesestrategies delivered to a broad population.

*Newly created intervention category following the GUIA literature review

Appendix B. Suitability of study design for assessing effectiveness in the Community Guide, adapted from Briss et al.3

Suitability Examples Attributes

Greatest Randomized group or individual trial;prospective cohort study; timeseries study with comparison group

Concurrent comparison groups and prospectivemeasurement of exposure and outcome

Moderate Case-control study; time series studywithout comparison group

All retrospective designs or multiple pre- orpost-measurements but no concurrentcomparison group

Least Cross-sectional study, case series,ecological study

Before-after studies with no comparison groupor exposure and outcome measured in asingle group at the same time

233.e3 American Journal of Preventive Medicine, Volume 34, Number 3

References for Appendixes1. Kahn EB, Ramsey LT, Brownson RC, et al. The effectiveness of interventions

to increase physical activity. a systematic review. Am J Prev Med 2002;22(Suppl 4):73–107.

2. Heath GW, Brownson RC, Kruger J, et al. The effectiveness of urbandesign and land use and transport policies and practices to increase

physical activity: a systematic review. J Phys Act Health 2006;3(Suppl 1):S55–S76.

3. Briss PA, Zaza S, Pappaioanou M, et al. Developing an evidence-basedGuide to Community Preventive Services: methods. The Task Force onCommunity Preventive Services. Am J Prev Med 2000;18(Suppl 1):35– 43.

Appendix C. Assessing the strength of a body of evidence on effectiveness of population-based interventions in theCommunity Guide, adapted from Briss et al.3

Evidence ofeffectivenessa Quality executionb Design suitability Number of studies Consistentc Effect sized

Strong Good Greatest At least 2 Yes SufficientGood Greatest or moderate At least 5 Yes SufficientGood or fair Greatest At least 5 Yes SufficientMeets criteria for execution, suitability, number, and consistency for sufficient but not

strong evidenceLarge

Sufficient Good Greatest 1 Not applicable SufficientGood or fair Greatest or moderate At least 3 Yes SufficientGood or fair Greatest, moderate,

or leastAt least 5 Yes Sufficient

Insufficiente A. Insufficient design or execution B. Too few studies C. Inconsistent D. SmallaThe categories are not mutually exclusive; a body of evidence meeting criteria for more than one of these should be categorized in the highestpossible category.bStudies with limited execution are not used to assess effectiveness.cGenerally consistent in direction and size.dSufficient and large effect sizes are based on the quality of the outcomes, magnitude of effect sizes compared with U.S. Community Guide results,and population reach of the intervention.eThese categories are not mutually exclusive, and one or more of these will occur when a body of evidence fails to meet the criteria for strongor sufficient evidence.

Am J Prev Med 2008;34(3) 233.e4

Physical Activity Interventions in Latin AmericaExpanding and Classifying the Evidence

Christine M. Hoehner, PhD, Isabela C. Ribeiro, PhD, Diana C. Parra, MPH,Rodrigo S. Reis, PhD, Mario R. Azevedo, MSc, Adriano A. Hino, MSc, Jesus Soares, PhD,

Pedro C. Hallal, PhD, Eduardo J. Simões, MD, MSc, MPH, Ross C. Brownson, PhD

Context: Systematic reviews of public health interventions are useful for identifying effective strat-egies for informing policy and practice. The goals of this review were to (1) update a previoussystematic review of physical activity interventions in Latin America which found that only school-based physical education had suffıcient evidence to recommend widespread adoption; (2) assess thereporting of external validity elements; and (3) develop and apply an evidence typology for classifyinginterventions.

Evidence acquisition: In 2010–2011, community-level, physical activity intervention studiesfrom Latin America were identifıed, categorized, and screened based on the peer-reviewed literatureor Brazilian theses published between 2006 and 2010. Articles meeting inclusion criteria wereevaluated using U.S. Community Guidemethods. External validity reporting was assessed among asubset of articles reviewed to date. An evidence rating typology was developed and applied to classifyinterventions along a continuum based on evidence about their effectiveness in the U.S. context,reach, adoption, implementation, institutionalization, and benefıts and costs.

Evidence synthesis: Thirteen articles published between 2006 and 2010met inclusion criteria andwere abstracted systematically, yet when combined with evidence from articles from the previoussystematic review, no additional interventions could be recommended for practice. Moreover, thereporting of external validity elements was low among a subset of 19 studies published to date(median!21% of elements reported). By applying the expanded evidence rating typology, oneintervention was classifıed as evidence-based, seven as promising, and one as emerging.

