Impact of environmental interventions based on social programs on physical activity levels: A systematic review

Background: The design of social programs at the environmental level such as in schools, parks, bicycle paths, or workspaces generates changes in the behavior of individuals and modifies lifestyles by increasing physical activity (PA) levels.

Objective: To determine the effectiveness of environmental interventions based on social programs by changing the population's level of PA.

Methodology: Natural experiment studies that involved environmental intervention programs at a social level were included. The primary outcome was PA levels with consideration of both objective and subjective measurements. An electronic search was carried out in Medline/Pubmed, SCIENCE DIRECT, WEB OF SCIENCE, and CINAHL databases up to January 2022 with two reviewers screening titles and abstracts and selecting studies for full-text reading. Two reviewers also acquired relevant data and evaluated study quality using the ROBINS I tool. A qualitative analysis was performed.

Results: Three thousand eight hundred and sixty-five articles were found in the 4 consulted databases. After eliminating duplication (200), two reviewers screened 3,665 titles and abstracts and excluded 3,566 that did not meet the inclusion criteria, leaving 99 articles to be read in full text. The 99 full texts were reviewed of which 24 papers met the eligibility criteria. All were natural experiments published between 2011 and 2020 and all evaluated environmental social programs revealing that social programs at the environmental level promoted PA in various populations at the community level worldwide.

Conclusion: The 24 reviewed studies suggest innovative proposals for social programs that seek to increase PA and promote healthy lifestyles related to public activity policies developed in the countries in which they were generated. Environmental social programs can positively impact PA levels among children and adults.

Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=229718, identifier: CRD42021229718.

Introduction

A variety of factors worldwide have altered patterns of physical activity (PA), with an increase in the level of sedentary lifestyles especially in middle and low-income countries (1). Low level of PA is one of the key factors related to the development of chronic diseases. In addition, morbimortality due to chronic diseases secondary to physical inactivity has been found to be related to the worldwide prevalence of type 2 diabetes, coronary artery disease, and cancer among others, with relative risk (RR) of physical inactivity of 1.16 (95% CI 1.04–1.30)for all causes worldwide (2).

The world's economic and health behavior changes, such as an increase in working hours especially for mothers, unhealthy food consumption, a reduction in leisure and recreation time, the reduced metabolic expenditure given the influence of the obesogenic space because of less PA and the imbalance between intake and consumption lead to the presence of childhood and adult obesity (3). In this sense, the evidence shows that the economic market has a substantial influence on the commercial aspect of food in advertising for children, television time, and high investments in fast food restaurants. In contrast to the above investments there is a low investment in environmental modifications that may have a greater effect on the time spent in PA which may have a favorable effect on the imbalance between intake and demand and decrease obesity (4, 5).

Health policies, especially the guidelines generated by the World Health Organization (WHO) are aimed to increase PA in populations, with a minimum of 150 min and nutritional improvement with a balanced diet, to reduce the presence of chronic non-communicable diseases (6, 7). Moreover, PA interventions or strategies at the individual, community, environmental, and social levels may favorably alter poor health behaviors and have a positive impact on levels of PA improving the population's general health and chronic non-communicable diseases (8, 9).

The WHO describes environmental strategies regarding social programs as global actions, community approaches and public policy developed to allow the implementation of social determinants of health within community spaces as schools, parks, bicycle routes, bicycle lanes, companies, or cities (10–13). Examples of such programs have been implemented worldwide as methods to promote PA (1, 14, 15). In the United Kingdom and other countries, national guidelines have been developed for environmental modification and the creation of social programs to encourage greater PA and reduce sedentary lifestyles (16, 17). The conceptual background of environmental social programs has been described in international documents such as the National Institute for Health and Care Excellence (NICE) in which the role of PA is highlighted stating “Local strategies, policies and plans to encourage and enable people to be more physically active” (18). The socio-ecological models of PA explain how to facilitate and implement PA at different levels of the individual including behavioral, social, and physical environmental constructs (19, 20). For example, schools with in-school or out-of-school programs for children are likely to promote more PA and less sedentary lifestyles. In addition, the implementation of active walking or cycling routes, modification of cities with the inclusion of active programs, and the reduction of spaces that induce obesity to reduce the level of sedentary lifestyles in men, women, and children throughout the life cycle have been reported (15, 21–25).

