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Cochrane Database of Systematic Reviews Protocol - Intervention

Policy interventions implemented through sporting organisations for promoting healthy behaviour change

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Abstract

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:

PRIMARY OBJECTIVES

  • To determine if policy interventions implemented through sporting organisations instigate and sustain healthy behaviour change within the sport setting.

  • To determine if policy interventions implemented through sporting organisations instigate and sustain changes in attitudes, knowledge or awareness of healthy behaviour or intention to change behaviour within the sport setting.

SECONDARY OBJECTIVES

  • To determine if policy interventions implemented through sporting organisations instigate and sustain healthy behaviour change outside the sport setting.

  • To determine if policy interventions implemented through sporting organisations instigate and sustain changes in attitudes, knowledge or awareness of healthy behaviour or intention to change behaviour outside the sport setting.

  • To determine if some interventions are more successful with particular participants, grouped by, for example, socio‐economic status, gender, age, ethnicity, or geographical location.

  • To determine if policy changes influence factors such as participation in sport.

  • To determine if the success of interventions is dependant on particular process indicators (ie. those that describe why and how a particular intervention has worked).

  • To determine if the success of interventions is dependant on particular contextual factors (eg. concurrent media campaigns at the time of implementation).

  • To determine if short term behaviour changes are maintained at 12 months and beyond.

  • To determine if short term changes in attitudes, knowledge or awareness of healthy behaviour or intention to change behaviour are maintained at 12 months and beyond.

  • To determine if multiple intervention strategies are more effective than single interventions in promoting and sustaining healthy behaviour change.

Background

Health behaviour and health behaviour change theories that focus on individual characteristics, and are not put into the broader context in which an individual lives, will leave many factors that influence health unexplained (Nutbeam 1998). The Ottawa Charter for Health Promotion advocates a comprehensive approach to public health and health promotion practice by, for example, emphasising the role of healthy public policy, the social and physical aspects of the health environment, and community education in health advocacy and action (O'Connor 1995). To encompass this, many health promotion initiatives utilise the settings in which people live, work or play to bring about healthy behaviour change. Sporting organisations as settings have been recognised for their potential to promote and create health promoting environments, and are the focus of this review.

Globally, over 60% of adults do not participate in a sufficient amount of sport and physical activity (UN 2003). Participation in sport is being addressed by the authors in a concurrent review entitled "Interventions implemented through sporting organisations for increasing participation in sport" (Howes 2004). Participation in sport or physical activity alone may or may not lead to other healthy behaviours such as smoking cessation and healthy eating. However, health promotion theory and evidence from successful health promotion campaigns show that environmental and policy changes must accompany behavioural change approaches to make the 'healthy choice the easy choice'. Policy interventions used within the sporting organisation setting are another means of targeting risk behaviours such as: smoking, harmful or hazardous alcohol consumption, excess sun exposure, unhealthy eating, and discrimination.

These risk factors are prevalent and have significant health consequences. In the developed world, smoking is considered the single most important preventable health risk and is an important cause of death worldwide (Fagerstrom 2002). Globally, the estimated number of deaths attributable to smoking in the year 2000 was 4.9 million (over one million more than it was in 1990), with the increase being most marked in developing countries (WHO 2002).

Alcohol consumption has increased worldwide in recent decades, with most or all of this occurring in developing countries (WHO 2002). The proportion of deaths and global disease burden however, was greatest in the Americas and Europe. Alcohol has been estimated to cause, worldwide, 20 to 30% of oesophageal cancer, liver disease, epilepsy, motor vehicle accidents, homicide and other intentional injuries (WHO 2002).

Skin cancer rates in Australia are the highest in the world (PHAA 2002) and it is the most common form of cancer in the United States (CDC 2003). Exposure to the sun's ultraviolet rays appears to be the most important environmental factor involved in its development (CDC 2003).

