1The names and affiliations of the Task Force members are listed at www.thecommunityguide.org

A Note from the Editors

In recent years many studies have been conducted to determine the effectiveness of various approaches to

promoting physical activity in our society. The Task Force on Community Preventive Services, with technical

support from the Centers for Disease Control and Prevention, has recently analyzed the evidence from these

studies to help determine which of these approaches is effective in community settings. Because of his

involvement with the Task Force, the editors asked Dr. Greg Heath to prepare a report for the Digest based on

the studies of the Task Force. This report is included in this issue of the Digest. The report refers to

interventions, a public health term, for approaches or programs designed to promote physical activity. It is our

hope that readers of this issue of the Digest will develop a clearer understanding of the effectiveness of various

strategies (interventions) in promoting physical activity in our communities.

Introduction

Physical inactivity is a leading contributor to morbidity and disability,

accounting for 22% of coronary heart disease, 22% of colon cancer, 18% of

osteoporotic fractures, 12% of diabetes and hypertension, and 5% of breast

cancer (Colditz, 1999). Physical inactivity accounts for about 2.4% of U. S.

health care or approximately $24 billion a year (Colditz, 1999). In the United

States, most people do not achieve the recommended amounts of physical

activity (Centers for Disease Control and Prevention, 2003). Communities can

do much to increase levels of physical activity among people of all ages and

thereby address this serious public health problem. 

Recommendations to increase physical activity have been made for

individuals and clinical settings, but not for community settings. Increased

physical activity has been linked not only to behavioral and social correlates,

but physical and social environmental correlates as well. Therefore, the role of

community-based interventions to promote physical activity has emerged as a

critical piece of an overall strategy to increase physical activity behaviors

among the people of the United States. In 1995, the American College of

Sports Medicine and the Centers for Disease Control and Prevention (CDC)

recommended that every adult in the United States accumulate 30 minutes or

more of moderate-intensity physical activity on most, preferably all, days of

the week (Pate, 1995). That same year, the U.S. Preventive Services Task

Force recommended that healthcare providers counsel all patients on the

importance of incorporating physical activity into their daily routines (U.S.

Preventive Services Task Force, 1996). To date, community-based

Series 4, No. 4 Dec. 2003

Increasing Physical Activity in Communities: What Really Works?

Task Force on Community Preventive Services1

Published quarterly by the

President’s Council on

Physical Fitness and Sports

Washington, D.C.

★

Guest Author:

Gregory W. Heath, DHSc, MPH,

Division of Nutrition

and Physical Activity,

Centers for Disease Control and

Prevention

★

Co-edited by:

Drs. Charles B. Corbin and

Robert P. Pangrazi,

Arizona State University, and

Dr. Don Franks, 

University of Maryland

President’s Council on Physical Fitness and Sports

ResearchDi est
interventions to increase physical activity have not been

summarized in an evidence-based process.

The recommendations in this report represent the work

of the independent, nonfederal Task Force on

Community Preventive Services (the Task Force). The

Task Force is developing the Guide to Community

Preventive Services (the Community Guide) with the

support of the U.S. Department of Health and Human

Services (DHHS) in collaboration with public and

private partners. The CDC provides staff support to the

Task Force for development of the Community Guide.

Task Force recommendations are based primarily on

the effectiveness of interventions as determined by a

systematic literature review process and are a

compendium of tested interventions that promote

physical activity at the community level. They can be

used for planning interventions to promote physical

activity or to evaluate existing programs, including

creation of or enhanced access to places for physical

activity combined with informational outreach

activities, community-wide campaigns, social support

interventions in community settings, “point-ofdecision” prompts to encourage use of stairs as an

alternative to elevators or escalators, school-based PE,

and individually adapted health behavior change

programs. The Task Force believes that recommended

and strongly recommended interventions can be used to

address objectives set out in Healthy People 2010 (U.S.

Department of Health and Human Services, 2000). 

Intervention Recommendations

The Task Force evaluated the evidence of effectiveness

of 11 selected types of interventions (see Table 1) that

were grouped into three larger strategies for increasing

physical activity: informational approaches, behavioral

and social approaches, and environmental and policy

approaches. Detailed findings from this evaluation

appear in the work of Kahn et al. in 2002. Evaluations

of additional interventions, including the effectiveness

of urban form (design) and land-use planning

approaches and changes to transportation and travel

infrastructure and policy, are still in progress. 

