ABSTRACT

OBJECTIVE

To summarize the main evidence from educational interventions designed to increase levels of physical activity (PA) among Brazilian adults.

METHODS

Systematic review of intervention studies carried out in Brazil that implemented educational components aimed at promoting increased levels of PA among adult populations (18 to 65 years old). In October 2020, systematic searches were conducted in six databases, and in the reference lists of the assessed studies.

RESULTS

Of the initial 2,511 studies, nine were included in the synthesis. Samples with specific characteristics (such as social vulnerability, physical inactivity, and overweight or obesity) were observed, with a greater number of women. Five interventions (55.6%) occurred in primary healthcare settings (PHC) of the Brazilian Unified Health System (SUS). Only four studies (44.4%) described the pedagogical frameworks structuring the educational approaches, among which counseling was the most used strategy, such as those carried out through face-to-face meetings, home visits, lectures, and phone calls (n = 8; 88.9%). Positive results were observed in three different indicators: increase in weekly PA volume (n = 4); increase in leisure-time PA rate (n = 1); and increase in the proportion of women classified as “very active/active” (n = 1). Given the sampling specificities, the domain “participant selection” showed a high number of interventions with high risk of bias.

CONCLUSIONS

Educational approaches engendered some positive effects on different PA indicators, notably counseling as the main strategy used and approaches involving other health themes, such as nutrition and stress. However, considering the several determinants of PA in Brazil, future interventions should be conducted in different locations of Brazil in order to evaluate, in a broader way, their implementation processes and articulation with the many professionals working in PHC.

Adult; Exercise; Health Education; Health Promotion; Systematic Review

INTRODUCTION

Due to the multidimensional impacts it has on an individual’s life, physical activity (PA) has been identified as an important factor for human development¹1. Programa das Nações Unidas para o Desenvolvimento. Movimento é Vida: Atividades Físicas e Esportivas para Todas as Pessoas: Relatório Nacional de Desenvolvimento Humano do Brasil 2017. Brasília, DF: PNUD; 2017 [cited 2020 Oct 10]. Available from: https://www.undp.org/content/dam/brazil/docs/publicacoes/relatorio-nacional-desenvolvimento-humano-2017.pdf
https://www.undp.org/content/dam/brazil/... . More specifically, PA is recognized to be a determinant of several positive health indicators²2. Warburton DER, Bredin SSD. Health benefits of physical activity: a systematic review of current systematic reviews. Curr Opin Cardiol. 2017;32(5):541-56. https://doi.org/10.1097/HCO.0000000000000437
https://doi.org/10.1097/HCO.000000000000... , so that actions and policies for its promotion at the population level and throughout the life cycle have been advocated by several health agencies around the world³3. World Health Organization. Global action plan on physical activity 2018–2030: more active people for a healthier world. Geneva (CH): WHO; 2018 [cited 2020 Oct 10]. Available from: https://apps.who.int/iris/bitstream/handle/10665/272722/9789241514187-eng.pdf?ua=1
https://apps.who.int/iris/bitstream/hand... ,⁴4. Klepac Pogrmilovic B, Ramirez Varela A, Pratt M, Milton K, Bauman A, Biddle SJH, et al. National physical activity and sedentary behaviour policies in 76 countries: availability, comprehensiveness, implementation, and effectiveness. Int J Behav Nutr Phys Act. 2020;17:116. https://doi.org/10.1186/s12966-020-01022-6
https://doi.org/10.1186/s12966-020-01022... .

In the last decades, PA promotion has deserved much attention in the Brazilian public health agenda, especially for its introduction in the Brazilian Health System (in Portuguese: Sistema Único de Saúde - SUS) and in several national public policies⁵5. Loch MR, Knuth AG, Silva ICM, Guerra PH. As práticas corporais/atividade física nos 30 anos do Sistema Único de Saúde. Cienc Saude Coletiva. 2018;23(10):3469. https://doi.org/10.1590/1413-812320182310.19102018
https://doi.org/10.1590/1413-81232018231... . However, despite this favorable institutional scenario, “promoting PA” is not a simple task in Brazil, since factors such as gender, income, education, and environment⁶6. Silva ICM, Mielke GI, Bertoldi AD, Arrais PSD, Luiza VL, Mengue SS, et al. Overall and Leisure-Time Physical Activity Among Brazilian Adults: national survey based on the Global Physical Activity Questionnaire. J Phys Act Health. 2018;15(3):212-8. https://doi.org/10.1123/jpah.2017-0262
https://doi.org/10.1123/jpah.2017-0262... are determinants of its practice.

