Interventions implemented through sporting organisations for increasing participation in sport
Abstract
This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:
PRIMARY OBJECTIVES
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To determine the effects of interventions implemented through sporting organisations for increasing (active and non‐active) participation in organised sport.
SECONDARY OBJECTIVES
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To determine if interventions are more successful with particular participants, grouped by, for example socio‐economic status, gender, age, ethnicity, geographical location and individual or team sports.
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To determine if the success of the interventions is dependant on particular process indicators (ie. those that describe why and how a particular intervention has worked).
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To determine if the success of the interventions is dependant on particular contextual factors (eg. concurrent media campaigns at the time of implementation).
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To determine if multiple intervention strategies are more effective than single interventions in increasing participation.
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To determine if different types of interventions are more effective than others.
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To determine if short term changes are maintained at 12 months and beyond.
Background
Physical inactivity is on the international health agenda. Prevalence rates may vary depending on definitions and measurement techniques used, however all show that a high proportion of adults are physically inactive (Armstrong 2000). Globally, over 60% of adults do not participate in an adequate amount of sport and physical activity (UN 2003). In Australia, rates are thought to have been stable, with approximately 30% of the adult population participating (ABS 2003; Armstrong 2000). However, Sport Canada found a high rate of decline from 45% to 34% over the six‐year period from 1992 to 1998 (Salmon 2000). To be sufficient for health gain, the National Physical Activity Guidelines for Australians and the United States Department of Health and Human Services suggest thirty minutes of moderate physical activity on most days of the week (Stephenson 2000; USSGR 1996).
Physical inactivity's contribution to ill health has been well documented. It is listed in the top three preventable causes of morbidity, mortality and disability by the United States Surgeon General's Report (1996) and the Australian Institute of Health and Welfare (1999) (Stephenson 2000). There is a growing body of evidence supporting a causal link between physical inactivity and disease. The strongest evidence exists for coronary heart disease, non‐insulin dependant diabetes mellitus, and colon cancer; with evidence also existing for breast cancer, stroke, depression, and obesity. Physical activity has been shown to reduce the risk of dying prematurely (PHAA 1998; Stephenson 2000; USDHHS 2002).
Internationally, the sport and recreation, health promotion and transport sectors are viewed as key priority areas for increasing rates of physical activity (Driscoll 2001) and policies have put an emphasis on sport. In Australia, initiatives of the Backing Australia's Sporting Ability ‐ A More Active Australia (2001) policy will focus on the "...delivery of successful sports participation programs to expand the reach and active membership of grass‐roots sporting clubs and associations" (ASC 2001, p.1). Expectations include a significant increase in the number of people, including those from regional and rural communities, participating in sport; a marked increase in youth participation in organised sport; and boosted active membership of sporting organisations (ASC 2001).
The United Kingdom also highlights the importance of sport, Canada has spread its interventions across sport and recreation and the United States of America have adopted mixed strategies (Driscoll 2001). South Africa places sport at the forefront of efforts to address issues of national importance, including improving health, and combating crime and unemployment (SRSA 2002). Finland has a 'Sport for All' policy, while East Germany's policy orientation is characterised by competitive sports (Stahl 2002). As sporting organisations have been recognised as a setting to create and encourage health promoting environments, we are undertaking a concurrent review entitled "Policy interventions implemented through sporting organisations for promoting healthy behaviour change" (Howes 2004).
The benefits derived from sport can extend beyond physical activity and physical health. Other benefits of playing sport and belonging to a sports club include: developing sports‐specific skills (Murphy 2002); providing a sense of achievement and personal empowerment (Brunton 2003; Dionigi 2002; Nies 1998; Pederson 2002; Rees 2001); developing respect for others and self esteem (Murphy 2002; UN 2003); teaching self‐discipline, and socialising individuals to the value of hard work, team work (cooperation) and competition (Brunton 2003; Murphy 2002; UN 2003). Sport and recreation has been noted as having the potential to reduce levels of substance abuse and self‐harm, and to improve social cohesion in Indigenous communities (Cairnduff 2001; Cameron 2001: Walker 2001 as cited in Beneforti 2002). It is also viewed as a strategy to reduce stress (Rees 2001) and teach coping mechanisms (UN 2003). It can provide opportunities for socialisation and friendship networks, which may act to reduce social isolation and enhance community wellbeing (Driscoll 1999).