Conclusions: Several physical activity interventions have been identifıed as promising for futureresearch and implementation in LatinAmerica. Enhanced reporting of external validity elementswillinform the translation of research into practice.(Am J Prev Med 2013;44(3):e31–e40) © 2013 American Journal of Preventive Medicine

Context

Thegrowing burden of chronic disease in low- andmiddle-income countries has stimulated publichealth efforts focused on increasing physical ac-

tivity.1 To address this burden, systematic reviews, orresearch syntheses, can provide a useful tool for identify-ing effective interventions that may help decisionmakersand practitioners prioritize limited resources.2,3 LatinAmerica represents a specifıc region of the world facedwith a growing burden of noncommunicable diseasesbut lacking evidence concerning the effectiveness ofcommunity-level physical activity interventions.4–6 Forexample, a systematic review of evaluated physical activ-ity interventions in Latin America published between1980 and 2006 found that only school-based physicaleducation had suffıcient evidence to recommend wide-spread adoption.4

From the Division of Public Health Sciences and Alvin J. Siteman CancerCenter (Hoehner, Brownson), School of Medicine; Prevention ResearchCenter in St. Louis (Parra, Brownson), Brown School,WashingtonUniver-sity in St. Louis, St. Louis; Department of Health Management and Infor-matics (Simões), University of Missouri School of Medicine, Columbia,Missouri; Public Health Division (Ribeiro), ICF International; PhysicalActivity and Health Branch, Division of Nutrition, Physical Activity andObesity (Soares), CDC, Atlanta, Georgia; School of Health and Biosciences(Reis, Hino), Pontifıcia Universidade Catolica do Parana; Post-GraduateProgram in Physical Education (Reis, Hino), Federal University of Parana,Curitiba; and Post-graduate Program in Physical Education (Azevedo,Hallal), Federal University of Pelotas, Pelotas, Brazil

Address correspondence to: Christine M. Hoehner, PhD, MSPH, Divi-sion of Public Health Sciences,WashingtonUniversity School ofMedicine,660 S. Euclid Ave., Campus Box 8100, St. Louis MO 63110. E-mail: [email protected].

0749-3797/$36.00http://dx.doi.org/10.1016/j.amepre.2012.10.026

©2013American Journal of PreventiveMedicine. All rights reserved. Am J PrevMed 2013;44(3):e31–e40 e31

mailto:[email protected]

mailto:[email protected]

http://dx.doi.org/10.1016/j.amepre.2012.10.026

Although the U.S. Community Guide has recom-mended eight community-level physical activity inter-ventions among adults and youth,7 other systematic re-views, primarily among adults, have found limitedsupport for the effectiveness of interventions targetingcommunities6,8 or multistrategic community-wide inter-ventions.9 Only one systematic review included non-English articles.9 Given the recent rapid growth in phys-ical activity programs and research in Latin America,10,11an update of the previous literature review could provebenefıcial in guiding further decisions concerning physi-cal activity promotion in this region.Although systematic reviews are helpful for informing

public health practice, they are focused primarily on in-tervention effectiveness, favoring controlled and ran-domized designs.12,13 Issues of potential population im-pact (e.g., reach, uptake in practice, contextual factors);feasibility; and costs rarely are considered yet influencereal-world generalizability (external validity) and repre-sent critical information for public health planning.14–16Improving the reporting of external validity informationmay aid in designing future research studies and informdecision making about public health interventions.Identifying best practices to address complex pub-

lic health problems is challenging. Yet, doing nothingwhile waiting for more evidence is unacceptable,14 andevidence-based action should be focused on using the“best evidence available” as opposed to the “best evidencepossible.”17–19 The L.E.A.D. framework (Locate Evi-dence, Evaluate Evidence, Assemble Evidence, InformDecisions) was developed in 2008 by an IOM committeeto address the evidence gap for complex decision makingabout public health problems such as obesity preven-tion.20 The L.E.A.D. framework articulates the need forconsidering external validity and for an expanded evi-dence typology.Several other frameworks have been developed to clas-

sify public health interventions in general2,21–23 and spe-cifıcally targeting obesity or physical activity, with thegoal of fostering evidence-based decision making.18,24,25These frameworks are helpful when evaluating singleprograms on a one-by-one basis, or when resources per-mit extensive evaluation including gray literature. How-ever, these existing frameworks do not provide directionon how to classify intervention strategies following a sys-tematic review of peer-reviewed articles that vary in studydesign and quality of execution.For example, they do not provide direction on how to

classify interventions that do not achieve the rigorousthreshold required for public health recommendations(e.g., based on U.S. Community Guide26). They also donot address transferability of evidence from systematicreviews of interventions in high-income countries (e.g.,