Primary healthcare (PHC) settings are, thus, potential settings for the implementation of strategies⁹9. Sanchez A, Bully P, Martinez C, Grandes G. Effectiveness of physical activity promotion interventions in primary care: a review of reviews. Prev Med. 2015;76 Suppl:S56-67. https://doi.org/10.1016/j.ypmed.2014.09.012
https://doi.org/10.1016/j.ypmed.2014.09.... ,¹⁰10. Garrett S, Elley CR, Rose SB, O’Dea D, Lawton BA, Dowell AC. Are physical activity interventions in primary care and the community cost-effective? A systematic review of the evidence. Br J Gen Pract. 2011;61(584):e125-33. https://doi.org/10.3399/bjgp11X561249
https://doi.org/10.3399/bjgp11X561249... to reduce inequities in access to PA. In the SUS context is can potentially increase the completeness and resoluteness of healthcare, enhancing the ability to promote PA in contexts of different levels of social vulnerability¹¹11. Guerra PH, Ribeiro EHC, Rodrigues TL, Andrade DR, Loch MR. Effects of community-based interventions on physical activity levels: systematic review. Rev Bras Ativ Fis Saude. 2020;25:e0130. https://doi.org/10.12820/rbafs.25e0130
https://doi.org/10.12820/rbafs.25e0130... ,¹²12. Costa EF, Guerra PH, Santos TI, Florindo AA. Systematic review of physical activity promotion by community health workers. Prev Med. 2015;81:114-21. https://doi.org/10.1016/j.ypmed.2015.08.007
https://doi.org/10.1016/j.ypmed.2015.08.... .

Literature also suggests that interventions based on educational processes¹³13. Heath GW, Parra DC, Sarmiento OL, Andersen LB, Owen N, Goenka S, et al. Evidence-based intervention in physical activity: lessons from around the world. Lancet. 2012;380(9838):272-81. https://doi.org/10.1016/S0140-6736(12)60816-2
https://doi.org/10.1016/S0140-6736(12)60... entail favorable results to increase PA levels at different moments of life. This evidence, however, is mainly supported by data from interventions developed in high-income countries. Even with the existence of a systematic review of interventions in Latin American countries¹⁴14. Hoehner CM, Ribeiro IC, Parra DC, Reis RS, Azevedo MR, Hino AA, et al. Physical activity interventions in Latin America: expanding and classifying the evidence. Am J Prev Med. 2013;44(3):e31-40. https://doi.org/10.1016/j.amepre.2012.10.026
https://doi.org/10.1016/j.amepre.2012.10... , the relevance of a more specific synthesis of the Brazilian studies is justified, as it would enable a debate grounded in the Brazilian reality, besides pointing out possible advances toward future national surveys.

This study aims at summarizing the main evidence of educational interventions designed to increase the PA levels of Brazilian adults.

METHODS

This study is characterized as a systematic literature review, with methodology and operational process based on “The Cochrane Handbook for Systematic Reviews of Interventions”¹⁵15. Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, et al., editors. Cochrane handbook for systematic reviews of interventions. 2. ed. Chichester (UK): John Wiley & Sons; 2019., and on the items of the “Preferred Reporting Items for Systematic Reviews and Meta-Analyses” (PRISMA)¹⁶16. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JP, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med. 2009;6(7):e1000100. https://doi.org/10.1371/journal.pmed.1000100
https://doi.org/10.1371/journal.pmed.100... list, respectively. This review is part of a larger project named “Translation of evidence for decision making in the Brazilian public health system: a review of interventions aiming physical activity promotion”, registered in the PROSPERO database (CRD42015015993).

The inclusion criteria were designed based on the “PICOS” logic, considering that the synthesis would be made up of original scientific studies with the following characteristics: (I) Participants: adult populations, without disabilities, health conditions, or specific diseases, except for samples exclusively composed of participants with overweight or obesity; (II) Interventions: developed in Brazil, implemented in community settings (such as territories, PHC centers, outpatient clinics, and community organizations) and based on educational actions aimed to increase PA levels, regardless of the form of contact (face-to-face or remote meetings) and approach (individual or group); (III) Comparators: no restrictions were imposed regarding the activities performed by the control groups (if there were more than one control group, it was decided that the group that had received the least theoretical and/or practical content would be chosen); (IV) Outcome: PA levels, regardless of the PA indicators used (such as levels of moderate or vigorous PA, and number of steps a day), contexts observed (such as total PA, leisure time displacement time), and the instruments used to measure these (such as questionnaires and motion sensors); and (V) Study design: all types of intervention studies (“trials”), with no restrictions regarding the presences of randomization between groups and/or control group.