Worldwide, environmental modification programs from the social perspective have gained relevance for the implementation of policy-based programs in countries whose impact has been evaluated through natural experiments. Natural experiments have been described as observational studies in which an event or a situation that allows for the random or seemingly random assignment of study subjects to different groups is used to answer a particular question (24). Thus, natural experiments can observe large populations in a real-world environment to examine the effects of global actions or community approaches. The medical research council has recommended the use of natural experimental approaches to evaluate population health interventions. Thus, natural experiments are extremely important since the exposure to an event or intervention of interest has not been manipulated by a researcher making the natural experiment not only an observational study, but an experimental study especially when a clinical trial may be impractical or unethical (26).

The effect of social programs at the environmental level can be assessed by natural experiments and appear to generate favorable change in the behaviors and lifestyles of individuals in work, school, and university settings. The use of transportation methods to facilitate healthy lifestyle habits has also been suggested as a strategy to improve PA, however, the results are inconclusive (15, 27–30). Therefore, this systematic review aims to examine the effectiveness of environmental interventions based on programs at a social level on levels of PA in studies that have employed natural experiments.

Methodology

This study is a systematic review conducted according to the guidelines of Cochrane methodology (31) and PRISMA guidelines (32). The protocol is registered in the international database of systematic reviews PROSPERO under the number CRD42021229718.

Selection criteria

Type of study

The type of study is natural experiments that involve environmental interventions at the social level which includes local strategies, plans, programs, or policies to promote PA with the understanding that a natural experiment is a research study in which the exposure to an event or intervention of interest has not been manipulated by a researcher (26).

Type of participants or population of interest

The type of participants and population of interest includes the general population such as students in schools and universities, individuals in the workplace, the population of individuals in cities and neighborhoods, and older adults in institutions. Studies that have targeted specific populations with diseases or conditions such as neuromuscular disease (sclerosis, cerebrovascular disease, and dystrophies), musculoskeletal diseases (lupus, arthritis, and osteoarthritis), or cardiovascular diseases (infarction, arrhythmia, valve diseases, etc.) as well as studies on athletes were excluded.

Type of interventions

Studies that evaluated programs focused on the promotion of PA from an environmental perspective at the social level such as programs involving parks, bicycle commuting, bicycle lanes, school curriculum modifications, or city programs to promote PA such as muevete and recreovia Bogota, Biking Barcelona, Biking Boulevards Australia, Agita São Paulo, role of public policy in active schools in Ontario, and others.

Type of outcomes

The primary outcome is PA defined as variation or levels reached and measured objectively or subjectively. Objective measurements included PA measured by pedometers, accelerometers, heart rate monitors, and direct and indirect calorimetry. Subjective measurements included self-reports or questionnaires such as the IPAQ, CHAMPS, or the PA Recall, among others. Both the objective and subjective measurements could be expressed continuously [such as total energy expenditure (Kcal/Kg/week, kcal/week), metabolic consumption in METS, oxygen consumption or differences in CO₂/Vo₂, heart rate, heart variability, total minutes of physical activity or the number of steps, among others] or categorically (such as of light, moderate, or vigorous PA). Participation in the programs, percentage or amount of PA performed, measures of fitness level if they were reported in metabolic expenditure or oxygen consumption, and measurement scales of individual or group physical activity were also examined.

Search strategy

A search for studies was performed through January 2022 using the following electronic databases: Medline/Pubmed, Web of Science, Science Direct, and CINAHL, using Mesh, Decs, and Emtree terms. Appendix 1 provides the search strategies employed in the study. Additionally, a search of crossed references was done manually as well as a search of gray literature in specialist journals, university repositories or general websites related to the topic.

Study selection

Study selection involved two reviewers (EH, EC) who screened the articles by title and abstract according to the inclusion criteria. The selected studies were then blinded, read in full text format by both reviewers and the results and conclusions compared. In the case of disagreements, a third reviewer acted as a peer evaluator to settle disagreements for the definitive selection of studies. To optimize the work at this stage, the Rayyan^© software was used (33).