Western countries wheremost evidence exists) to low- tomiddle-income countries (with limited evidence and re-sources for evaluation).13,27 Region- or country-specifıcreviews are important but not always feasible for coun-tries with limited resources for evaluation; therefore,guidance on prioritizing interventions based on evidencefromhigh-income countriesmay be helpfulwhile consid-ering important contextual factors.The goal of the current study was to accelerate the

transfer of research to practice and identify research op-portunities by (1) updating the prior systematic review ofphysical activity interventions in Latin America usingU.S. Community Guide methods by adding publishedarticles andBrazilian theses from2006 to 2010; (2) assess-ing the reporting of external validity elements among asubset of articles included in the review; and (3) develop-ing an evidence rating typology for physical activity inter-ventions in Latin America and applying it to the updatedreview (Figure 1).7,26 This review is part of a larger cross-national initiative, called Project GUIA (Guide for UsefulInterventions for Activity in Brazil and Latin America),intended to promote evidence-based strategies to in-crease physical activity in Latin America.11

Evidence AcquisitionOverview of the Literature Review UpdateAlthough the review was expanded to include only 5 more years ofpublications, an update was important given the rapid growth inevaluation and funding of physical activity interventions in LatinAmerica in recent years10,11 and desire to include the most recentevidence in the external validity assessment and application of theevidence typology. Updating the prior systematic review involvedsimilar searching, screening, categorization, and abstraction pro-cedures as described previously and modeled after the U.S. Com-munity Guide.4,7,26,28 All reviews were carried out in 2010–2011.In the fırst phase, peer-reviewed literature and Brazilian theses

were searched for studies on physical activity interventions. Thefollowing databases were searched systematically for entries ap-

Goal 1Update previous

systematic review of physical activity inter-

ventions in Latin America

Apply U.S. Community Guide methodsAdd articles published in years 2006−2010Assess which interventions had sufficient evidence to support a recommendation

Goal 2Assess reporting of

external validity elements

Develop tool to assess external validity elements (reach, adoption, implementation, outcomes for decision-making, maintenance, and institutionalization) Identify articles from systematic review to assess reporting of external validity elementsAssess reporting by domain, intervention strategy, and country where implemented

Goal 3Develop and apply an

evidence rating typology

Expand U.S. Community Guide evidence classification to differentiate interventions classified as insufficient and address transferability of evidence between countriesIncorporate information about external validityApply evidence rating typology to the review of Latin American physical activity interventions

Figure 1. Goals and key methods of the review

e32 Hoehner et al / Am J Prev Med 2013;44(3):e31–e40

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pearing from 2006 to 2010: Biblioteca Virtual de Saúde (whichincludes LILACS,MEDLINE,MedCarib,OPAS/OMS, PAHO, andWHOLIS), SciELO, PubMed, Scopus, Web of Science, Transpor-tationResearch Information Systems, andCAPES. Studies of phys-ical activity interventions were identifıed using 22 search terms inPortuguese, Spanish, andEnglish related to physical activity, healthpromotion, and urban environment. Additional English searchterms included intervention, program, policy, Latin America,Brazil, Colombia, Argentina, Chile, Bolivia, Venezuela, Peru,and Mexico. Other peer-reviewed articles and theses were lo-cated by (1) contacting Latin American researchers and practi-tioners; (2) manually searching 113 issues of seven Brazilianpublic health or physical activity journals from 2006 to 2010 andarticles in the 2010 special issue of the Journal of PhysicalActivity and Health focused on Latin America; and (3) manuallysearching reference lists of identifıed articles.

Screening and Categorizing StudiesAll intervention studies that met search criteria were synthesizedby trained researchers into one-page summary tables in English.Using the synthesis tables, three reviewers each independentlycategorized the intervention studies by the U.S. Community Guidecategories and categories specifıc to the Latin American review(Appendix A, available online at www.ajpmonline.org)4 andscreened the studies for inclusion in a full abstraction process toassess the strength of the evidence. Decisions about categorizationand selection of studies were based on the opinions of amajority ofthe reviewers.