Informational Approaches 

Informational approaches focus on increasing physical

activity by providing information that will motivate and

enable people to change behavior and to maintain that

change over time. The focus is primarily on the

cognitive skills that are thought to precede behavior.

The interventions primarily use educational approaches

to present both general information, including

2

Table 1.

Task Force for Community Preventive Services:

Physical Activity Intervention Recommendations

The Task Force strongly recommends:

• Community-wide campaigns: These largescale, highly visible, multicomponent campaigns 

direct their messages to large audiences using a 

variety of approaches, including television, radio,

newspapers, movie theaters, billboards, and 

mailings. 

• Individually adapted health behavior change 

programs: These programs are tailored to a 

person’s specific interests or readiness to make a 

change in physical activity habits. Teaching 

behavioral skills such as goal setting, building 

social support, self-rewards, problem solving,

and relapse prevention, the programs help people

learn to incorporate physical activity into their 

daily routines.

• School-based physical education (PE): This 

approach seeks to modify school curricula and 

policies, to increase the amount of time students 

spend in moderate to vigorous activity while in 

PE class. Schools can accomplish this either by 

increasing the amount of time spent in PE class 

or by increasing students’ activity levels during 

PE classes. 

• Social support interventions in community 

contexts: The goal of this approach is to increase

physical activity by creating or strengthening 

social networks. Examples include exercise 

buddies, exercise contracts, and walking groups.

• Creating or improving access to places for 

physical activity combined with informational 

outreach: Examples include building walking or 

biking trails or making it possible for people to 

use exercise facilities in community centers or in 

the workplace. Informational outreach includes 

activities such as providing training on 

equipment, seminars, counseling, risk screening,

and health forums and workshops.

The Task Force recommends:

• Point-of-decision prompts to encourage stair 

use: These signs are placed by elevators and 

escalators and encourage people to use nearby 

stairs instead.
3

information about cardiovascular disease prevention

and risk reduction, and specific information about

physical activity and exercise. These programs were

originally developed to complement a medical model

of disease management by involving communities in

understanding the cognitive antecedents of behavior.

Information is intended to change knowledge about the

benefits of physical activity, increase awareness of

opportunities for increasing physical activity, explain

methods for overcoming barriers and negative attitudes

about physical activity, and increase physical activity

behaviors among community members. Interventions

reviewed here are “point-of-decision” prompts to

encourage use of stairs as an alternative to elevators or

escalators, community-wide campaigns, mass media

campaigns, and classroom-based health education

focused on information provision and skills related to

decision making.

“Point-of-decision” prompts: Recommended

Point-of-decision prompts are motivational signs placed

by elevators and escalators to encourage people to use

nearby stairs for health benefits or weight loss. For

people who want to increase their level of physical

activity these prompts serve as a reminder to take the

stairs and offer information about a health benefit from

using the stairs. All interventions evaluated in this

category were single component interventions, in

which the placement of signs was the only intervention

activity. 

Point-of-decision prompts are recommended on the

basis that they increase the number of people using

stairs rather than escalators or elevators. This

intervention has been shown to be effective in a range

of settings and a variety of population subgroups. No

harms or other potential benefits were reported and no

qualifying economic information was identified from

the literature. 

Community-wide campaigns: Strongly

Recommended

Community-wide campaigns are sustained efforts with

ongoing high visibility. These are large-scale

campaigns that deliver messages promoting physical

activity using television, radio, newspaper columns and

inserts, and trailers in movie theaters. They use many

components and include individually focused efforts

such as support and self-help groups; physical activity

counseling; risk factor screening and education at

worksites, schools, and community health fairs; and

environmental activities such as community events and

the creation of walking trails. Community-wide

education is strongly recommended on the basis of its

effectiveness in increasing physical activity and

improving physical fitness among adults and children.

Other positive effects include increases in knowledge

about exercise and physical activity, and in intentions to

be physically active. No harms were reported and no

qualifying economic information was identified from

the literature.

Mass media campaigns: Insufficient Evidence

Mass media campaigns, designed to increase

knowledge, influence attitudes and beliefs, and change

behavior, address messages about physical activity to

large and relatively undifferentiated audiences.