Data extraction and risk of bias evaluation

Data extraction was accomplished using a spreadsheet in which the characteristics of the studies were recorded, such as title, authors, year and place of publication, program undertaken and its characteristics, start and end date, the scope of the program's intervention, outcomes and considered measurements, and reported results.

The risk of bias was assessed using the recommendations and evaluation criteria of the ROBINS I tool for non-randomized intervention studies (34). Which made it possible to evaluate specific risks of bias at three points in the study: (1) pre-intervention where the bias of confounding and participant selection were considered, (2) during the intervention where measurement bias was assessed, and (3) post-intervention where the bias of the interventions performed and outcome measurements as well as attrition bias were considered.

Data analysis

The data analysis was undertaken qualitatively through figures and tables showing the information obtained in the data extraction process which provided an organized and visual presentation of the intervention programs, methodological findings, and results of each study.

Results

Three thousand eight hundred and sixty-five articles were found in the 4 databases. After eliminating duplicates (200), two reviewers screened 3,665 titles and abstracts and excluded 3,566 articles because they did not meet the inclusion criteria. Thus, 99 full texts were reviewed in depth to determine that 28 studies fulfilled the eligibility criteria. The reasons for exclusion were: 20 articles were not natural experiments, 27 did not have outcomes of interest, and 24 were natural experiments but focused on physical environmental structural modification. It is important to note that of these 28 full-text readings, 4 had double reporting in different articles, resulting in a total of 24 reports. Of these 24, 7 studies examined both physical environmental modifications and social programs. The 24 papers used in this study as well as those with double reports are shown in Figure 1.

FIGURE 1

Figure 1. Study distribution around the world.

Characteristics of the selected studies

The 28 study reports (35–62). That were selected were natural experiments published between 2011 and 2020, with the evaluation of environmental social programs from different parts of the world (Figure 2). Regarding the scope, 10 were implemented at school programs, 6 were related to active transportation, 4 were in active cities, 2 were in parks, and 2 were in workspaces (Table 1).

FIGURE 2

Figure 2. Flowchart of the selection process.

TABLE 1

Table 1. Characteristics of the studies included and areas of emphasis.

Designs of the natural experiments found

Several approaches were used in the natural experiments as shown in Table 2. From pre- and post-cohorts with a control group or prospective cohorts (36, 38, 43, 52, 53, 60), controlled before and after studies (40, 46–48, 57, 59, 62) before and after studies with and without a control group (49–51, 54, 55), as well as quasi-experimental (37, 56), cross-sectional pre- and post-intervention studies with or without a control group (35, 39, 41, 42, 58, 61) providing repeated measures and retrospective studies (44, 45). The 24 studies indicated that they were working on PA policies worldwide or nationally, but 25% did not specify the specific PA policy Using natural experiments to evaluate population health interventions: new Medical Research Council guidance (36, 44, 47, 51, 59, 62), 37.5% described the PA policy, but did not evaluate its development (35, 37, 40–42, 55, 57, 58, 60) and the remaining studies were framed within national public policies on PA or active transportation clearly showing the evaluation of implementation at the level of parks, cities, schools or active transportation (Table 2).

TABLE 2

Table 2. Main methodological characteristics of the studies.

Measurements of physical activity in the studies

All included studies reported the outcome of PA with valid and reliable measurements as shown in Table 2. At the non-instrumental level, the IPAQ PA questionnaire was used in 2 studies, the SOPARC leisure or activity measurement system in parks in another 2 studies, and the RPARQ PA level measurement survey in recreation in one study (35–37, 40, 41). Fifteen studies provided levels of PA as light, moderate or vigorous (35–38, 40, 41, 47, 48, 50, 52, 54, 57–59, 62), and the hours/minutes of activity were reported in 19 studies (43, 50–52, 54, 57, 58, 62).

Objective measurement data of PA was measured with the following instruments including an accelerometer in 7 studies (35, 36, 40, 44, 48, 58, 59) a pedometer in 1 (62); and global or geographic location such as GPS, and ACTIVE-PAL-3C in 4 studies (36, 40, 47, 50). Finally, 8 studies reported other physiologic measures including anthropometrics, vascular resistance, METS, and blood chemistry such as lipid profile, cholesterol, triglycerides, and glycemia (38, 42–44, 48, 49, 55, 59).