To retrieve the potential studies, we conducted: systematic searches in six electronic databases (Lilacs, Pubmed, Physical Education Index, Scielo, Scopus, and Web of Science) covering the available literature from the beginning until October 5, 2020, based on the strategy developed for Pubmed: (“physical activity”[Text Word] OR “exercise”[Text Word] OR “sport”[Text Word] OR “walk”[Text Word] OR “walking”[Text Word] OR “run”[Text Word] OR “running”[Text Word] OR “bike”[Text Word] OR “cyclying”[Text Word]) AND “Brazil”[Text Word] AND (“experimental study”[Text Word] OR “randomised controlled trial”[Text Word] OR “randomized controlled trial”[Text Word] OR “quasi-experimental”[Text Word] OR “clinical trial”[Text Word]). In addition to this strategy, manual searches were performed in the reference lists of the studies assessed by its full-texts.

The titles, abstracts and full texts assessments were performed independently by six researchers (AM, HF, GC, IC, JF and WW), supported by a senior researcher to clarify doubts, and establish consensus (PG). Data extraction was also conducted by the same six researchers, also independently, and supported by two senior researchers (ER and PG), on a spreadsheet initially divided into three domains: (I) descriptive features (such as intervention name/acronym, location, population description, and age/age group); (II) methods (such as recruitment and implementation location, group size at baseline and sample losses, description and strategies used in the intervention and control groups, intervention implementation team, and instruments and procedures used for measuring PA); and (III) PA-related outcomes (such as variables analyzed, procedures used for PA data analysis, and statistical magnitude and significance of findings based on “p-value”). Regarding the outcomes of interventions, effect sizes were considered for synthesis, as well as the results of the statistical comparison tests.

The risk of bias of the included studies was assessed by two researchers (ER and PG) using an adapted version of the EPHPP¹⁷17. Thomas BH, Ciliska D, Dobbins M, Micucci S. A process for systematically reviewing the literature: providing the research evidence for public health nursing interventions. Worldviews Evid Based Nurs. 2004;1(3):176-84. https://doi.org/10.1111/j.1524-475X.2004.04006.x
https://doi.org/10.1111/j.1524-475X.2004... instrument, which assesses seven methodological domains of an intervention study: “selection bias”, “adjustment of confounding variables”, “methods used in data collection”, “losses and dropouts”, “intervention integrity”, “protocol used in the analysis”, and “use of intention to treat”.

RESULTS

The electronic database searches resulted in 2,511 potentially relevant studies, of which 165 were initially identified as duplicates and thus excluded from the process (Figure 1). At the end of the evaluation by titles and abstracts, 110 studies were selected for reading of their full texts. Considering the exclusion of 102 of these, mainly due to “age group” (n = 36) and “study design” (n = 29), and the inclusion of one study retrieved by manual search on reference lists, the descriptive synthesis of the current review was composed from data of nine intervention studies conducted in Brazil¹⁸18. Assunção MCF, Gigante DP, Cardoso MA, Sartorelli DS, Santos IS. Randomized, controlled trial promotes physical activity and reduces consumption of sweets and sodium among overweight and obese adults. Nutr Res. 2010;30(8):541-9. https://doi.org/10.1016/j.nutres.2010.07.006
https://doi.org/10.1016/j.nutres.2010.07... .