Articles were assigned to only one intervention category andscreened according to these seven criteria described more fullyelsewhere: (1) evaluated an intervention with a signifıcant focus onphysical activity; (2) original investigation of intervention; (3) eval-uated physical activity behavior or aerobic capacity as outcomes;(4) compared outcomes between groups with different levels ofexposure to the intervention; (5) were conducted in a communitysetting (e.g., school, worksite) and were not therapeutic or rehabil-itation interventions or that addressed a population group becausethe members shared a clinical condition; (6) did not solely involveone-to-one advice or counseling in a healthcare setting; and(7) were published in a format in which details about the inter-vention and its execution were available.4

Abstracting Studies to Evaluate the Evidence andCalculate Net EffectsThe abstraction phase followed the same procedure as those in theU.S. Community Guide and had been applied previously.4,29 Twotrained bilingual researchers independently abstracted each studyand came to consensus on the suitability of the design and qualityof intervention execution—the two measures by which the studieswere evaluated. Design suitability was coded as greatest, moderate,and least using established criteria.26 Based on the number oflimitations, quality of execution was categorized as good (0 or 1limitations); fair (2–4); or limited (!5).26 Limitations werecounted in the following nine categories, as described elsewhere29:(1) description of the study population and intervention; (2) sam-pling; (3) measurement of exposure; (4) measurement of outcomeand independent variables; (5) confounding bias; (6) data analysis;(7) participation; (8) comparability and bias; and (9) other biases.If an intervention had the potential to achieve strong or suffı-

cient evidence of effectiveness using the Community Guide

criteria,26 net effects were calculated as the relative, net percentchange from baseline for participants in both the intervention andcontrol groups. The formula for calculating the net interventioneffect varied depending on the study design (with or without acontrol group and/or pre-intervention measurement of out-come).7 Net intervention effects were calculated for all reportedmeasurements of aerobic capacity and physical activity behavior,for all time periods relative to baseline, and for all subgroups (e.g.,gender, country of study). Suffıcient and large intervention effectsare based on the quality of the outcomes, magnitude of effect sizes,and population reach of the intervention. Results from the assess-ments of design suitability, quality of execution, and net interven-tion effects were combined to determine whether an interventionhad strong, suffıcient, or insuffıcient evidence of effectiveness forrecommendation.26

Assessing External ValidityAlong with evaluating intervention effectiveness (internal valid-ity), the systematic review included an assessment of external va-lidity elements among a subset of reviewed articles. Articles wereselected if they evaluated interventions that (1) possessed suffıcientevidence for recommendation (i.e., school-based physical educa-tion)30–37; (2) were candidates for recommendation (i.e., multi-component instructional programs, based on number and qualityof studies included in the review)38–42; or (3) included specifıcprograms in Latin America, namely Academia da Cidade,43–45

Ciclovia,46 Curitibativa,47 and Agita São Paulo,48 with extensivepractice-based evidence (i.e., evidence of institutionalization orspread to other communities) although with limited research-based evidence (i.e., limited number or quality of peer-reviewedarticles) based on knowledge of the research team. The assessmentincluded all articles of these specifıc intervention strategies re-viewed to date.An external validity assessment tool (EVAT) was developed

based on previous work by others.49–52 The EVAT adapted theRE-AIM model15 and was organized into fıve sections: (1) reach;(2) adoption; (3) implementation; (4) outcomes for decision mak-ing; and (5) maintenance and institutionalization (www.projectguia.org/en/research_publications.html). Although the items were thesame for programs and environmental and policy interventions,the protocol defınitions of items were tailored.Examples of differences in defınitions between the external va-

lidity factors are presented in Appendix B (available online atwww.ajpmonline.org). With the exception of one item, all askedwhether a specifıc element of external validity was reported, withresponse choices yes, no, or not applicable. Not applicable wasassigned to studies inwhich the interventionwas eithermandatory,and thus no selectionwas involved (e.g., students in school physicaleducation program for target population participation rate); onlytargeted one setting (e.g., citywide program for setting participa-tion rate); or was delivered as part of standard care or curriculum(e.g., existing physical education teachers as delivery agent items).Five trained abstractors completed an electronic form, with two

abstractors assigned to independently assess each study and withsubsequent discussion about any discrepancies. Interrater agree-ment was 96%–100% among a sample of seven articles. Descriptiveanalyses included the frequency of studies reporting each element,as well as the average number of elements reported per study.

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http://www.projectguia.org/en/research_publications.html

http://www.projectguia.org/en/research_publications.html


Developing a Modified Evidence Rating Typology

Amodifıed evidence rating typologywas adapted fromexisting typol-ogies.2,18,21,22,24 The evidence typology places various forms of evi-dence about physical activity interventions into categories rangingfrom “evidence-based” (i.e., based on systematic reviews) to “insuffı-cient.” The current typology includes only research-tested interven-tions, defıned here as broad intervention strategies that have under-gone empirical investigations and for which their evaluation has beenpublished in peer-reviewed articles or systematic reviews.This typology and methodology for rating population interven-

tions combine elements of internal and external validity as well asfuture translation potential. The internal validity elements arethose from theU.S.CommunityGuidewithminor adaptation,4 andthe external validity and translation elements are based on theEVAT. The fıve criteria by which interventions are rated include(1) effectiveness; (2) reach; (3) feasibility; (4) sustainability; and(5) benefıts and costs.

