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Health Education Research Advance Access originally published online on October 13, 2006
Health Education Research 2006 21(6):806-825; doi:10.1093/her/cyl120
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© The Author 2006. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oxfordjournals.org

Young people and physical activity: a systematic review matching their views to effective interventions

Rebecca Rees1,*, J Kavanagh1, A Harden1, J Shepherd2, G Brunton1, S Oliver1 and A Oakley1

1 Evidence for Policy and Practice Information and Co-ordinating Centre (EPPI-Centre), Social Science Research Unit, Institute of Education, University of London, 18 Woburn Square, London WC1H ONR, UK and
2 Wessex Institute for Health Research and Development (WIHRD), Mailpoint 728, Boldrewood, University of Southampton, SO16 7PX, UK

* Correspondence to: R. Rees. E-mail: r.rees{at}ioe.ac.uk


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 Conclusion
 Conflict of interest statement
 Acknowledgements
 References
 
A systematic review was conducted to examine the barriers to, and facilitators of, physical activity among young people (11–16 years). The review focused on the wider determinants of health, examining community- and society-level interventions. Four trials and 16 studies of young people's views were included. Evidence for the effectiveness of the interventions was limited, with some suggestions of improvements in knowledge and possible differences according to gender. Young women in particular identified barriers to physical activity associated with certain ways of providing physical education in schools. Young people in general identified a need for increased choice and facilities within the community and emphasized physical activity's social side. Some of the barriers and facilitators identified by young people had been addressed by ‘soundly evaluated’ effective interventions but significant gaps were identified where no evaluated interventions appear to have been published (e.g. initiatives explicitly addressing gender issues or the combination of sport and other leisure activities), or where there were no soundly evaluated interventions. Rigorous evaluation is required particularly to assess initiatives that address the limited practical and material resources that young people identify as barriers to physical activity.


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 Conclusion
 Conflict of interest statement
 Acknowledgements
 References
 
Physical activity promotion is high on the health policy agenda. Low levels of physical activity in young people have been linked to increased rates of obesity, cardiovascular disease and poor mental health [1]. Guidelines recommend that all young people should participate in physical activity, of at least moderate intensity, for 1 hour day–1 [2]. Yet, in the late 1990s, only 58% of young men (aged 16–24 years) and 32% of young women achieved even 30 min on ≥5 days week–1 [3]. Recent figures also reveal alarming levels of obesity and overweight in young people. A recent government report recognized that changing health behaviour is complex. It noted ‘it is critical that obesity is tackled first and foremost at a societal rather than an individual level’ [4]. Effective promotion of physical activity remains a key strategy in achieving a mass shift in activity levels [5].

Policy makers and practitioners require evidence-based summaries of research on what helps and what hinders physical activity in order to plan effective interventions that are likely to bring about sustainable changes to activity levels and to identify future research needs. The objectives of the systematic review reported in this paper were:

(i) systematically to ‘locate and characterize’ the existing research literature on the barriers to, and facilitators of, physical activity among young people, especially those from socially excluded groups (e.g. low income, ethnic minority—in accordance with government health policy);
(ii) to prioritize a sub-set of studies to review systematically ‘in-depth’;
(iii) to ‘synthesize’ what is known from these studies about the barriers to, and facilitators of, physical activity among young people, and how these can be addressed and
(iv) to identify gaps in existing research evidence.


   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 Conclusion
 Conflict of interest statement
 Acknowledgements
 References
 
This study followed standard procedures for a systematic review, which include transparent and principled methods for identifying, describing, appraising and collating research addressing a specified research question [6, 7]. It was innovative in that it aimed to answer not only questions about effectiveness but also questions about the appropriateness of interventions in terms of whether they address the expressed needs of young people. These methods have been applied to other health areas, including the promotion of healthy eating [8–12].

The review adopted a conceptual framework of barriers to, and facilitators of, health, where interventions are thought of as aiming to modify or remove barriers and/or build upon existing facilitators. The review had two stages [13, 14]. First, systematic searches and screening identified research matching a broad review question. This research was classified so as to describe the range of existing research in a ‘systematic map’ (see Fig. 1). The second stage was an in-depth review of a sub-set of this research. The in-depth review contained three syntheses:

(i) of effectiveness studies (trials);
(ii) of data from surveys or interview-based studies of young people's experiences and perspectives (views studies) and
(iii) a ‘cross-study synthesis’, where trials data were juxtaposed with data from the views studies.


Figure 1
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  		Fig. 1 The review process.