The overall burden of disease associated with diet is difficult to assess (Mathers 1999). Overweight and obesity lead to adverse metabolic changes including increases in blood pressure, unfavourable cholesterol levels and increased resistance to insulin, raising the risks of cardiovascular disease, stroke, diabetes mellitus and many forms of cancer (WHO 2002). According to the American Cancer Society, about one third of all cancer deaths in the United States are attributable to dietary risk factors (CDC 2002). Adopting healthy behaviours to prevent or delay disease onset is well illustrated in the case of type 2 diabetes. A multi‐centre randomised controlled trial demonstrated that lifestyle changes reduced the risk of developing type 2 diabetes, in those at high risk of developing the disease, by 58% (Knowler 2002).

Krieger (2000) outlined the health consequences of discrimination. They include social deprivation and socially inflicted trauma (mental, physical or sexual). Also relevant are the health consequences of peoples' responses to discrimination, which may include internalised oppression and the use of psychoactive substances (Krieger 2000).

Many sporting organisations derive funding from governments and health promotion associations. Funding to the sport sector can be quite substantial. The United Kingdom, for example, has allocated two billion pounds sterling of Government and lottery money to sport over three years (UKG 2002). Australia's annual investment in sport and recreation in 2001‐2002 was just over 758 million pounds (ABS 2000‐2001), and South Africa invested just over 737 million pounds in the same time period (SRSA 2001‐2002). Contractual funding agreements may require the introduction of health promoting policies (Corti 1996), therefore reviewing the effects of health promotion interventions within the sport sector is important.

In Australia, the National Health and Medical Research Council (NHMRC) has recognised sporting organisations as an important setting for improving the health outcomes of individuals (Corti 1996). Sport settings are considered appropriate for the conduct of health promotion activities because: participation is likely to benefit physical, mental and social health; there is the potential to reach large numbers of people; those who access sport settings have elevated risk behaviours (cross‐sectional data from the Western Australian Health Promotion Foundation, Healthway, found that those involved in sport had elevated risk behaviours in nearly all areas except physical activity participation, such as consumption of alcohol at unsafe levels and poor sun protection); many issues of importance to public health can be aligned to sport sector interests; and physical venues can be health promoting through structural and environmental policies (Corti 1996).

The World Health Organization (WHO) identified settings as a means for health promotion as they offer practical opportunities for the implementation of comprehensive strategies (WHO 1997). The settings approach is consistent with the view that health and health behaviour are greatly influenced by environments (Kelleher 1998). Health promotion theory underpins the relationship between settings and the behaviour of individuals. For example, Social Learning Theory defines human behaviour as a triadic, dynamic, and reciprocal interaction of personal factors, behaviour and the environment. An individual's behaviour is uniquely determined by each of these three factors (Stone 1998). This theory avoids overly simple solutions to health problems which focus on behaviour in isolation from the physical and social environment (Nutbeam 1998). Nutbeam and Harris (1998) provide a case in point when illustrating Social Learning Theory: a young woman who is quitting smoking may be very confident in her ability to abstain at work where smoking is banned and none of her workmates smoke, but she may be less confident when she goes out (to a sporting fixture where smoking is not banned) with her friends who are heavy smokers (own example in italics).

Evaluation of policy level interventions is difficult. Ideally one wants to show that the intervention strategy led to policy change, the policy change produced the desired behaviour and the behaviour then contributed to the health outcome (Clark 1998). Making clear connections may be impossible and the challenge may be to identify indicators that most would accept as reliable and valid signs that change is occurring in the desired direction (Clark 1998). Hence, immediate and intermediate behavioural outcomes are often used to measure the effectiveness of interventions. These may include intention to change behaviour, or increased knowledge and shifts in attitudes and beliefs. This review will include these outcomes as well as actual behaviour change.

Process factors are also important to include. A survey carried out in sports clubs found that clubs had difficulty with developing healthy policies due to lack of training and resources, and if they had limited control over their facilities (Dobbinson 2002). These issues need to be identified to determine factors important to the effectiveness of interventions. Historical and socio‐political contextual factors are also of relevance, as these factors may influence the effects of interventions in particular settings and at particular times.