These criteria are described in Table 1 and rated based onwhether they have support documentation and their plausibility.“Documented” means that written documentation must be pro-vided in peer-reviewed articles. To be “plausible,” an interventionmust possess a high degree of face validity for each criterion, asdetermined by expert opinion that can be derived from researchersand/or practitioners, similar to informed judgments that are usedin assessing applicability in the U.S. Community Guide26 or forevaluability assessments.53

In this evidence rating typology, evidence-based refers to inter-ventions identifıed as effective in a systematic review of evidencefrom the country to which the evidence ratings are being applied.Promising includes interventions that (1) have at least three studiesof fair or better quality in which the positive effects outweighadverse effects or (2) systematic reviews of interventions carriedout in different countries (e.g., the U.S.). Interventions in thiscategory may have an insuffıcient number of studies to be eligible

Table 1. Evidence rating typology for research-tested interventionsa

Criteria Evidence-based Promising Emerging Insufficient

EffectivenessBased on direction of effecton public health outcomes,evidence source, andcontext

Direction ofeffect

!b ! ! Mixed

Source Systematic review Three or more peer-reviewed studiesc

orsystematic review in

different country

Less than threepeer-reviewedstudiesc

Peer-reviewedstudies

Country or globalcontext whereimplemented

Same Same (for three ormore studies)

orDifferent (if

systematicreview)

Same Same

ReachApplied to entire communities or individualswithin large organization(s) with representationby lower-income populations

Documentedd Documented Plausiblee Plausible

FeasibilityFeasible for replication in othersettings/populations given complexity, costs,and political considerations

Plausible Plausible Plausible Plausible

SustainabilityMaintained with institutional/agency support orintegrated into existing programs and/oroperating procedures to achieve desiredoutcomes over time


Benefits and costsPossesses health, economic, environmental,and/or social benefits to society that outweighcosts


Note: Ineffective includes the following types of interventions: (1) interventions that consistently show null or adverse effects; (2) interventionsthat show evidence of effectiveness but lack plausibility across one of more of the other criteria (reach, feasibility, sustainability, benefits, andcosts).aResearch-tested interventions include broad intervention strategies that have undergone empirical investigations and for which theirevaluation has been published in peer-reviewed articles or systematic reviews.

bPositive effects outweigh adverse effects (based on significance and magnitude of effect).cWith at least fair quality of executiondDocumented"written documentation in majority of peer-reviewed articles or theses from Latin AmericaePlausible"no written documentation required; however intervention must possess high degree of face validity as determined by expert opinionderived from researchers and/or practitioners.


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for a systematic review or may be candidates for a systematicreview. Evidence-based and promising interventions must all havedocumentation that they can reach large populations with repre-sentation by low-income or underserved groups, and feasibility,benefıts, and costs must all be plausible.Emerging include interventions evaluated by fewer than three

studies with positive effects that outweigh adverse effects. Insuffı-cient interventions are those evaluated in peer-reviewed articles butshow either mixed effects or positive effects with limited quality ofexecution. Ineffective interventions include those that (1) consis-tently shownull or adverse effects or (2) show evidence of effective-ness but lack plausibility across one or more of the other criteria(reach, feasibility, sustainability, benefıts, and costs).

Evidence SynthesisLiterature Review UpdateOf the 2465 peer-reviewed articles and theses thatmet thesearch criteria for the updated review, as well as 113journal issues manually searched, 32 articles and twotheses were selected as physical activity interventions inLatin America (Figure 2). Of these, two articles evaluatedassociations between built environment characteristicsand nonmotorized transportation.54,55 Given the differ-ences in analytic approaches and sources of articles, theseand other built environment studies were recommendedto be included in a separate, future systematic review.28

The remaining 32 articles/theses were screened a sec-ond time by multiple reviewers using the list of selectioncriteria defıned previously. Only 13 of the 32 (41%) arti-cles/theses met all of the criteria for inclusion in theabstraction process.34,35,38,40,41,43–45,47,56–59 The distri-bution of the articles from the past4 and current re-views are shown by level of screening, study character-istics, and intervention categories in Table 2, Figure 2,and Appendix C (available online at www.ajpmonline.org). Most interventions were conducted in Brazil and inschool or community settings.