 
This approach aims to contextualize the findings of effectiveness studies, and to discover to what extent they address issues important to potential intervention recipients.

Literature searching and screening
Highly sensitive searches were run across a wide range of electronic databases (e.g. The Cochrane Library, PsycINFO, ERIC and the Social Science Citation Index). A range of controlled and free-text terms for physical activity was combined with those for health promotion/determinants of health and young people. The searches covered the full range of publication years available in each database up to 2001 (when the review was completed). Full details of searches and all other methods are reported elsewhere [15].

Inclusion criteria were applied to each study. For a study to be included in the map it had to: focus on physical activity of any kind; include young people aged 11–16 years; be about the promotion of physical activity, and/or the barriers to, or facilitators of, physical activity; be a relevant study type (an outcome or process evaluation, a systematic review or a UK-based study that did not involve an intervention) and be published in the English language.

Selecting studies for the in-depth review
The research topics covered in the map were discussed in a meeting with government policy makers. They identified several policy-relevant questions and agreed that trials and UK-based non-intervention studies of young people's views should be prioritized for the in-depth review. The review team then drew up the following inclusion criteria for the in-depth review.

Trials were included in the in-depth review if they met the criteria for the map and:

(i) reported an intervention that aimed to make a change at the level of the community or society;
(ii) used a comparison group design;
(iii) reported both pre- and post-test data;
(iv) used random allocation or demonstrated equivalence between groups before intervention and
(v) measured either the behaviour or health of young people.
UK-based non-intervention studies were included in the in-depth review, if, in addition to meeting the map criteria, they:
(i) studied young people's definitions of and/or ideas about physical activity or factors influencing their own or other young people's physical activity;
(ii) presented views as data and
(iii) were published after 1990 (to maximize the relevance of the review findings to current policy issues).

Data extraction and quality assessment
All studies meeting inclusion criteria for the in-depth systematic review underwent data extraction and quality assessment, using a standardized framework [16]. Data for each study were entered independently by two researchers into a specialized computer database [17].

Trials were considered ‘methodologically sound’ for the purposes of this review if they reported:

(i) a control or comparison group equivalent to the intervention group on socio-demographic characteristics and pre-intervention outcome variables;
(ii) pre-intervention data for all individuals or groups recruited into the evaluation;
(iii) post-intervention data for all individuals or groups recruited into the evaluation and
(iv) data on all outcomes described in the aims of the intervention.
Only studies meeting these criteria were used to draw conclusions about effectiveness. The results of the studies that did not meet these criteria were judged unclear and their findings were not used to inform conclusions about intervention effectiveness.

Views studies were assessed according to a total of seven criteria common to those proposed by four research groups for qualitative research [18].

(i) An explicit account of theoretical framework and/or the inclusion of a literature review.
(ii) Clearly stated aims and objectives.
(iii) A clear description of context which includes detail on factors important for interpreting the results.
(iv) A clear description of the sample.
(v) A clear description of methodology, including systematic data collection methods.
(vi) Analysis of the data by more than one researcher.
(vii) The inclusion of sufficient original data to mediate between data and interpretation.

Data synthesis
Three types of analyses were performed:

(i) narrative synthesis of trials,
(ii) narrative synthesis of views studies and
(iii) synthesis of trials and views studies together.
In the second synthesis, each study's findings were considered in relation to developing interventions for promoting participation in physical activity, using four separate questions (presented under Results below). For the last synthesis, a matrix was constructed which laid out the barriers and facilitators identified by young people alongside descriptions of the interventions included in the in-depth systematic review of trials [19].


   Results
Top
 Abstract
 Introduction
 Methods
 Results
Discussion
 Conclusion
 Conflict of interest statement
 Acknowledgements
 References
 
Of the total of 7048 citations identified, 96 reports (describing 90 studies) were included in the descriptive map (Fig. 1). A sub-set of 12 trials and 16 studies of young people's views entered the in-depth review.

Trials
Twelve trials were included in the in-depth systematic review. Following quality assessment, eight were excluded from the synthesis since they did not meet the review's methodological quality criteria [20–27]. While their findings were not synthesized, we did refer to the interventions studied in these evaluations later in our cross-study synthesis (see below). For the remainder of this section, we report only the results of the four evaluations that met the review's methodological quality criteria.

Table I reports the characteristics of the four studies. Three studies (reported in two papers) were conducted in the United States [28, 29], and one in the United Kingdom [30]. Two of the evaluations [29] studied the same intervention but in two very different parts of New York State. All the interventions took place in schools. Three of the evaluations were judged to have limited findings because they reported effects only for some of the outcomes measured, and we judged the findings of the fourth evaluation to be unclear.