Effectiveness of the programs

The percentage of PA performed at the end of the intervention was examined in 10 studies (36, 38, 40, 41, 47, 48, 52, 58, 59, 61) as shown in Table 3. The level of PA in the majority of the populations was found to be light PA (LPA). For example, the reports in two of the largest studies, one conducted in Pernambuco Brazil on active cities (41) and another one recreo via in Colombia (61), found that 25.8 and 57.8% of the population performed LPA, respectively. In addition, the greatest effects of environmental interventions at the social level were in schools and workplaces. In schools, the percentage increase of PA was 2.3–6 points after a period of 12–16 weeks of the program (38). Regarding workplaces, the increase from moderate to vigorous activity was 19.3% in 1 week (47). In contrast, in two studies, one with an intervention of activity in the neighborhood in the cities (52) and the other examining bicycle commuting (36), no changes in the use of bicycle areas or boulevards were reported.

TABLE 3

Table 3. Effectiveness of the programs.

The increase of PA as an outcome was reported in 14 records corresponding to 11 studies (35, 37, 40, 43–45, 51, 54, 57, 59, 60). In these studies, aerobic activities such as running, jogging, or walking were implemented. Also, the use of bicycles as an activity, commuting as a means of transportation, or as a method to access public areas was found (35, 37) with bicycling being the most effective as a means of transportation reported in 7 studies (35, 37, 40, 45, 51, 57, 60). One of these studies (40) reported an increase in the prevalence of bicycle use from 5.81 to 6.78%, with an Odds Ratio (OR) of bicycle use of 1.09 (95%CI: 1.07–1.11), and a decrease in the use of the vehicle with an OR of 3.01 (95%CI: 3.13 to −2.88). Three studies found an increase in school activities and walking, and also intra- or extracurricular PA with two of the studies in schools (44, 59) and one in parks (35). The study examining PA in parks found an increase of 97% in walking on the playground, 84% in cardiovascular activities, and 18% in cycling as transportation.

Changes in the time of PA were also examined of which 15 of 22 studies) (35–37, 39, 41, 43, 44, 46, 48–50, 52–62) demonstrated that the changes generated an increase or modification in minutes spent in PA, whether it was daily, weekly, and total PA for the population. Eight studies in the school area (43, 44, 48, 49, 55, 56, 58, 59) reported an increase of 89.4 min of weekly PA in students with increases in LPA from 422 to 460 min, vigorous PA from 30 to 40 min per week, and total PA from 187 to 230 min per week. Similarly, the studies of PA in parks and cities (35, 41, 50, 52) found an increase in the minutes of participation in recreational pathways, parks, or modified city areas, with an accumulated total time of 27 min of moderate-vigorous PA (MVPA). An improvement in the number of women actively participating in provided programs was also reported, with an increase in walking time that was >30 min with a variation of 82 (54, 61). In children, an increase in PA of 40 min was observed, and in children over 10 years of age or in children from economically deprived families, the increase in PA time ranged from 96 to 113 min (50, 52). The study of Brazilian cities (41) demonstrated a dose-response relationship where a stronger association with adherence to leisure time PA guidelines was found the more exposed the population was to the program and whether the exposure was current compared to a past exposure. In this same sense, commuting as a form of transportation increased the time spent cycling or walking as shown in Table 3.

Finally, three studies reported a change from sedentary to active lifestyle (47, 52, 59) with an increase in PA time and a decrease in sedentary time highlighted by a diminution in sitting time from 337 to 281 min in participants who were examined in the workplace, school children, and city programs.

Risk of bias in the included studies

Natural experiments are very useful in public policy due to the fact that the population is assessed in their environment at the time that programs or policies are implemented (63, 64). At the same time, one weakness of natural experiments is the risk of bias. Table 4 illustrates the results of the risk of bias assessment of the studies included. As shown, the risk of bias differs among studies, but there is an implicit risk of bias in natural experiments in the pre-intervention, during intervention, and post-intervention periods.