Assessment of the quality of execution and design suit-ability of all of the studies indicated that only those studiesclassifıed as multicomponent instructional programs hadthe potential to achieve suffıcient evidence for recommen-dation based on U.S. Community Guide criteria.26,29 Al-though the net effects of the fıve studies in this categorysuggested a positive pattern in effects on physical activityoutcomes (Figure 3), multicomponent instructional pro-grams could not be recommended based on U.S. Commu-nityGuide criteria for the following reasons: (1) the groupsizes of many interventions were small (i.e., n!103);(2) none used randomized designs and three studieslacked an external control group; (3) many effects werenot signifıcant; and (4) the interventions mostly targetedvolunteers with limited reach. School-based physical ed-ucation remained the only intervention with suffıcientevidence for recommendation, whereas the other six

evaluated interventions had an insuffıcient number ofstudies to support a recommendation given their designsuitability (54% of studies in moderate or least category)or quality of execution (85% of studies in fair to limitedcategory).

External Validity AssessmentAmong the 19 studies assessed for external validity, inter-ventions included school-based physical education(n!8)30–32,34–37,57; multicomponent instructional pro-grams (n!5)38–42; physical activity classes in communitysettings (n!4)43–45,65; community-wide policies andplanning (n!1)47; and community-wide campaigns(n!1).48 The median reporting of elements was 21%(range!0%–100%; Appendix D, available online atwww.ajpmonline.org). The median number of reportedelements per study varied by region where the study wasconducted and by intervention type. The fıve studies con-ducted on the U.S.-Mexico border reported a median of17 elements (range 10–26), as compared with 12 ele-ments (range 8–20) from the 14 studies carried out inLatin America. Studies classifıed as school-based physicaleducation had the highest number of elements reported(median!15; Table 2).A summary of the reported external validity elements

is presented in Appendix D (available online at www.ajpmonline.org). Elements describing reach were re-ported by most studies, with the exception of representa-tiveness. Elements related to adoption, such asrecruitment, participation, and representativeness, were

Studies that met search criteria3652 (1980–2006)2465 (2006–2010)

Candidate physical activity intervention studies61 (1980–2006)34 (2006–2010)

Studies that met inclusion criteria 19 (1980–2006)13 (2006–2010)

Studies abstracted for systematic review18 (1980–2006)13 (2006–2010)

Studies assessed for external validity9 (1980–2006)

10 (2006–2010)

Figure 2. Results from the search of Latin Americanpeer-reviewed literature and Brazilian thesesa

aFrom the original4 and updated review


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lacking in the majority of studies. No study reportedsetting-level representativeness, and for three studies,this element was considered not applicable because theintervention was implemented in only one setting.Regarding implementation, nearly all studies re-

ported intervention characteristics and frequency ofexposure to the intervention. Few studies reportedinformation about selection process, participationrate, training, and payment of delivery agents. Morethan two thirds of the studies reported outcomes in a

way that could be compared to clinical guidelines orpublic health goals, and nearly one third reportedother benefıts of the intervention beyond physical ac-tivity. However, few studies reported effects on qualityof life, adverse consequences, and cost of intervention.Information on maintenance and institutionalizationwas reported by less than half of the studies, with 42%reporting on acceptability of the intervention and only16% reporting long-term effects of intervention onhealth-related outcomes.

Table 2. External validity reporting and evidence rating for physical activity interventions in Latin America

Intervention category

Number of studiesa Median (rangeb)number of

external validityelements reported Evidence rating

Original review(Years 1980–2006)

Updated review(Years 2006–2010) Total

Informational approaches

Community-wide campaigns 0 158 1 14 Promising

“Point-of-decision” prompts 160 0 1 —c Promising

Classroom-based health educationfocused on information provision

361–63 0 3 — Insufficient

Mass media campaigns 0 0 0 — Insufficient

Delivery of short physicalactivity–related messages

164 0 1 — Insufficient

Behavioral and social approaches

School-based physical education 531–33,36,37 135 6 14 (9–26) Evidence-based

Physical activity classes in communitysettings

165 343–45 4 11 (8–15) Promising

Multicomponent instructionalprograms

239,42 338,40,41 5 11 (8–20) Promising

Health education with component forturning off TV/video games


College-age physical education/healtheducation


Family-based social support 0 0 0 — Insufficient

Environmental and policy approaches

Creation of or enhanced access toplaces for physical activity combinedwith activities in informationaloutreach

0 0 0 — Promising

Community-scale urban design andland-use policies and practices

— — Pendingd — Promising

Street-scale urban design andland-use policies and practices

— — Pendingd — Promising

Transportation policy andinfrastructure changes

— — Pendingd — Insufficient

Community-wide policies and planning 146 147 2 9 Emerging

Total 14 9 23

aQualifying studies included all eligible studies, except those with limited quality of execution.bWhere applicable (i.e., n!1 study)cNot assessed for external validitydGiven the differences in analytic approaches and sources of articles, it was determined that these and other built environment studies shouldbe included in a separate, future systematic review.