In this review, policies will be defined as laws, regulations, formal or informal rules and understandings that are adopted on a collective basis to guide individual and collective behaviour. This includes legislation and organisational policy. Legislation includes formal, documented policies that influence laws enacted by relevant governing bodies. Organisational policies are policies implemented within specific organisations that define and establish appropriate behaviour within the realms of the organisation (Salmon 2000). We will consider policies that alter either the physical environment (eg. erection of a sun‐shade cloth), and/ or the socio‐cultural environment (eg. anti‐vilification policies).

Participation will be defined as per the Active Australia framework. Thus participation is "not just confined to a role as a player, but includes involvement as a coach, instructor, teacher, administrator, manager, official and volunteer, etcetera" (SRMC 1997). The definition for sporting organisation has been modified from that used in the Australian Sports Commission Amendment Bill 1999 (ASCAB 1999): sporting organisations include any organisation that controls sports or sporting events; organises or administers sports or sporting events; accredits people to take part in sporting competition; provides teams to compete in sporting competition; or trains, or provides finance for people to take part in sporting competition, and encompasses professional and amateur sporting bodies.

The authors are currently unaware of any systematic reviews of policy interventions implemented through sporting organisations for promoting healthy behaviour change.

Objectives

PRIMARY OBJECTIVES

  • To determine if policy interventions implemented through sporting organisations instigate and sustain healthy behaviour change within the sport setting.

  • To determine if policy interventions implemented through sporting organisations instigate and sustain changes in attitudes, knowledge or awareness of healthy behaviour or intention to change behaviour within the sport setting.

SECONDARY OBJECTIVES

  • To determine if policy interventions implemented through sporting organisations instigate and sustain healthy behaviour change outside the sport setting.

  • To determine if policy interventions implemented through sporting organisations instigate and sustain changes in attitudes, knowledge or awareness of healthy behaviour or intention to change behaviour outside the sport setting.

  • To determine if some interventions are more successful with particular participants, grouped by, for example, socio‐economic status, gender, age, ethnicity, or geographical location.

  • To determine if policy changes influence factors such as participation in sport.

  • To determine if the success of interventions is dependant on particular process indicators (ie. those that describe why and how a particular intervention has worked).

  • To determine if the success of interventions is dependant on particular contextual factors (eg. concurrent media campaigns at the time of implementation).

  • To determine if short term behaviour changes are maintained at 12 months and beyond.

  • To determine if short term changes in attitudes, knowledge or awareness of healthy behaviour or intention to change behaviour are maintained at 12 months and beyond.

  • To determine if multiple intervention strategies are more effective than single interventions in promoting and sustaining healthy behaviour change.

Methods

Criteria for considering studies for this review

Types of studies

  • Randomised controlled trials (RCTs)

  • 'Quasi‐randomised' trials

  • Controlled before and after studies (CBAs)

If there are studies which do not fall into these study types but meet the other inclusion criteria, the scope of these excluded studies will be described and presented in an annex to the review.

Types of participants

People of all ages.

Types of interventions

Any policy intervention implemented through sporting organisations to instigate and/ or sustain healthy behaviour change, intention to change behaviour, or changes in attitudes, knowledge or awareness of healthy behaviour.

Policy interventions that will be included are:

  • Policies surrounding smoking eg. indoor and/ or outdoor, partial or total smoking bans.

  • Policies surrounding the responsible use of alcohol eg. drink driving awareness programs, alcohol server training and availability of low or non‐alcoholic beverages.

  • Policies surrounding sun protection eg. shaded outdoor areas or avoidance of outdoor activity around noon or policies on use of hats and sunscreen.

  • Policies surrounding healthy eating eg. provision of healthy eating choices in the clubrooms such as low fat, low sugar and low salt choices, fresh fruit and vegetables.

  • Policies to promote inclusion and social and emotional health eg. anti‐harassment, anti‐discrimination, anti‐vilification and anti‐gambling policies. Policies to promote access for disadvantaged groups eg. very low income, English as a second language. Policies surrounding disability access eg. provision of marked parking, ramps, special seating, toilets and other facilities.

  • Policies to improve physical safety eg. well lit facilities, safe transport to and from facilities.

EXCLUSION CRITERIA

  • Policies and practices surrounding sports injury prevention (such as padding for goal posts) will be excluded.

Types of outcome measures

  • Behaviour change.

