BACKGROUND: Physical activity is important for healthy ageing, however most older adults are inactive. Numerous reviews with a range of inclusion criteria have been conducted on digital interventions to promote physical activity in older adults, and a synthesis of these is needed. Therefore, the objective of this study is to conduct an umbrella review and meta-meta-analysis on the effectiveness of digital interventions to promote physical activity in older adults.
METHODS: Nine databases were searched from January 2010 to December 2023. Systematic reviews and meta-analyses of primary studies using digital physical activity interventions to target healthy older adults or clinical populations of older adults with a self-reported or device measured physical activity outcome were eligible for inclusion.
RESULTS: In total, 22 systematic reviews and meta-analyses covering 185 primary research papers were eligible for inclusion. The total number of participants across all primary studies was 28,198. Most (21, 95%) reviews and meta-analyses were rated as having a low or critically low AMSTAR-2 confidence rating. Of the 22 included systematic reviews, 13 (59%) conducted a meta-analysis and 10 (45%) conducted a narrative synthesis. Most systematic reviews with a narrative synthesis found strong evidence for a positive effect or moderate evidence for a positive effect for physical activity outcomes (7/9, 78%) and steps (3/3, 100%). The meta-meta-analysis of primary papers included in meta-analyses demonstrated a significant moderate effect for steps and a significant small effect for total PA and MVPA. The strength of effect did not vary by intervention components (activity tracker, app-based, SMS/phone, web-based, and face-to-face), population (primary or secondary prevention), control group (none, other digital intervention, or non-digital intervention), or outcome measurement (self-reported or device measured). Only 3 (14%) reviews included longer term follow up outcomes after the end of the intervention, with mixed results.
CONCLUSIONS: Evidence from 22 reviews and meta-analyses suggests that digital physical activity interventions are effective at increasing physical activity in older adults. Further primary research is needed in adults 65 years and over exclusively, and with longer-term follow up of physical activity outcomes. Future reviews should include a published protocol and interpret results according to risk-of-bias.
Síntesis amplia/ Revisión panorámica de revisiones sistemáticas
BACKGROUND: As a source of readily available evidence, rigorously synthesized and interpreted by expert clinicians and methodologists, clinical guidelines are part of an evidence-based practice toolkit, which, transformed into practice recommendations, have the potential to improve both the process of care and patient outcomes. In Brazil, the process of development and updating of the clinical guidelines for the Brazilian Unified Health System (Sistema Único de Saúde, SUS) is already well systematized by the Ministry of Health. However, the implementation process of those guidelines has not yet been discussed and well structured. Therefore, the first step of this project and the primary objective of this study was to summarize the evidence on the effectiveness of strategies used to promote clinical practice guideline implementation and dissemination.
METHODS: This overview used systematic review methodology to locate and evaluate published systematic reviews regarding strategies for clinical practice guideline implementation and adhered to the PRISMA guidelines for systematic review (PRISMA).
RESULTS: This overview identified 36 systematic reviews regarding 30 strategies targeting healthcare organizations, healthcare providers and patients to promote guideline implementation. The most reported interventions were educational materials, educational meetings, reminders, academic detailing and audit and feedback. Care pathways-single intervention, educational meeting-single intervention, organizational culture, and audit and feedback-both strategies implemented in combination with others-were strategies categorized as generally effective from the systematic reviews. In the meta-analyses, when used alone, organizational culture, educational intervention and reminders proved to be effective in promoting physicians' adherence to the guidelines. When used in conjunction with other strategies, organizational culture also proved to be effective. For patient-related outcomes, education intervention showed effective results for disease target results at a short and long term.
CONCLUSION: This overview provides a broad summary of the best evidence on guideline implementation. Even if the included literature highlights the various limitations related to the lack of standardization, the methodological quality of the studies, and especially the lack of conclusion about the superiority of one strategy over another, the summary of the results provided by this study provides information on strategies that have been most widely studied in the last few years and their effectiveness in the context in which they were applied. Therefore, this panorama can support strategy decision-making adequate for SUS and other health systems, seeking to positively impact on the appropriate use of guidelines, healthcare outcomes and the sustainability of the SUS.
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BACKGROUND: The underuse or overuse of knowledge products leads to waste in healthcare, and primary care is no exception.
OBJECTIVE: We aimed to characterize which knowledge products are frequently implemented, the implementation strategies used in primary care, and the implementation outcomes that are measured.
METHODS: We performed a systematic review of systematic reviews (SR) using the Cochrane systematic approach to include eligible SR. The inclusion criteria were: any primary care contexts; healthcare professionals and patients; any EPOC implementation strategies of specified knowledge products; any comparator; and any implementation outcomes based on the Proctor framework. We searched the Medline, EMBASE, CINAHL, Ovid PsycINFO, Web of Science, and Cochrane Library databases from their inception to October 2019, without any restriction. We searched the references of the included SR. Pairs of reviewers independently performed selection, data extraction and methodological quality assessment with AMSTAR 2. Data extraction was informed by EPOC taxonomy for implementation strategies and the Proctor framework for implementation outcomes. We performed a descriptive analysis and summarized the results using a narrative synthesis.