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Evidence Rating TypologyThe evidence rating typology was applied to the reviewedinterventions to better differentiate their levels of sup-porting evidence, particularly among those that could notbe recommended based on U.S. Community Guide crite-ria alone. Among the physical activity interventions re-viewed, one was classifıed as evidence-based school-based physical education (Table 2). Based on studies fromLatin America, physical activity classes in communitysettings and multicomponent instructional programswere classifıed as promising. Based on suffıcient orstrong evidence for recommendation by the U.S. Com-munity Guide,7,28 other promising interventions in-cluded community-wide campaigns, point-of-decisionprompts, creation of or enhanced access to places forphysical activity with activities involving informationaloutreach, community-scale urban design and land-usepolicies and practices, and street-scale urban design andland-use policies and practices. Community-wide poli-cies and planning were classifıed as emerging based onLatin American research evidence.

DiscussionAlthough publications of physical activity interventionevaluations in Latin America have increased in recentyears, this updated systematic review of physical activityinterventions found that school-based physical education

continues to represent theonly evidence-based inter-vention for recommenda-tion using the U.S. Com-munity Guide criteria. Inorder to include more in-formation on external va-lidity and maximize theutility of this review fordecision makers, the crite-ria for evaluating evidencewere expanded to incor-porate information frominterventions with an in-suffıcient number of sup-porting studies as well asexternal validity informa-tion. In doing so, seveninterventions emerged aspromising approaches forincreasing physical activitylevels at a population level,including community-wide campaigns, point-of-decision prompts, physicalactivity classes in commu-

nity settings, multicomponent instructional programs,creation of or enhanced access to places for physical ac-tivity combinedwith activities in informational outreach,community-scale urban design and land-use policies andpractices, and street-scale urban design and land-use pol-icies and practices.The majority of interventions rated as promising were

recommended approaches by the U.S. Community Guidewith limited evidence from Latin America; the transfer-ability of these interventions will need to be tested todetermine their appropriateness in this region.13,27,66Therefore, these interventions should be considered aspriorities for future evaluation rather than evidence-based recommendations to practitioners. Although im-perfect, by using a tiered approach for evidence classifı-cation,more informationwas available to judge themanyinterventions that originally were classifıed as insuffıcientbased on the U.S. Community Guide criteria. Certainly,continued work and cross-national dialogue are neededto build on this important and understudied concept ofcross-national transferability of evidence about commu-nity health interventions. Application of systematic ap-proaches may assist in assessing the adaptability of effec-tive interventions from one country to another.67

The expanded evidence typology is a starting point forproviding decision makers with a tool for translatingresearch evidence into practice and for identifying evalu-

Net % change from baseline

Costa (2009)40

Brazil*

Exercise scale among Seventh-Day Adventist women (SDAW) and nonSDAW(NSDAW), self-report

% meeting recommendations through moderate-to-vigorous physical activity, based on self-report IPAQ

Minutes per week of walking (self-report)% engaging in 150 minutes of leisure-time physical activity (self-report)

Index of habitual physical activity, by type (self-report)

–10 10 30 400 20 50 60 80 90

Carreño (2006)39

Chile*

Bandini (2007)38

Brazil

Staten (2005)42

Brazil*

Gomes (2008)41

Brazil

70

SDAWNSDAW

ModerateFast

N=2

01–2

16

sam

ple

size

N=3

6–10

3

sam

ple

size

Grey symbols, net effects that did not attain significance* No control group

Median

150

Totalandwork ExerciseLeisure

Figure 3. Net effect size plot for multicomponent instructional programs to promotephysical activityIPAQ, International Physical Activity Questionnaire; NSDAW, non–Seventh-Day Adventist women; SDAW,Seventh-Day Adventist women