  • Intention to change behaviour.

  • Change in attitudes, knowledge or awareness of healthy behaviour.

Search methods for identification of studies

We will search:

  • The Cochrane Central Register of Controlled Trials (CENTRAL)

  • MEDLINE and MEDLINE In‐Process and Other Non‐Indexed Citations (1966 to present)

  • EMBASE (1985 to present)

  • CINAHL (1982 to present)

  • PsycINFO (1872 to present)

  • Sociological Abstracts (1963 to present)

  • SPORTDiscus (1973 to present)

  • Dissertation Abstracts (1997 to present)

We will check reference lists of relevant trials and contact authors of relevant studies to identify additional published and unpublished trials.

We will conduct internet searches of electronic databases of relevance to health promotion and public health. These include:

  • BiblioMap, the Evidence for Policy and Practice Information and Co‐ordinating Centre (EPPI Centre) database of health promotion research, http://eppi.ioe.ac.uk;

  • The Health Technology Assessment Database through the Cochrane Library, http://www.cochrane.org;

  • The Health Evidence Bulletins, Wales, http://hebw.uwcm.ac.uk/;

  • The Effective Public Health Practice Project, http://www.city.hamilton.on.ca/sphs/EPHPP/ephppSumRev.htm;

  • HealthPromis, the public health database for England through the Health Development Agency, http://www.hda‐online.org.uk/;

  • Evidence Network research through the Medical Research Council Social and Public Health Sciences Unit, http://www.msoc‐mrc.gla.ac.uk;

  • The Community Guide ‐ Guide to Community Preventive Services ‐ Systematic reviews and evidence‐based recommendations, http://www.thecommunityguide.org/home_f.html;

  • C2‐SPECTR, the social, psychological, educational, and criminological trials register of the Campbell Collaboration, http://www.campbellcollaboration.org.

We will search the Leisure Information Network website (http://www.lin.ca/htdocs/rcentre.cfm).

We will contact a sample of individuals and organisations with knowledge in this area to identify unpublished reports, internal reports and conference proceedings.

We will search the conference proceedings: Conference paper index 1982+ (CSA) and PapersFirst 1993+ (FS) available through the Sports Science Research Guide.

There will be no language or date restrictions for the electronic search.

The following search strategy will be used to identify relevant studies in MEDLINE (Ovid) and then modified as necessary to search the other listed databases:

1. exp Health Promotion/
2. Primary Prevention/
3. preventive medicine/
4. Public Health/
5. Health Education/
6. exp social control policies/
7. social control, formal/ or government regulation/
8. social control, informal/
9. social environment/
10. Legislation/
11. Environment/ or Environment Design/
12. ( legislat$ or polic$ or regulat$).tw.
13. ((polic$ or modus operandi or statute or understanding$ or law$ or legislat$ or directive$ or ruling$ or regulat$ or rule$ or plan$ or protocol$ or strateg$ or guiding principle$ or course of action or guideline$ or procedure$) adj5 (smoking or anti‐smoking or tobacco or anti‐tobacco or alcohol$ or sun or shade or skin cancer$ or eat$ or nutrition$ or obesity or inclusion$ or social$ or emotional or anti‐discrimination or anti‐harassment or anti‐vilification or disability or safety)).tw.
14. or/1‐13
15. exp Sports/
16. exp recreation/
17. Leisure Activities/
18. Physical Fitness/
19. Exercise/
20. Exertion/
21. sport$.tw.
22. (physical adj1 activit$).tw.
23. physical fitness.tw.
24. exercise$.tw.
25. game$.tw.
26. leisure.tw.
27. recreation$.tw.
28. or/15‐27
29. fitness centers/
30. gym$.tw.
31. club$.tw.
32. (sport$ adj1 (body or bodies)).tw.
33. (facility or facilities).tw.
34. (sport$ adj1 organi$).tw.
35. swimming pool$.tw.
36. (wellness centre$ or wellness center$).tw.
37. ((sport$ or physical$ or exercise$ or game$ or leisure$ or recreation$ or fitness) adj5 (event$ or setting$ or sector$ or program$ or venue$ or site$ or centre$ or center$ or facilit$)).tw.
38. or/29‐37
39. 28 or 38
40. 14 and 39
41. randomized controlled trial.pt.
42. controlled clinical trial.pt.
43. randomized controlled trials.sh.
44. random allocation.sh.
45. double blind method.sh.
46. single blind method.sh.
47. or/41‐46
48. animal/ not (human/ and animal/)
49. 47 not 48
50. clinical trial.pt.
51. exp clinical trials/
52. (clin$ adj25 trial$).ti,ab.
53. ((singl$ or doubl$ or trebl$ or tripl$) adj25 (blind$ or mask$)).ti,ab.
54. placebos.sh.
55. placebo$.ti,ab.
56. random$.ti,ab.
57. research design.sh.
58. or/50‐57
59. 58 not 48
60. 49 or 59
61. (time adj series).tw.
62. (pre test or pretest or (post test or posttest)).tw.
63. 60 or 61 or 62
64. 40 and 63
65. 14 and 28 and 38
66. 64 or 65