In Table 1, it can be observed that interventions were conducted in six Brazilian cities from five states, covering the Southeast (n = 6)¹⁹19. Baba CT, Oliveira IM, Silva AEF, Vieira LM, Cerri NC, Florindo AA, et al. Evaluating the impact of a walking program in a disadvantaged area: using the RE-AIM framework by mixed methods. BMC Public Health. 2017;17:709. https://doi.org/10.1186/s12889-017-4698-5
https://doi.org/10.1186/s12889-017-4698-... ,²⁰20. Chaves EC, Oyama SM. Abordagem telefônica como estratégia para promoção da saúde. Rev Gaucha Enferm. 2007;28(2):171-9.,²²22. Costa EF, Andrade DR, Garcia LM, Ribeiro EH, Santos TI, Florindo AA. Avaliação da efetividade da promoção da atividade física por agentes comunitários de saúde em visitas domiciliares. Cad Saude Publica. 2015;31(10):2185-98. https://doi.org/10.1590/0102-311X00106014
https://doi.org/10.1590/0102-311X0010601... ,²³23. Ferreira M, Matsudo S, Matsudo V, Braggion G. Effects of an intervention program of physical activity and nutrition orientation on the physical activity level of physically active women aged 50 to 72 years old. Rev Bras Med Esporte. 2005;11(3):172-6. https://doi.org/10.1590/S1517-86922005000300004
https://doi.org/10.1590/S1517-8692200500... ,²⁵25. Meurer ST, Lopes ACS, Almeida FA, Mendonça RD, Benedetti TRB. Effectiveness of the VAMOS strategy for increasing physical activity and healthy dietary habits: a randomized controlled community trial. Health Educ Behav. 2019;46(3):406-16. https://doi.org/10.1177/1090198118820095
https://doi.org/10.1177/1090198118820095... ,²⁶26. Ribeiro EHC, Garcia LMT, Salvador EP, Costa EF, Andrade DR, Latorre MDRDO, et al. Assessment of the effectiveness of physical activity interventions in the Brazilian Unified Health System. Rev Saude Publica. 2017;51:56. https://doi.org/10.1590/s1518-8787.2017051006654
https://doi.org/10.1590/s1518-8787.20170... , South (n = 2)¹⁸18. Assunção MCF, Gigante DP, Cardoso MA, Sartorelli DS, Santos IS. Randomized, controlled trial promotes physical activity and reduces consumption of sweets and sodium among overweight and obese adults. Nutr Res. 2010;30(8):541-9. https://doi.org/10.1016/j.nutres.2010.07.006
https://doi.org/10.1016/j.nutres.2010.07... ,²⁴24. Gomes MA, Duarte MFS. Efetividade de uma intervenção de atividade física em adultos atendidos pela Estratégia Saúde da Família: Programa Ação e Saúde Floripa – Brasil. Rev Bras Ativ Fis Saude. 2008;13(1):44-56. https://doi.org/10.12820/rbafs.v.13n1p44-56
https://doi.org/10.12820/rbafs.v.13n1p44... and Northeast (n = 1)²¹21. Costa PRF, Assis AMO, Silva MCM, Santana MLP, Dias JC, Pinheiro SMC, et al. Mudança nos parâmetros antropométricos: a influência de um programa de intervenção nutricional e exercício físico em mulheres adultas. Cad Saude Publica. 2009;25(8):1763-73. https://doi.org/10.1590/S0102-311X2009000800012
https://doi.org/10.1590/S0102-311X200900... regions, most of them conducted in cities of São Paulo state (n = 5–55.6%)¹⁹19. Baba CT, Oliveira IM, Silva AEF, Vieira LM, Cerri NC, Florindo AA, et al. Evaluating the impact of a walking program in a disadvantaged area: using the RE-AIM framework by mixed methods. BMC Public Health. 2017;17:709. https://doi.org/10.1186/s12889-017-4698-5
https://doi.org/10.1186/s12889-017-4698-... ,²⁰20. Chaves EC, Oyama SM. Abordagem telefônica como estratégia para promoção da saúde. Rev Gaucha Enferm. 2007;28(2):171-9.,²²22. Costa EF, Andrade DR, Garcia LM, Ribeiro EH, Santos TI, Florindo AA. Avaliação da efetividade da promoção da atividade física por agentes comunitários de saúde em visitas domiciliares. Cad Saude Publica. 2015;31(10):2185-98. https://doi.org/10.1590/0102-311X00106014
https://doi.org/10.1590/0102-311X0010601... ,²³23. Ferreira M, Matsudo S, Matsudo V, Braggion G. Effects of an intervention program of physical activity and nutrition orientation on the physical activity level of physically active women aged 50 to 72 years old. Rev Bras Med Esporte. 2005;11(3):172-6. https://doi.org/10.1590/S1517-86922005000300004
https://doi.org/10.1590/S1517-8692200500... ,²⁶26. Ribeiro EHC, Garcia LMT, Salvador EP, Costa EF, Andrade DR, Latorre MDRDO, et al. Assessment of the effectiveness of physical activity interventions in the Brazilian Unified Health System. Rev Saude Publica. 2017;51:56. https://doi.org/10.1590/s1518-8787.2017051006654
https://doi.org/10.1590/s1518-8787.20170... . Most of the interventions involved populations with mean age of 40 years (n = 6–66.7%)¹⁸18. Assunção MCF, Gigante DP, Cardoso MA, Sartorelli DS, Santos IS. Randomized, controlled trial promotes physical activity and reduces consumption of sweets and sodium among overweight and obese adults. Nutr Res. 2010;30(8):541-9. https://doi.org/10.1016/j.nutres.2010.07.006
https://doi.org/10.1016/j.nutres.2010.07... , and women as the majority in all samples with available data (n = 8–88.9%)¹⁸18. Assunção MCF, Gigante DP, Cardoso MA, Sartorelli DS, Santos IS. Randomized, controlled trial promotes physical activity and reduces consumption of sweets and sodium among overweight and obese adults. Nutr Res. 2010;30(8):541-9. https://doi.org/10.1016/j.nutres.2010.07.006
https://doi.org/10.1016/j.nutres.2010.07... ,¹⁹19. Baba CT, Oliveira IM, Silva AEF, Vieira LM, Cerri NC, Florindo AA, et al. Evaluating the impact of a walking program in a disadvantaged area: using the RE-AIM framework by mixed methods. BMC Public Health. 2017;17:709. https://doi.org/10.1186/s12889-017-4698-5
https://doi.org/10.1186/s12889-017-4698-... ,²¹21. Costa PRF, Assis AMO, Silva MCM, Santana MLP, Dias JC, Pinheiro SMC, et al. Mudança nos parâmetros antropométricos: a influência de um programa de intervenção nutricional e exercício físico em mulheres adultas. Cad Saude Publica. 2009;25(8):1763-73. https://doi.org/10.1590/S0102-311X2009000800012
https://doi.org/10.1590/S0102-311X200900... .