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  		Table I Soundly evaluated outcome evaluations: study characteristics

 
The ‘Wessex Healthy Schools Award’ took a whole school approach that sought to make health-promoting changes in the ethos, organization and curriculum [30]. In a cluster-controlled trial, 11 English intervention schools were compared with five control schools matched on area and socio-economic status. The intervention only appeared possibly to be effective for increasing reported physical activity levels in girls. Statistical significance is not reported.

The aim of the ‘Know Your Body’ programme was to promote good nutrition and physical activity and prevent smoking among children aged 9 years old (at the start of the 5-year study), with the objective of reducing future risk for cardiovascular disease and cancer [29]. The programme was evaluated in two separate randomized-controlled trials in demographically diverse areas of New York; the Bronx area and Westchester County suburb. For the intervention group in the Bronx, there was a statistically significant net increase in knowledge about preventing heart disease and cancer. Net improvements were not seen in other measurements (including exercise recovery rate, blood cholesterol and blood pressure measures). While the authors reported favourable net effects of the intervention in Westchester County for knowledge and cholesterol levels, we judged the results of the evaluation to be unclear. Here, the reviewers were concerned about a mismatch between the study's unit of assignment and unit of analysis (schools were assigned rather than pupils in this study).

A third US study, the ‘Slice of Life’ initiative, involved peer education and motivation for health behaviour change, with an emphasis on sociocultural and environmental influences on healthy eating and physical activity [28]. The study was undertaken in a suburban high school with ninth grade (14- to 15-year old) students. Six measures of physical activity were assessed, incorporating knowledge, intentions and reported exercise. Significant differences between study groups at follow-up were seen only for young women on four of the six measures (knowledge of the benefits of exercising; taking regular exercise; intensity of exercise and intentions to increase the frequency, intensity and duration of exercise). No significant differences were seen for time spent on exercising or healthy exercise choices. The evaluation found no evidence of impact of the intervention on young men.

Young people's views
Table II provides details of the 16 studies included in the synthesis of young people's views [31–45] (one report [44] contained two studies).


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  		Table II Characteristics of young people's views studies

 
The characteristics of the young people participating in these studies were not always easy to assess. Only age and sex were consistently reported. Most of the studies included a range of ages between 11 and 16 years. Three studies focused only on young women. Only five studies indicated participants' social class: two of these were with primarily working-class samples. Only six studies indicated that young people from ethnic minority groups were included. Most studies used school samples and collected data from young people when they were in school. The findings from these studies may therefore not be applicable to young people who are excluded from, infrequently attend, or have left, school.

The methodological quality of the studies was variable. While the majority provided a clear description of study context and clearly stated their aims, only three reported any attempt to establish the reliability or validity of their data analysis.

The findings of the studies are grouped below under the four questions applied during synthesis. A common theme was young people's desire for autonomy, choice and respect. Young women were also regularly reported to have more negative perspectives.

What are young people's perceptions of and attitudes to physical activity? What does physical activity mean to young people?
All but one of the studies addressed one or both of these questions. Gender and current physical activity levels were key factors in understanding variation. The vast majority saw physical activity as important and had positive beliefs about its benefits. Physical activity was valued for increasing health and fitness (including mental health) and developing new skills and creating opportunities for socializing and enjoyment. Gentle et al. [34] found that young people with low activity levels had less positive beliefs about the social value of physical activity. Another study found no difference in reasons for exercising between different ethnic groups in north London [43]. In three studies, young women particularly valued the role of physical activity in maintaining weight and a toned figure [40, 42, 43].

Preferred sports included badminton, tennis, swimming, football and basketball, with young women expressing a preference for more recent additions to the curriculum, such as cycling and aerobics [37, 40, 42]. Other studies also reported varying views on preferences for competitive exercise, with young women and young men with low activity levels expressing a dislike for this kind of physical activity [34, 41].

Whereas young men reported physical activity to fit comfortably within their leisure time both within and outside of school [33, 41], in many studies it did not feature as part of young women's leisure time. Their descriptions of what it meant to ‘become a woman’ did not include physical activity, which they also saw as ‘babyish’. For young men, participation confirmed their masculinity [33], and they were more likely than young women to see themselves as physically active and fit even if their activity levels were low. Physical activity and fitness were predominantly equated with sport and exercise. Both were seen as requiring hard work, as competitive and requiring considerable skill. Young men held negative stereotypes about young women's abilities in sport.