TABLE 4

Table 4. Risk of bias in the studies included.

Discussion and conclusions

This systematic review focused on environmental social strategies to increase PA. The results found multiple social programs worldwide were studied through natural experiments. Twenty-four experiments from 28 reports developed in different environments such as schools, workplaces, streets or cities, neighborhoods, and parks were reviewed and analyzed to determine the effectiveness of promoting PA in populations. Of the included studies, 12 were carried out in external environments such as parks, cities, neighborhoods, or crosswalks, and the other 12 were carried out indoors or outdoors such as in schools and companies. The experiments provided innovative proposals for social programs that seek to increase PA and promote healthy lifestyles related to public policies developed in the countries in which they were generated.

Worldwide, environmental modification programs from the social perspective have gained relevance for the implementation of policy-based programs in countries whose impact has been evaluated through natural experiments (26). Natural experiments have strengths and weaknesses inherent to their methodological design and the scope of their conclusions. These studies have a higher risk of bias given population selection and confounding in the management of variables. But it is important to note that, although they have these central problems, they allow the analysis of community or environmental interventions in large populations and groups. In our systematic review, natural experiments were of vital importance given the prospects of working on PA from a population standpoint and reducing chronic non-communicable diseases as established by the WHO (65).

The use of natural experiments and their impact on the modification of public health problems like our study have been presented in three key studies. One of the largest studies was reported by the WHO in a different area with three large projects. The first was from Austria about the regulation of trans fatty acids to prevent mortality from all cardiovascular causes and coronary heart disease (66). The second was from Russia on the effects of tobacco control policy to prevent cardiovascular disease (67) and finally, a study from Romania on the increase in tobacco taxes (68). These three experiments from the WHO European project of natural experiments raise the strengths of their use in implementing public policies but their methodological weaknesses as well.

Another important factor to consider is the manner in which environmental modification and active transportation is related to health equity (69). A previous review included 28 studies carried out in adult and child populations. In contrast to our study, they included prospective, longitudinal, cross-sectional, repeated measures studies, and a natural experiment. Although the types of studies were different, all programs were focused on promoting PA through walking, bicycling, park-based programs, neighborhood modification, and even environmental recreation activities. Another difference was the list of risk of bias evaluation in which the instrument of evaluation of public policies in health practices of the Canadian Association for observational studies was used, but although the list was different, the evaluation was similar, finding weaknesses in the studies methodology but with the advantage in the description of the effectiveness of the promotion of PA. The previous research measured the activity reported ranging from the use of types of transportation to specific measures of activity in metabolic expenditure in METS or level of PA from mild to moderate to vigorous. Within the impact reports, increases in the number of users, metabolic work, or the level of moderate or vigorous activity were found to have a greater impact in school and adult physical activity programs, followed by those of parks or playgrounds modifications and those of urban renewal with the implementation of programs in the scenarios similar to our review.

In this same line, but in systematic reviews in different levels of evidence related to public policies and environmental modifications is an integrative review of systematic reviews and meta-analysis of urban modification and promotion of PA in Latin America. The results were reported in 14 articles and included 8 systematic reviews with studies of different levels from cohorts, cross-sectional, experimental, cases, and controls among others (70). The studies were developed especially in Australia, the United States, and England. The findings showed that programs which were proposed in the environment such as the development of bike paths or recreational spaces, transportation, and commute to active transportation increased the PA. Within the programs found there was evidence of an improvement in the levels of activity within a range of 8–33 min of walking per day with an increase in activity similar to that found in our results. In addition, the study found that the development of outdoor spaces that created scenarios in the population for the practice of the activity and the use of active transportation such as bicycles, walking at school and work level improved PA. The results of the study also suggest that the level of activity could rise by maximizing the use of physical spaces by satellite geo-referencing in neighborhoods and cities to increase activity and shows the relevance of developing public policies related to PA.