As for duration, interventions ranged from two²⁰20. Chaves EC, Oyama SM. Abordagem telefônica como estratégia para promoção da saúde. Rev Gaucha Enferm. 2007;28(2):171-9. to 12 months²¹21. Costa PRF, Assis AMO, Silva MCM, Santana MLP, Dias JC, Pinheiro SMC, et al. Mudança nos parâmetros antropométricos: a influência de um programa de intervenção nutricional e exercício físico em mulheres adultas. Cad Saude Publica. 2009;25(8):1763-73. https://doi.org/10.1590/S0102-311X2009000800012
https://doi.org/10.1590/S0102-311X200900... ,²⁶26. Ribeiro EHC, Garcia LMT, Salvador EP, Costa EF, Andrade DR, Latorre MDRDO, et al. Assessment of the effectiveness of physical activity interventions in the Brazilian Unified Health System. Rev Saude Publica. 2017;51:56. https://doi.org/10.1590/s1518-8787.2017051006654
https://doi.org/10.1590/s1518-8787.20170... , and five of them (55.6%) were developed over at least six months¹⁸18. Assunção MCF, Gigante DP, Cardoso MA, Sartorelli DS, Santos IS. Randomized, controlled trial promotes physical activity and reduces consumption of sweets and sodium among overweight and obese adults. Nutr Res. 2010;30(8):541-9. https://doi.org/10.1016/j.nutres.2010.07.006
https://doi.org/10.1016/j.nutres.2010.07... ,¹⁹19. Baba CT, Oliveira IM, Silva AEF, Vieira LM, Cerri NC, Florindo AA, et al. Evaluating the impact of a walking program in a disadvantaged area: using the RE-AIM framework by mixed methods. BMC Public Health. 2017;17:709. https://doi.org/10.1186/s12889-017-4698-5
https://doi.org/10.1186/s12889-017-4698-... ,²¹21. Costa PRF, Assis AMO, Silva MCM, Santana MLP, Dias JC, Pinheiro SMC, et al. Mudança nos parâmetros antropométricos: a influência de um programa de intervenção nutricional e exercício físico em mulheres adultas. Cad Saude Publica. 2009;25(8):1763-73. https://doi.org/10.1590/S0102-311X2009000800012
https://doi.org/10.1590/S0102-311X200900... ,²²22. Costa EF, Andrade DR, Garcia LM, Ribeiro EH, Santos TI, Florindo AA. Avaliação da efetividade da promoção da atividade física por agentes comunitários de saúde em visitas domiciliares. Cad Saude Publica. 2015;31(10):2185-98. https://doi.org/10.1590/0102-311X00106014
https://doi.org/10.1590/0102-311X0010601... ,²⁶26. Ribeiro EHC, Garcia LMT, Salvador EP, Costa EF, Andrade DR, Latorre MDRDO, et al. Assessment of the effectiveness of physical activity interventions in the Brazilian Unified Health System. Rev Saude Publica. 2017;51:56. https://doi.org/10.1590/s1518-8787.2017051006654
https://doi.org/10.1590/s1518-8787.20170... (Table 2). In two interventions, participants were followed up and evaluated for six months after the end of the intervention¹⁹19. Baba CT, Oliveira IM, Silva AEF, Vieira LM, Cerri NC, Florindo AA, et al. Evaluating the impact of a walking program in a disadvantaged area: using the RE-AIM framework by mixed methods. BMC Public Health. 2017;17:709. https://doi.org/10.1186/s12889-017-4698-5