Messages about benefits and opportunities for physical

activity are transmitted using such media as

newspapers, radio, television, and billboards, singly or

in combination. Mass media campaigns include paid

advertisements, donated time and space for promotions,

and news or lifestyle features. These interventions

differ from community-wide education in that they do

not include other components such as support groups,

risk factor screening and education, or community

events.

The Task Force identified three qualifying studies that

evaluated the effect of mass media campaigns. The

studies identified in our search are over 10 years old;

however, research is currently being conducted on the

effects of mass media campaigns on physical activity.

On the basis of the small number of available studies

and variability in the interventions evaluated,

insufficient evidence was found to assess the

effectiveness of single component mass media

campaigns.

Classroom-based health education focused on

information provision: Insufficient Evidence

Health education classes that provide information and

skills related to decision making are usually

multicomponent, with curriculum typically addressing

physical inactivity, nutrition, tobacco use, and alcohol

and drug misuse. Health education classes, taught in

elementary, middle, or high school, are designed to

effect behavior change through personal and behavioral

factors that provide children or adolescents with the

skills they need for rational decision making. The

classes in this review did not include physical

education (PE) but sometimes included behavioral

instruction. (For recommendations on classes involving

PE, see School-based PE, below.)
4

The Task Force identified six qualifying studies that

evaluated the effect of classroom-based health

education on students’ physical activity levels and

physical fitness. Because results were inconsistent

across the body of evidence, insufficient evidence

exists to make a conclusion about the effectiveness of

classroom-based health education focused on

information provision in improving physical activity

levels and physical fitness. It is important to note,

however, that such classes may provide other benefits,

including increased knowledge, more supportive

attitudes for physical activity initiatives, or changes in

other health-related behaviors. 

Behavioral and Social Approaches 

Behavioral and social approaches focus on increasing

physical activity by teaching widely applicable

behavioral management skills and by structuring the

social environment in ways that provide support for

people trying to initiate or maintain behavior changes.

Behavioral and social approaches were combined

because these interventions often involve group

behavioral counseling, and may also involve the friends

or family members that constitute the individual’s

social environment. Skills focus on recognizing cues

and opportunities for physical activity, ways to manage

high-risk situations, and ways to maintain desired

behaviors and prevent relapse. These interventions also

involve making changes in the home, family, school,

and work environments.

Interventions reviewed here are school-based PE,

college-based health education and PE, classroombased health education focusing on reducing television

viewing and video game playing, family-based social

support interventions, social support interventions in

community settings, and individually adapted health

behavior change programs.

School-based PE: Strongly Recommended

These interventions involve modifying curricula and

policies to increase the amount of time students spend

in moderate to vigorous activity while in PE classes.

Increasing the amount of time students are active can

be achieved either by increasing the amount of time

spent in PE class or increasing the amount of time

students are active during already-scheduled PE

classes. Interventions in this review included changing

the activities taught (e.g., substituting soccer for

softball) and modifying the rules of the game so that

students are more active (e.g., having the entire team

run the bases together when the batter makes a base

hit). School-based PE is strongly recommended based

on its effectiveness in increasing physical activity and

improving physical fitness among adolescents and

children. Other positive effects associated with schoolbased PE are increases in physical activity knowledge

and increases in muscular endurance. One potential

harm suggested in the literature is that PE classes could

take away from the time that schools can devote to

academic subjects, thereby harming academic

performance. Examination of these studies and a

systematic search for other studies of the effects of PE

on academic performance found no evidence of this

harm. No qualifying economic information was

identified from the literature.

College-based health education and PE: Insufficient

Evidence 

These interventions use didactic and behavioral

education efforts to increase physical activity levels

among college students with the aim of setting longterm behavioral patterns during the transition to

adulthood. The PE classes do not have to be offered by

PE or wellness departments in college and university

settings, but do include supervised activity in the class.

These classes have both lectures and laboratory-type

sessions; students engage in supervised physical

activity, develop goals and activity plans, and write

term papers based on their experiences. Social support

is also built into these programs. 