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ation gaps. Yet, it requires factoring information aboutintervention processes, contextual factors, and popula-tion impact that are not always available or encouraged inpeer-reviewed publications. Indeed, the current reviewfound that reporting of external validity elementswas lowamong the 19 studies examined, with variation by type ofintervention and country where implemented. Moststudies failed to report key elements that are important toensure translation of fındings into implementation ofinterventions in various settings and contexts.Other external validity reviews of English-language

studies—including of childhood obesity prevention re-search,51 behavioral childhood obesity treatments,68 andhealth behavior change interventions69—found similar lowreporting acrossmany external validity elements. For exam-ple, participation rate and representativeness of the targetpopulation were reported, respectively, by 68% and 5% ofstudies from this review and 76% and 14% from controlledhealth behavior change interventions.69 In addition, the re-porting of representativeness and participation of settings,as well as reporting of consistent implementation of theprogram, costs, differential attritionbycondition, anddrop-out representativeness,were reported less commonly.51,68,70The fındings from the current review differed signifı-

cantly (by !10 percentage points) and fell outside therange of at least one of the other three external validityreviews51,68,69 for reporting of staff expertise or training(current, 10%; others, 60%–89%); long-term effects (cur-rent, 15%; others, 29%–74%); program sustainability (cur-rent, 40%;others, 0%–2%); and timeneeded todeliver inter-ventions (current, 85%; others, 0%–68%). The EVAT alsoexpanded on existing external validity assessment tools bymodifying/adding items and protocol language tomake thetool relevant to environmental and policy interventions aswell as individually based programs.

LimitationsThis study included several limitations. First, this reviewmay have missed some studies published in non-Braziliantheses that were not indexed and therefore excluded fromthe literature databases searched. Similar to the originalsystematic review,4 this review was limited to Brazilian the-ses that were readily available using databases on the Inter-net or through professional contacts. Second, similar to theU.S. Community Guide, the current review provides infor-mationon“what todo”but limitedguidanceon“howto”doit.71 Studies were classifıed into intervention categories de-fıned by the U.S. Community Guide with only slight modi-fıcations. Use of taxonomies may improve replicability andimplementation in practice.72Third, the EVAT was designed to assess reporting of

external validity elements and did not defıne under whichconditions the effective interventions would be optimal.16

Moreover, the only criterion for assessing contextual factorsin the evidence classifıcation system was country or region.In addition, the plausibility of the criterion is subjective andbased on informed expert opinion, not different from otherestablished evidence rating systems.26,53 The transferabilityof interventions to multiple settings, and other countries,will depend on the unique circumstances of the setting andprogram intended for implementation. As Green andGlas-gow suggest, interpretation of evidence for one’s local pur-poses requires the strategic combination of experimentalevidence with local surveillance evidence, theory, profes-sional judgment, andparticipatoryplanningwith thosewhohave local experience.15 The next phase of this review in-cludesaqualitativeassessmentofexternalvalidity, includingcontextual factors. Future work is needed to develop frame-works for rating external validity elements.16,23Fourth, because a systematic assessment of the gray liter-

ature was not conducted, this review did not incorporateformally how practice-based evidence contributes to thecontinuum. Promising and emerging practices would likelyinclude programs, environmental approaches, and policiesthat have proven sustainable in practice but whose evidenceof effectiveness is limited to the gray literature or consideredplausible based only on theory or face validity. A bettermarriage between research and practice is needed to maxi-mize public investment and relevance of public health re-search for practice (e.g., building so-called practice-basedevidence).20,73,74

ConclusionAccelerating the translation of research (i.e., knowledge onwhich interventions are effective) into practice (i.e., inform-ing how to implement interventions) will depend in part onfunders’ willingness to provide resources for and requireevaluationof external validity components.Researchers alsoshould be encouraged, particularly by journal editors andpeer reviewers, to improve reporting of these factors.51 Inaddition, capacity-building among practitioners can be ad-dressed in several ways: (1) workforce development inevidence-based decision making; (2) emphasis on transla-tionof evidence topractice amongpublichealth leaders; and(3) building partnerships to support research translation.75This review and evidence rating typology represents an im-portant early step in the integration of both internal andexternal validity evidence that will contribute to dissemina-tion and implementation research.76

This study was funded through the CDC’s Prevention ResearchCenters Program contract U48/DP001903 (Applying Evidence–Physical Activity Recommendations in Brazil). The authorsthank all members of Project GUIA for their valuable contribu-tion and input, and especially Carlos Arango and Grace Gomesfor assisting with article abstractions and Drs. Michael Pratt


www.ajpmonline.org

and Luiz Ramos for their insightful feedback as members of theGUIA Science Committee. The fındings and conclusions in thisarticle are those of the authors and do not necessarily representthe offıcial position of the CDC.No fınancial disclosures were reported by the authors of this

paper.

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Appendix

Supplementary data

Supplementary data associatedwith this article can be found, in theonline version, at http://dx.doi.org/10.1016/j.amepre.2012.10.026.


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http://dx.doi.org/10.1016/j.amepre.2012.10.026

Documents

Physical Activity Interventions in Latin America