RESULTS: Of the 11,101 records identified, 81 SR were included. Forty-seven SR involved healthcare professionals alone. Fifteen SR were of high or moderate methodological quality. Most of them addressed one type of knowledge product (56/81), common clinical practice guidelines (26/56) or management, and behavioural or pharmacological health interventions (24/56). Mixed strategies were used for implementation (67/81), predominantly educational-based (meetings in 60/81, materials distribution in 59/81, and academic detailing in 45/81), reminder (53/81) and audit and feedback (40/81) strategies. Education meetings (P=.13) and academic detailing (P=.11) seem to be more used when the population is composed of Healthcare professionals alone. The improvement of the adoption of knowledge products was the most commonly measured outcome (72/81). The evidence level was reported in 10/81 SR on 62 outcomes (including 48 improvement of adoption), of which 16 outcomes were of moderate or high level.
CONCLUSIONS: Clinical practice guidelines and management, behavioural or pharmacological health interventions are the most commonly implemented knowledge products through the mixed use of educational, reminders and audit and feedback strategies. There is need for a strong methodology for the SR of RCTs to explore their effectiveness and the whole cascade of implementation outcomes.
CLINICALTRIAL: Not applicable.
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Poor quality diet, physical inactivity, and obesity are prevalent, covariant risk factors for chronic disease, suggesting that behavior change techniques (BCTs) that effectively change one risk factor might also improve the others. To examine that question, registered meta-review CRD42019128444 synthesized evidence from 30 meta-analyses published between 2007 and 2017 aggregating data from 409,185 participants to evaluate whether inclusion of 14 self-regulatory BCTs in health promotion interventions was associated with greater improvements in outcomes. Study populations and review quality varied, with minimal overlap among summarized studies. AMSTAR-2 ratings averaged 37.31% (SD = 16.21%; range 8.33-75%). All BCTs were examined in at least one meta-analysis; goal setting and self-monitoring were evaluated in 18 and 20 reviews, respectively. No BCT was consistently related to improved outcomes. Although results might indicate that BCTs fail to benefit diet and activity self-regulation, we suggest that a Type 3 error occurred, whereby the meta-analytic research design implemented to analyze effects of multi-component intervention trials designed for a different purpose was mismatched to the question of how BCTs affect health outcomes. An understanding of independent and interactive effects of individual BCTs on different health outcomes and populations is needed urgently to ground a cumulative science of behavior change.
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Health care providers, policy makers, and investigators are dependent upon the quality and accuracy of published research findings to inform and guide future practice and research in their field. Systematic reviews, the synthesis of outcomes across studies are increasingly more common in the family literature; however, published review reports often lack information on strategies reviewers used to insure dependability of findings, and minimize methodological bias in the review. In this article, we summarize findings from systematic reviews of interventions and outcomes from family involvement in adult chronic disease care published between 2007 and 2016. In addition, we explore procedures reviewers used to insure the quality and methodologic rigor of the review. Our discussion provides guidance and direction for future studies of family involvement in chronic disease care.
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PURPOSE: Health interventions based on theory may be more effective than those that are not. This review of reviews synthesizes all published randomized controlled trial (RCT) meta-analytic evidence from the last decade to examine whether theory-based interventions were found to be associated with more effective adult health behaviour change interventions.
METHODS: Systematic reviews including meta-analyses were identified by searching Medline, CINAHL, PsycINFO, and CDSR. A narrative synthesis was used to summarize and analyse the evidence. Only reviews including RCTs of health behaviour change interventions with adults aged 18+ published from 2007 to 2017 were included.
RESULTS: Of 8,659 articles, nine systematic reviews met inclusion criteria. The majority of reviews (n = 8) suggested no increased effectiveness for theory-based compared to non-theory-based interventions for effectiveness of outcomes relating to health behaviour. Less than half of the RCTs included in the reviews reported the use of theory (85/183). Two reviews suggested interventions based on control theory, motivational interviewing, or self-determination theory were associated with greater effectiveness for physical activity and/or dietary interventions and outcomes. Methodological and reporting issues limit the conclusions.