The social model of health identifies that major influences on participation may operate at the level of the individual, the family, the community and wider society (PCPDHPG 2000). Studies have shown that participation rates are lower in females, decline with age, and are reduced in lower socio‐economic and minority groups (ABS 2003; Armstrong 2000; Dale 2002; UN 2003; USDHHS 2002). This could relate to perceived barriers. Potential barriers to participation in sport include cost (of transport, membership, participation fees and equipment), time constraints (family and work responsibilities), and safety (Alexandris 1997; Booth 2002; Brunton 2003; Rees 2001; Richter 2002; Salmon 2003; VicHealth 2003). Other barriers cited include poor transport infrastructure (Rees 2001); lack of childcare (Richter 2002); lack of opportunities and age or skill‐specific options (particularly in rural and regional areas) (Brunton 2003; Rees 2001; VicHealth 2003); lack of family support (Brunton 2003; Nies 1998); intimidating club culture (particularly for women, older people or people from diverse cultural backgrounds) (VicHealth 2003); cultural irrelevance (cultural influences were seen as important in determining the type of physical activity) (Richter 2002; Seefeldt 2002); the natural environment (for example, the weather) (Burton 2003; Nies 1998; Salmon 2003); self consciousness (Burton 2003); lack of confidence due to real or perceived inadequacy of physical or social skills (Burton 2003), injury or poor health (Booth 2002); and sport acting to promote 'win at all cost' strategies (people feel pressured to compete and achieve which leads to stress) (Rees 2001).
Sporting organisations have an important role to play in attracting and maintaining participants. Interventions utilised may enhance the benefits, reduce the barriers or use a combination of the two to achieve the engagement and sustainability of their membership. Examples of interventions could include policies or initiatives to improve the socio‐cultural environment to encourage people of a specific age, gender or ethnicity to join, or changes to traditional programs such as modified rules.
Participation has been defined in many ways. For example, the Australian Bureau of Statistics defines participants as only "those playing a sport or physically undertaking an activity" and excludes, for example, those involved solely as a referee or umpire (ABS 1999‐2000). This review, however, will define participation as per the Active Australia framework. 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). Thus, 'active' and 'non‐active' participation will be included. 'Non‐active' roles in sport are considered important as they may influence mental and social as well as physical health.
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.
Numerous reviews have been undertaken to evaluate the effectiveness of various approaches to increasing physical activity (eg. Brunton 2003; Kahn 2002; and Rees 2001) and a Cochrane review is currently being undertaken, entitled "Interventions for promoting physical activity" (Hillsdon 2002). However, questions remain about the role of sporting organisations in attracting and maintaining active and non‐active participants. The authors are currently unaware of any systematic reviews of interventions implemented through sporting organisations to increase participation. It is necessary to establish an evidence base, as policy emphasises the importance of sport and recreation sectors for increasing physical activity. We have broadened the definition of participation to reflect other potential health benefits and we are interested in extracting process and contextual factors. This review will be of particular interest to policy makers, the sport and recreation and health promotion sectors, health promotion and public health practitioners, researchers, sporting organisations, individuals and families.
Objectives
PRIMARY OBJECTIVES
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To determine the effects of interventions implemented through sporting organisations for increasing (active and non‐active) participation in organised sport.
SECONDARY OBJECTIVES
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To determine if interventions are more successful with particular participants, grouped by, for example socio‐economic status, gender, age, ethnicity, geographical location and individual or team sports.
-
To determine if the success of the interventions is dependant on particular process indicators (ie. those that describe why and how a particular intervention has worked).
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To determine if the success of the interventions is dependant on particular contextual factors (eg. concurrent media campaigns at the time of implementation).
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To determine if multiple intervention strategies are more effective than single interventions in increasing participation.
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To determine if different types of interventions are more effective than others.
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To determine if short term changes are maintained at 12 months and beyond.
Methods
Criteria for considering studies for this review
Types of studies
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Randomised controlled trials (RCTs)
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'Quasi‐randomised' trials
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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 intervention designed to increase active and/ or non‐active participation in sport.