What do young people think stops them from taking part in physical activity?
Twelve studies addressed this question [31, 33, 35, 37–45]. Barriers identified by young people included: not feeling competent enough to take part; negative reactions from peers over skill and choice of activity; feelings of inertia and conflicting interests; self-consciousness about bodies; parental constraints, sometimes related to concerns about safety or cultural restrictions; time and facilities and dislike of highly structured activities or those organized by adults. Many of these issues were particularly problematic for young women. Consistent across a number of studies was a lack of practical and material resources needed for taking part or sustaining involvement in physical activity. Several studies reported that young people held negative perceptions of physical education (PE) at school. Participation in school PE was particularly problematic for young women. While generally identifying a lack of choice of activities on offer and a lack of consultation in what activities they would like to do, many of the barriers identified by young women were to do with PE facilities and rules such as inadequate changing and showering facilities, a lack of time for changing and unacceptable gym kits such as short skirts.

What do young people think helps them to take part in physical activity?
Six studies addressed this question [33, 37–39, 41, 44]. Many of the facilitators were identified by young people who were already physically active. Young people described a range of things to do with the self that helped or motivated them. These included a chance to show off their skills; enjoyment and using exercise as a way of relieving stress. Mulvihill et al. [41] identified different facilitators according to whether young people were active (social benefits, competitiveness, sense of achievement and feelings of confidence) or inactive (enjoyment, well-being, avoiding boredom and help with losing weight for females). Parental support was important for creating opportunities for physical activity, encouragement and financial support; and social support from friends was important for young women, especially in terms of trying out a new activity. Liking and respecting PE teachers was described as helpful to participation at school [38].

What ideas do young people have for what could or should be done to promote their participation in physical activity?
Five studies addressed ways of facilitating participation in physical activity [31, 35, 40–42]. The majority of the young people's suggestions was about increasing practical and material resources such as: creating more cycle lanes, making activities more affordable, increasing access to clubs for dancing and provision of single sex physical activities in youth clubs alongside or followed by mixed sex (non-physical) activities (combining sports and leisure facilities). Young people suggested emphasizing the fun and social aspects of physical activity. Young women's ideas reflected a desire for more equal opportunities.

Cross-study synthesis
Evaluations of interventions addressing the barriers or facilitators expressed by young people were identified in four areas: the school; physical and material resources; relationships with family and friends and the self (see Table III).


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  		Table III Synthesis matrix

 
In schools, young people identified specific barriers related to PE. For young women in particular, this included a dislike of activities they saw as too routine; inappropriate or inadequate facilities (e.g. gym kit, showers); the ‘rules and arrangements’ surrounding PE (e.g. lack of time for changing) and unsupportive teachers. None of the soundly evaluated interventions directly addressed issues of gender and PE. One UK intervention using a ‘whole school’ approach was possibly effective in increasing participation in physical activity among women [30]. Young people recommended that school PE should involve consultation over choice of activities and new activities such as aerobics and cycling. None of the soundly evaluated interventions built on these facilitators.

Three interventions targeting young women whose evaluations were not judged ‘sound’ by our criteria addressed the suggestion from young women that they should be given more choice of activities in school [22, 23, 27]. These all provided programmes of physical activity that included activities such as dancing, gymnastics and ‘health hustles’ (moving to music).

Relationships with family and friends presented both barriers and facilitators. Limiting factors included: parental constraint (due to safety concerns, monitoring of leisure time, particular cultural values); fear of negative evaluation from peers (particularly from young men) and young women prioritizing boyfriends' preferences for leisure time activities. Parents and friends could also be a source of support for physical activity. Two interventions addressed these barriers and facilitators in ways that appear effective. One involved both parents and young people through family exercise days, an approach that was effective in improving knowledge in one setting [29]. In another intervention, the aim was to increase peer support and to teach peer pressure resistance skills [28]. This was effective in young women in terms of increasing knowledge of the benefits of physical activity and intentions to exercise. Young people also recommended that physical activity could be encouraged by combining sports and (non-active) leisure facilities for socializing. However, no effective interventions were identified which built on this facilitator.

That parents could be a source of support for physical activity was addressed by five evaluations judged not to be methodologically sound [20, 21, 23, 25, 26]. These involved educational programmes that either brought young people and their parents together to engage in physical activity or educated parents separately about its benefits.