CONCLUSIONS: Theory-based interventions as currently operationalized in systematic reviews were not found to be more effective than non-theory-based interventions. Methodological and reporting issues at study and review level may not reflect the true utility of theory use within health behaviour interventions. The promotion of theory use may benefit from using a multifaceted argument, rather than a narrow focus of increased effectiveness. Statement of contribution What is already known on this subject? Theory use is regularly promoted by claiming that it will lead to more effective behaviour change interventions. Theory use has been frequently linked to effectiveness within systematic reviews of behaviour change interventions. The theory-effectiveness hypothesis has not been systematically examined at the systematic review level. What does this study add? Theory use as operationalized by systematic review authors was not associated with increased effectiveness within systematic reviews examining randomized controlled trials of behaviour change interventions in adults. Interventions based on control theory, motivational interviewing, or self-determination theory were associated with greater effectiveness for physical activity and/or dietary interventions and outcomes. Theory use should be promoted using a multifaceted argument, and assertions for increased effectiveness of theory-based interventions should only be used in domains where specific evidence exists to support this claim.
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Programmes that promote dietary behaviour change for the prevention of chronic disease must include components that are rooted in best practice and associated with effectiveness. The purpose of this overview of systematic reviews was to examine the characteristics and dietary behaviour change outcomes of nutrition interventions among populations with or at risk of non-communicable chronic diseases. Systematic reviews of randomised controlled trials (RCTs) testing dietary behaviour change interventions published between January 2006 and November 2015 were identified via searches in Cochrane Library, PubMed, EMBASE and PsycINFO. Quality of reviews were appraised using AMSTAR. Dietary behaviour change and intervention details were extracted and systematically summarised. Fifteen articles met the inclusion criteria. Dietary behaviour changes in response to nutrition interventions were significant in over half of interventions. Reducing dietary fat and increasing fruits and vegetables were the most common behaviour changes. The characteristics of nutrition interventions and their relationship to effectiveness for dietary behaviour change among chronic disease or at-risk populations were reported inconsistently. However, associative evidence exists to support more frequent contacts and the use of specific behaviour change techniques. No clear relationships were found between effectiveness and intervention setting, mode of delivery or intervention provider, although some population-specific relationships were identified. Interventions that promote long-term maintenance of dietary behaviour changes are lacking in the literature. This comprehensive umbrella review identifies specific characteristics of interventions that are associated with effectiveness in interventions that promote dietary behaviour change among different at-risk populations. In order to maximise outcomes, public health, health promotion and healthcare organisations should consider these results in order to inform the development and improvement of nutrition programmes.
INTRODUCCIÓN Se ha planteado que factores ambientales y relacionados con el estilo de vida pueden contribuir a la severidad y progresión de la inflamación en la artritis reumatoide. Una intervención que genera un alto interés, debido a sus supuestas propiedades antiinflamatorias es la dieta mediterránea. MÉTODOS Realizamos una búsqueda en Epistemonikos, la mayor base de datos de revisiones sistemáticas en salud, la cual es mantenida mediante el cribado de múltiples fuentes de información, incluyendo MEDLINE, EMBASE, Cochrane, entre otras. Extrajimos los datos desde las revisiones identificadas, analizamos los datos de los estudios primarios, realizamos un metanálisis y preparamos una tabla de resumen de los resultados utilizando el método GRADE. RESULTADOS Y CONCLUSIONES Identificamos siete revisiones sistemáticas que en conjunto incluyeron cuatro estudios primarios, de los cuales sólo uno corresponde a un ensayo aleatorizado. Concluimos que la dieta mediterránea podría hacer poca o nula diferencia en el dolor articular o actividad de la enfermedad, y aumentar levemente el peso en pacientes con artritis reumatoide, pero la certeza de la evidencia es baja. Por otra parte, no es posible establecer con claridad si la dieta mediterránea tiene algún efecto sobre la funcionalidad, rigidez matinal o calidad de vida, debido a que la certeza de la evidencia existente ha sido evaluada como muy baja.
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BACKGROUND: Current interventions to support medication adherence in people with type 2 diabetes are generally resource-intensive and ineffective. Brief messages, such as those delivered via short message service (SMS) systems, are increasingly used in digital health interventions to support adherence because they can be delivered on a wide scale and at low cost. The content of SMS text messages is a crucial intervention feature for promoting behavior change, but it is often unclear what the rationale is for chosen wording or any underlying mechanisms targeted for behavioral change. There is little guidance for developing and optimizing brief message content for use in mobile device-delivered interventions.
OBJECTIVE: This review aimed to (1) identify theoretical constructs (ie, the targets that interventions aim to change) and behavioral strategies (ie, features of intervention content) found to be associated with medication adherence in patients with type 2 diabetes and (2) map these onto a standard taxonomy for behavior change techniques (BCTs, that is, active ingredients of interventions used to promote behavioral change, to produce an evidence-based set of approaches that have shown promise of improving adherence in previous studies and which could be further tested in digital health interventions.