The Task Force identified two qualifying studies that

evaluated the effectiveness of college-based health

education and PE. Based on both the small number of

available studies and variability in the interventions

evaluated, insufficient evidence exists to assess the

effectiveness of college-based health education and PE

interventions.

Classroom-based health education focusing on

reducing television viewing and video game playing:

Insufficient Evidence 

In these interventions, health education classes taught

in elementary school classrooms as part of a general

health curriculum by regular classroom teachers

specifically emphasize decreasing the amount of time

spent watching television and playing video games.

Lessons include behavioral management strategies such

as self-monitoring of viewing behavior, limiting access

to television and video games, and budgeting time for

television and video. All studies reviewed included a

“TV turnoff challenge” in which students were

encouraged not to watch television for a specified
number of days. Alternative activities that required

greater energy expenditure were not specifically

recommended. Parental involvement was a prominent

part of the intervention, and all households were given

automatic television use monitors.

The Task Force identified three qualifying studies that

evaluated the effectiveness of these interventions.

Although the studies showed decreases in the amount

of time spent in television viewing and other sedentary

behaviors, and found reductions in adiposity, they did

not provide consistent evidence for increased physical

activity. Based on the small number of available

studies, the variability in the interventions evaluated,

and the lack of information specifically linking these

programs to increases in PA, insufficient evidence

exists to assess the effectiveness of classroom-based

health education focused on reducing television

viewing and video game playing in increasing physical

activity.

Family-based social support: Insufficient Evidence 

These interventions attempt to change health behavior

through strategies that increase the support of family

members for behavioral change. The intent is to create

and facilitate behavioral patterns, social interactions,

and family norms that support greater levels of physical

activity. These interventions target environmental

factors and interpersonal and behavioral patterns.

Typical elements include setting up behavioral

“contracts” between family members as well as goalsetting, problem-solving, and other family behavioral

management techniques. Interventions may be targeted

to families with children or to couples without children.

Programs typically include educational sessions on

health, goal-setting, and problem-solving; family

behavioral management; or both educational sessions

and behavioral management. The programs may also

incorporate some physical activities. Interventions

directed toward children and their families are often

implemented as part of a more comprehensive

approach that includes school-based interventions, such

as school-based PE or classroom-based health

education. In these instances, the family component is

often seen as an adjunct to the school activities,

involving take-home packets, reward systems, and

family recordkeeping. These interventions may also

include family-oriented special events.

The Task Force identified eleven qualifying studies that

evaluated the effect of family-based social support

programs on physical activity levels and physical

fitness. Because results across the body of evidence

were inconsistent, the Task Force could not reach a

conclusion about the effectiveness of these programs in

improving physical activity levels and physical fitness. 

Social support interventions in community settings:

Strongly Recommended

These interventions focus on changing physical activity

behavior through building, strengthening, and

maintaining social networks that provide supportive

relationships for behavior change, specifically physical

activity. This can be done either by creating new social

networks or working within pre-existing networks in a

social setting outside the family, such as the workplace.

Interventions typically involved setting up a “buddy”

system, making “contracts” with others to complete

specified levels of physical activity, or setting up

walking or other groups to provide friendship and

support. These programs are strongly recommended

based on their effectiveness in increasing physical

activity (specifically the time spent exercising and

frequency of exercise) and improving physical fitness

among adults. Other positive effects include increases

in muscular strength and flexibility and decreases in

adiposity. No harms were reported and no qualifying

economic information was identified from the

literature. 

Individually adapted health behavior change

programs: Strongly Recommended

Individually adapted health behavior change programs

are tailored to the individual’s specific interests,

preferences, and readiness for change. These programs

teach participants the behavioral skills needed to

incorporate moderate-intensity physical activity into

daily routines. Behaviors may be planned (e.g., a daily

scheduled walk) or unplanned (e.g., using the stairs

when the opportunity arises). Many of these

interventions use constructs from one or more

established health behavior change models (e.g., Social

Cognitive Theory [Bandura, 1986], the Health Belief

Model [Rosenstock, 1990], or the Transtheoretical

Model of Change [Prochaska & DiClemente, 1984]).