Data collection and analysis

We will screen the references from all the electronic databases using Endnote (version 6). Two reviewers (FH, JD) will screen titles and abstracts. One reviewer (FH) will retrieve the full text of the remaining references, and two reviewers (FH, JD) will judge them independently against the inclusion criteria. If there is any disagreement or uncertainty a third reviewer will be consulted (NJ).

Two reviewers will extract the data independently. Any discrepancies will be resolved by a third reviewer. We will extract data on the study population (eg. number and description of participants), study methods (eg. instruments used and assessment intervals), the type of intervention (including length, duration of follow‐up), the outcomes evaluated, the results, conclusions and limitations. Authors will be contacted for further information if required.

Process factors will also be sought, for example methods of involvement of relevant stakeholders during the process of planning and implementation of the intervention; descriptions of formative research, pilot studies and on‐going evaluation; and modification of the program, program reach, completeness of the implementation of the intervention and maintenance of the program after the intervention has ceased.

Where possible the underlying theory of the intervention and contextual factors will be noted, including historical factors, the policy environment, and sanctions surrounding the policies.

Two reviewers (FH, JD) will independently assess the quality of each eligible study using a modified version of the Cochrane Effective Practice and Organisation of Care Review Group (EPOC) criteria. For each study, the reviewers will indicate whether the quality criteria were met. Disagreement or uncertainty will be settled by discussion with a third reviewer (NJ).

The decision on whether to combine the studies quantitatively or qualitatively will be made once we have completed the search. We will examine the characteristics of the interventions and the comparability of the outcome measures. If there is homogeneity with respect to both the interventions and the outcomes we may be able to employ quantitative (meta‐analytic) methods to their synthesis and analysis, however if they are heterogenous with respect to interventions and outcomes we will employ narrative synthesis techniques (descriptive data synthesis) (Khan 2001). Subgroup analysis will be conducted only if there are sufficient studies. Subgroup analysis will be conducted in order to provide answers for each of the primary objectives, and further, again if sufficient studies enable it, to provide detailed answers in order to meet the secondary objectives. We will attempt to analyse the differential effectiveness of the interventions across socio‐demographic backgrounds (age, gender, socioeconomic group and ethnicity), if primary data enables it.

Consumer participation

For systematic reviews to be relevant to policy and practice, potential users of the review must be involved in key stages of the review process (Oliver 1997). This involvement can ensure that the review will address the key questions that policy‐makers and practitioners consider important, consider all relevant outcomes; and present its findings and recommendations in an accessible way (Oliver 2003).

This review was conceived by the Sport and Active Recreation Team of the Victorian Health Promotion Foundation (VicHealth), an independent health promotion organisation in Victoria, Australia. An advisory panel consisting of members from VicHealth, VicSport, the Evidence for Policy and Practice Information and Co‐ordinating (EPPI) Centre and the Victorian Little Athletics Association was consulted during the development of the protocol. Other individuals identified as having knowledge in this area from South Africa and Germany were contacted for feedback but unfortunately this was unsuccessful.

This process of consultation will be repeated for the draft of the full review and whenever significant amendments of the published review are considered.