METHODS: A rapid systematic review of existing relevant systematic reviews was conducted. MEDLINE and PsycINFO databases were searched from inception to April 10, 2017. Inclusion criteria were (1) systematic reviews of quantitative data if the studies reviewed identified predictors of or correlates with medication adherence or evaluated medication adherence-enhancing interventions and included adult participants taking medication to manage a chronic physical health condition, and (2) systematic reviews of qualitative studies of experiences of medication adherence for adult participants with type 2 diabetes. Data were extracted on review characteristics and BCTs, theoretical constructs, or behavioral strategies associated with improved adherence. Constructs and strategies were mapped onto the BCT version 1 taxonomy.
RESULTS: A total of 1701 references were identified; 25 systematic reviews (19 quantitative reviews, 3 qualitative reviews, and 3 mixed-method reviews) were included. Moreover, 20 theoretical constructs (eg, self-efficacy) and 19 behavioral strategies (eg, habit analysis) were identified in the included reviews. In total, 46 BCTs were identified as being related to medication adherence in type 2 diabetes (eg, habit formation, prompts or cues, and information about health consequences).
CONCLUSIONS: We identified 46 promising BCTs related to medication adherence in type 2 diabetes on which the content of brief messages delivered through mobile devices to improve adherence could be based. By using explicit systematic review methods and linking our findings to a standardized taxonomy of BCTs, we have described a novel approach for the development of digital message content. Future brief message interventions that aim to support medication adherence could incorporate the identified BCTs.
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OBJECTIVES: Globally, healthcare policy promotes supported self-management as a strategy for people with long-term conditions. This meta-review aimed to explore how people with hypertension make sense of their condition, to assess the effectiveness of supported self-management in hypertension, and to identify effective components of support.
METHODS: From a search of eight databases (January 1993-October 2012; update June 2017) we included systematic syntheses of qualitative studies of patients' experiences, and systematic reviews of randomized controlled trials evaluating the impact of supported self-management on blood pressure and medication adherence. We used meta-ethnography, meta-Forest plots and narrative analysis to synthesise the data.
RESULTS: Six qualitative and 29 quantitative reviews provided data from 98 and 446 unique studies, respectively. Self-management support consistently reduced SBP (by between 2 and 6 mmHg), and DBP (by between 1 and 5 mmHg). Information about hypertension and treatment, home BP monitoring (HBPM) and feedback (including telehealth) were widely used in effective interventions. Patients' perceptions of a disease with multiple symptoms contrasted with the professional view of an asymptomatic condition. HBPM, in the context of a supportive patient-professional relationship, changed perceptions of the significance of symptoms and fostered confidence in ability to self-manage hypertension.
CONCLUSION: Our systematic qualitative and quantitative meta-reviews tell complementary stories. Supported self-management can improve blood pressure control. Interventions are complex and encompass a broad range of support strategies. HBPM (with or without telehealth) within the context of a supportive patient-professional partnership can bridge the gap between medical and lay perspectives of hypertension and enable effective self-management.
Physical activity is important for healthy ageing, however most older adults are inactive. Numerous reviews with a range of inclusion criteria have been conducted on digital interventions to promote physical activity in older adults, and a synthesis of these is needed. Therefore, the objective of this study is to conduct an umbrella review and meta-meta-analysis on the effectiveness of digital interventions to promote physical activity in older adults.
METHODS:
Nine databases were searched from January 2010 to December 2023. Systematic reviews and meta-analyses of primary studies using digital physical activity interventions to target healthy older adults or clinical populations of older adults with a self-reported or device measured physical activity outcome were eligible for inclusion.
RESULTS:
In total, 22 systematic reviews and meta-analyses covering 185 primary research papers were eligible for inclusion. The total number of participants across all primary studies was 28,198. Most (21, 95%) reviews and meta-analyses were rated as having a low or critically low AMSTAR-2 confidence rating. Of the 22 included systematic reviews, 13 (59%) conducted a meta-analysis and 10 (45%) conducted a narrative synthesis. Most systematic reviews with a narrative synthesis found strong evidence for a positive effect or moderate evidence for a positive effect for physical activity outcomes (7/9, 78%) and steps (3/3, 100%). The meta-meta-analysis of primary papers included in meta-analyses demonstrated a significant moderate effect for steps and a significant small effect for total PA and MVPA. The strength of effect did not vary by intervention components (activity tracker, app-based, SMS/phone, web-based, and face-to-face), population (primary or secondary prevention), control group (none, other digital intervention, or non-digital intervention), or outcome measurement (self-reported or device measured). Only 3 (14%) reviews included longer term follow up outcomes after the end of the intervention, with mixed results.
CONCLUSIONS:
Evidence from 22 reviews and meta-analyses suggests that digital physical activity interventions are effective at increasing physical activity in older adults. Further primary research is needed in adults 65 years and over exclusively, and with longer-term follow up of physical activity outcomes. Future reviews should include a published protocol and interpret results according to risk-of-bias.