All programs reviewed incorporated the following set

of skills: (1) setting goals for physical activity and selfmonitoring of progress toward goals; (2) building social

support for new behavioral patterns; (3) behavioral

reinforcement through self-reward and positive selftalk; (4) structured problem-solving geared to

maintaining the behavior change; and (5) prevention of

relapse into sedentary behaviors. All of the

interventions evaluated were delivered either in group

settings or by mail, telephone, or directed media.

5
activity. Access to places for physical activity can be

created or enhanced both by building trails or facilities

and by reducing barriers (e.g., reducing fees or

changing operating hours of facilities). Many of these

programs also provide training in use of equipment,

other health education activities, and incentives such as

risk factor screening and counseling. Several programs

reviewed were conducted at worksites. These

interventions are strongly recommended based on their

effectiveness in increasing physical activity and

improving physical fitness among adults. Other positive

effects include decreases in adiposity. No harms were

reported and no qualifying economic information was

identified from the literature. 

Interpreting and Using the Recommendations

Choosing interventions that are well-matched to local

needs and capabilities, and then carefully implementing

those interventions, are vital steps for increasing

physical activity at the community level. In setting

priorities for the selection of interventions to meet local

objectives, recommendations and other evidence

provided in the Community Guide should be considered

along with such local information as resource

availability, administrative structures and policies, and

economic and social environments of organizations and

practitioners. Taking into consideration local goals and

resources, the use of strongly recommended and

recommended interventions should be given priority for

implementation. A finding of insufficient evidence of

effectiveness should not be seen as evidence of

ineffectiveness, but rather reflects the fact that the

systematic review did not identify enough information

for the Task Force to make a recommendation. 

Although many of the recommended or strongly

recommended interventions had small to moderate

behavior change scores, readers should keep in mind

that the interventions were targeted at populations of

people rather than individuals and that such small

changes occurring among populations can amount to

significant changes in terms of public health. In

addition, the largest public health benefit of physical

activity interventions is a result of increased activity

among sedentary populations, rather than increased

activity among already-active people. Therefore, the

interventions, if widely implemented, could create

significant public health benefits.

6

Individually adapted health behavior change programs

are strongly recommended based on their effectiveness

in increasing physical activity and improving physical

fitness among adults and children. Other positive

effects include decreases in weight and percentage of

body fat and increases in flexibility, strength, and

cognitive effects related to physical activity. No harms

were reported and no qualifying economic information

was identified from the literature.

Environmental and Policy Approaches 

Environmental and policy approaches are designed to

help people adopt healthier behaviors. The creation of

healthful physical and organizational environments is

attempted through development of public policy that

supports healthy practices, creation of supportive

environments, and strengthening of community action.

Correlational studies have shown that the availability of

exercise equipment in the home and the proximity and

density of places for physical activity within

neighborhoods are associated with physical activity

levels. Other neighborhood and environmental

characteristics such as safety lighting, weather, and air

pollution also affect physical activity levels, regardless

of individual motivation and knowledge. 

Interventions in this category are not aimed at

individuals but rather affect entire populations by

targeting physical and organizational structures. They

are implemented and evaluated over a longer period of

time than more individually oriented interventions.

Interventions are conducted by traditional health

professionals, but also involve many sectors that have

not previously been associated with public health, such

as community agencies and organizations, legislators,

departments of transportation and planning, and the

media. The goal is to create changes in social networks,

organizational norms and policies, the physical

environment, and laws. In addition to the intervention

discussed here, reviews of two other interventions are

underway: (1) urban form (design) and land-use

planning strategies that lead to increased physical

activity and (2) changes to transportation and travel

policy and infrastructure that reduce dependence on

motorized transport and increase physical activity.

Creation of or enhanced access to places for

physical activity combined with informational

outreach activities: Strongly Recommended

These interventions attempt to change the local

environment to create opportunities for physical
7

Please Post

President’s Council on Physical Fitness & Sports

200 Independence Avenue, S.W., Washington, DC 20201

(202) 690-9000 • FAX (202) 690-5211

“....the largest public health benefit

of physical activity interventions is

a result of increased activity among

sedentary populations, rather than

increased activity among already-active

people. Therefore, the interventions, if

widely implemented, could create

significant public health benefits.”

Gregory W. Heath, DHSc, MPH,

Division of Nutrition

and Physical Activity,

Centers for Disease Control

and Prevention
8

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Kahn, E., et al. (2002). The effectiveness of

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