In relation to the self, young people identified as barriers: lack of confidence and competence, feelings of discomfort and self-consciousness about bodies (young women only), lack of motivation and ‘inertia’, preference for other activities and lack of knowledge about the benefits of physical activity. They also described the social and psychological benefits of exercise as motivators. Two effective interventions included educational components emphasizing the benefits of physical activity (both showed effects for young women only). It is not clear to what extent these also addressed other barriers such as lack of confidence. Young women endorsed magazine articles on women taking part in physical activity as a way of promoting physical activity, but no interventions were identified which built on this.

In terms of practical and material resources, young people recommended: the creation of more cycle lanes, making activities more affordable and providing more acceptable forms of physical activity (e.g. not highly structured and organized by adults). Although young people feel that they have enough information on the facilities available, some want more consensus about desirable levels of activity. No effective interventions were identified which built on these facilitators.


   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
Conclusion
 Conflict of interest statement
 Acknowledgements
 References
 
This review has systematically identified the research on the barriers to, and facilitators of, participation in activity in young people. We found a lack of good quality studies evaluating the effectiveness of interventions. In the four high quality outcome evaluations identified, the effectiveness of the interventions studied was limited.

One UK-based intervention, using a whole school approach, was possibly effective at increasing physical activity levels, but only for young women [30]. One teacher-led intervention from the United States was effective for increasing health-related knowledge in a low-income sample of mostly African American or Hispanic young people [29]. However, the effectiveness of the same intervention conducted in a more affluent neighbouring area was unclear [29]. One peer-led intervention in the United States showed no apparent effect for reported time spent on physical activity or healthy exercise choices, though females reported more regular exercise, an increase in the intensity of physical activity, more favourable intentions to undertake physical activity and an increase in knowledge [28].

The trials indicate differences in effectiveness between genders. The synthesis of young people's views also revealed gender to be an important factor in the promotion of physical activity. Young women in particular identified specific barriers related to the way PE is provided in schools, including a dislike for activities run too many times, inappropriate or inadequate facilities, the rules and arrangements surrounding PE and unsupportive or insensitive teachers. One of the key recommendations from young people about how physical activity might be promoted was that there should be increased choice. They emphasized the need to develop the social side of physical activity and provide more opportunities for activities that are fun, with space and time for both single-sex and mixed activities.

Our findings bring together several pertinent research gaps on: community-based interventions, the promotion of active recreation or active lifestyles and the reduction of sedentary behaviour and promoting physical activity among socially excluded groups. Our systematic searches highlighted that there has been very little research on physical activity that attends to social diversity among young people.

Searches for systematic reviews and trials published since this review was conducted indicate that these research gaps are yet to be filled. We have identified one systematic review that complements this one in that it looks beyond our focus on community- or society-level changes to include interventions that work solely with young people's knowledge, attitudes or skills [46]. Further physical activity-promoting initiatives are likely to be underway, some of which may match the needs identified by studies of young people's views. It is important for all physical activity-promoting initiatives to be thoroughly evaluated using, where possible, controlled trials, preferably randomized, with comprehensive formative and process evaluation. Such evaluations should be included in a future updated systematic review.


   Conclusion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conclusion
Conflict of interest statement
 Acknowledgements
 References
 
On the basis of the evidence identified so far, the promotion of physical activity at the community-and society level has uncertain benefits. The essential components for success are unclear, and may not translate to long-term participation in physical activity. A multi-faceted or whole school approach might be promising. Other promising approaches include those that aim to support teachers to foster supportive and sensitive teaching strategies that include activities other than competitive sports and team games.

Interventions which take into account young people's views and so require rigorous evaluation include those which aim to: increase the range of ‘free’ diverse activities through after-school clubs and community-based initiatives, provide community and school facilities for safe bicycling, improve PE facilities at school, provide young people with choices about types of physical activity and emphasize the fun and social aspects of sport and exercise. Future initiatives to promote physical activity among young people should also take their views as a starting point.


   Conflict of interest statement
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conclusion
 Conflict of interest statement
Acknowledgements
 References
 
None declared.


   Acknowledgements
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conclusion
 Conflict of interest statement
 Acknowledgements
References
 
We would like to thank Chris Bonell and Dina Kiwan for undertaking data extraction in this report. We would also like to acknowledge the invaluable help of Amanda Nicholas, James Thomas, Elaine Hogan, Sue Bowdler and Salma Master at the EPPI-Centre for support and helpful advice throughout the preparation and write up of this report. The Department of Health, England, funds a specific programme of health promotion work at the EPPI-Centre. The views expressed in the report are those of the authors and not necessarily those of the Department of Health.


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conclusion
 Conflict of interest statement
 Acknowledgements
 References
 
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Received on October 3, 2005; accepted on August 29, 2006


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