In the area of environmental programs focused on active transportation, there were two reviews, one systematic and the other synthesis of evidence from systematic reviews. The first was based on interventions to increase cycling (71) and the second was on urban environmental interventions to increase PA (72). In the first report with 12 studies, 2 clinical trials and 10 pre- and post-intervention of individual, group, and environmental interventions with outcomes to promote active transportation found that the implementation of programs focused on the individual or environmental infrastructure increases the level of transportation trips from 7 to 12%, with an OR of 7.8 in participants who rode a bicycle more than 2 km. Also an increment of 27.5% during the use of cyclists who use active transportation in the last 5 months, similar to what was reported in our study with the increase in time and number of trips. Similarly, an increase of 47.5% in the number of cyclists was found in a program in New Zealand where a bridge was constructed and not only improved PA levels, but also increased health status (71). Secondly, eight systematic reviews all of which were focused on the impact of urban interventions on PA demonstrated an increase in activities such as walking, cycling, switching from bus transportation to walking, or the use of bike lanes for the control of chronic non-communicable diseases (70).

Related to the topic of environmental modification, a systematic review but in different levels of evidence ranging from controlled trials to cross-sectional studies in the school setting, focused on in-school programs as in our study. The review of the effects of classroom-based programs on PA outcomes and academic performance (73) included 39 studies that examined the effect of activity programs in school settings. As in this review, there were programs to increase activity in the classroom for children and adolescents and included active rest periods based on aerobic activity to achieve the movement of students in the class to extra-classroom programs focused on sports or with additional equipment and implements to increase the level of activity. It is also noteworthy that the time and activity were variable among the programs ranging from 4-min of daily vigorous-level classroom activities to 20 min of moderate PA twice a week. Also, programs focused on the curriculum, such as the Ontario Natural Experiment have been studied in which in mathematics, language, science, or social studies classes incorporated cognitive academic skills with PA goals. In this paper three studies, two experimental cluster studies and one quasi-experimental study, were meta-analyzed to determine the effect of the program on PA, finding 95% heterogeneity with a non-significant effect of 0.40 CI −0.15 to 0.95.

About the applicability of these results in our review is important to consider since most of the studies come from high-income countries, and little information exists on middle- and low-income countries, likely because the urban modifications in-built environments is determined by the use of the land, density, and urbanization. This is important because economic and educational aspects influence the type of environmental interventions implemented and the possibility of changing behaviors in the population. The evidence shows some favorable results related to the implementation but stronger evidence is needed to determine the changing in behaviors (72, 74).

In conclusion the 24 reviewed studies suggest innovative proposals for social programs that seek to increase PA and promote healthy lifestyles related to public activity policies developed in the countries in which they were generated. Environmental social programs can positively impact PA levels among children and adults. It is important to highlight that these documents presented and this research reflect the importance of implementing public policies aimed at promoting PA from an environmental perspective. Structural modifications and the creation of social programs from socioecological perspectives allow the establishment of other perspectives of approaching PA that not only focus on the individual but also how changes in the environment facilitate the implementation of plans, programs, and public policies for PA. It appears important that a central mission of a country is to implement policies to promote PA with a comprehensive vision centered on the populations within a country.

Strengths and limitations

This systematic review based on natural experiments has several advantages including (1) the examination of large populations in natural settings providing an understanding of the effect programs and modifications to existing program may promote PA and (2) examining the implementation and measurement of public policies and programs established in the studies. A risk of bias is implicit in natural experiments and may introduce bias in the selection, measurement, and reporting of results. Nonetheless, natural experiments are an important type of study for decision-making in public health and especially in assessment of PA in environmental interventions.

Data availability statement

The original contributions presented in the study are included in the article/Supplementary material, further inquiries can be directed to the corresponding author.

Author contributions

Overall content as guarantor: EH. Study concept and design: EH and PS. Screening titles and abstracts: EH, PS, and EC. Search and extracted the evidence: EH and EC. Writing and revising the manuscript for important intellectual content and approved the final manuscript: EH, EC, LC, and PS. All authors contributed to the article and approved the submitted version.

Funding

This project has no financing but does have the support of the Universidad Nacional de Colombia and Minciencias (before Colciencias) Colombia doctoral scholarships.

Acknowledgments

EH is a Ph.D. candidate in the Methodology of Biomedical Research and Public Health program, at Universitat Autònoma de Barcelona (UAB), Barcelona, Spain.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Supplementary material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpubh.2023.1095146/full#supplementary-material

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