These could include:
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mass media campaigns;
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information or educational sessions;
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management or organisational change strategies;
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policy changes, for example to improve the socio‐cultural environment to encourage people of specific age, gender or ethnicity to participate;
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changes to traditional or existing programs, for example club or association‐initiated rule modification programs;
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provision of activities beyond traditional or existing programs, for example 'Come and Try' initiatives, skill improvement programs, volunteer encouragement programs;and
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role modelling initiatives.
EXCLUSION CRITERIA:
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Programs designed specifically for treatment or as therapy for specific medical conditions (eg. rehabilitation programs).
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Programs designed specifically to increase paid active or paid non‐active participation.
Types of outcome measures
PRIMARY OUTCOMES
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Change in the number of (active and non‐active) participants in organised sport.
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Change in status from non‐participating to non‐active or active participation.
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Change in status from non‐active to active participation.
SECONDARY OUTCOMES
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Sustainability of participation eg. the length of new or continuing memberships, or length of involvement in the organisation.
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Physical, social and mental health outcomes (both positive and negative).
Search methods for identification of studies
We will search:
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The Cochrane Central Register of Controlled Trials (CENTRAL)
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MEDLINE and MEDLINE In‐Process and Other Non‐Indexed Citations (1966 to present)
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EMBASE (1985 to present)
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CINAHL (1982 to present)
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PsycINFO (1872 to present)
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Sociological Abstracts (1963 to present)
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SPORTDiscus (1973 to present)
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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.
Internet searches of electronic databases of relevance to health promotion and public health will be conducted. These include:
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BiblioMap, the Evidence for Policy and Practice Information and Co‐ordinating Centre (EPPI Centre) database of health promotion research, http://eppi.ioe.ac.uk;
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The Health Technology Assessment Database through the Cochrane library, http://www.cochrane .org;
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The Health Evidence Bulletins, Wales, http://hebw.uwcm.ac.uk/;
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The Effective Public Health Practice Project, http://www.city.hamilton.on.ca/sphs/EPHPP/ephppSumRev.htm;
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HealthPromis, the public health database for England through the Health Development Agency, http://www.hda‐online.org.uk/;
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Evidence Network research through the Medical Research Council Social and Public Health Sciences Unit, http://www.msoc‐mrc.gla.ac.uk;
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The Community Guide ‐ Guide to Community Preventive Services ‐ Systematic reviews and evidence‐based recommendations, http://www.thecommunityguide.org/home_f.html;
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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 also 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. (prevent$ or promot$ or program$ or project$ or educat$ or campaign$ or intervent$ or strateg$).tw.
7. or/1‐6
8. exp sports/
9. exp recreation/
10. leisure activities/
11. physical fitness/
12. exercise/
13. exertion/
14. (physical adj5 (fit$ or train$ or activ$ or endur$)).tw.
15. (exercise$ or game$ or sport$ or leisure$ or recreation$).tw.
16. ((lifestyle or life‐style) adj5 activ$).tw.
17. ((lifestyle or life‐style) adj5 physical$).tw.
18. or/8‐17
19. fitness centers/
20. (gym$ or club$ or swimming pool$).tw.
21. (wellness centre$ or wellness center$).tw.
22. (organi?ed adj1 sport$).tw.
23. (sport$ adj1 (body or bodies)).tw.
24. (sport$ adj1 organi$).tw.
25. ((sport$ 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 facility or facilities)).tw.
26. or/19‐25
27. 7 and 18 and 26
28. randomized controlled trial.pt.
29. controlled clinical trial.pt.
30. randomized controlled trials.sh.
31. random allocation.sh.
32. double blind method.sh.
33. single blind method.sh.
34. or/28‐33
35. animals/ not (human/ and animals/)
36. 34 not 35
37. clinical trial.pt.
38. exp clinical trials/
39. (clin$ adj25 trial$).ti,ab.
40. ((singl$ or doubl$ or trebl$ or tripl$) adj25 (blind$ or mask$)).ti,ab.
41. placebos.sh.
42. placebo$.ti,ab.
43. random$.ti,ab.
44. research design.sh.
45. or/37‐44
46. 45 not 35
47. 36 or 46
48. (time adj series).tw.
49. (pre test or pretest or (post test or posttest)).tw.
50. 47 or 48 or 49
51. 27 and 50
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, and 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 such as: 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 were 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.