https://doi.org/10.1186/s12889-017-4698-... ,²⁶26. Ribeiro EHC, Garcia LMT, Salvador EP, Costa EF, Andrade DR, Latorre MDRDO, et al. Assessment of the effectiveness of physical activity interventions in the Brazilian Unified Health System. Rev Saude Publica. 2017;51:56. https://doi.org/10.1590/s1518-8787.2017051006654
https://doi.org/10.1590/s1518-8787.20170... . In regard of settings, we may highlight five interventions taking place in PHC settings of the SUS, either in health units¹⁹19. Baba CT, Oliveira IM, Silva AEF, Vieira LM, Cerri NC, Florindo AA, et al. Evaluating the impact of a walking program in a disadvantaged area: using the RE-AIM framework by mixed methods. BMC Public Health. 2017;17:709. https://doi.org/10.1186/s12889-017-4698-5
https://doi.org/10.1186/s12889-017-4698-... ,²²22. Costa EF, Andrade DR, Garcia LM, Ribeiro EH, Santos TI, Florindo AA. Avaliação da efetividade da promoção da atividade física por agentes comunitários de saúde em visitas domiciliares. Cad Saude Publica. 2015;31(10):2185-98. https://doi.org/10.1590/0102-311X00106014
https://doi.org/10.1590/0102-311X0010601... ,²⁴24. Gomes MA, Duarte MFS. Efetividade de uma intervenção de atividade física em adultos atendidos pela Estratégia Saúde da Família: Programa Ação e Saúde Floripa – Brasil. Rev Bras Ativ Fis Saude. 2008;13(1):44-56. https://doi.org/10.12820/rbafs.v.13n1p44-56
https://doi.org/10.12820/rbafs.v.13n1p44... ,²⁶26. Ribeiro EHC, Garcia LMT, Salvador EP, Costa EF, Andrade DR, Latorre MDRDO, et al. Assessment of the effectiveness of physical activity interventions in the Brazilian Unified Health System. Rev Saude Publica. 2017;51:56. https://doi.org/10.1590/s1518-8787.2017051006654
https://doi.org/10.1590/s1518-8787.20170... , or in centers of the Health Academy Program²⁵25. Meurer ST, Lopes ACS, Almeida FA, Mendonça RD, Benedetti TRB. Effectiveness of the VAMOS strategy for increasing physical activity and healthy dietary habits: a randomized controlled community trial. Health Educ Behav. 2019;46(3):406-16. https://doi.org/10.1177/1090198118820095
https://doi.org/10.1177/1090198118820095... , with great variability among people who delivered the interventions, as examples, professionals working in PHC-SUS settings, research teams, and specialists. Seven interventions had as their primary objective the increase in PA levels (77.8%)¹⁹19. Baba CT, Oliveira IM, Silva AEF, Vieira LM, Cerri NC, Florindo AA, et al. Evaluating the impact of a walking program in a disadvantaged area: using the RE-AIM framework by mixed methods. BMC Public Health. 2017;17:709. https://doi.org/10.1186/s12889-017-4698-5
https://doi.org/10.1186/s12889-017-4698-... ,²⁰20. Chaves EC, Oyama SM. Abordagem telefônica como estratégia para promoção da saúde. Rev Gaucha Enferm. 2007;28(2):171-9.,²²22. Costa EF, Andrade DR, Garcia LM, Ribeiro EH, Santos TI, Florindo AA. Avaliação da efetividade da promoção da atividade física por agentes comunitários de saúde em visitas domiciliares. Cad Saude Publica. 2015;31(10):2185-98. https://doi.org/10.1590/0102-311X00106014
https://doi.org/10.1590/0102-311X0010601... .

In four studies²²22. Costa EF, Andrade DR, Garcia LM, Ribeiro EH, Santos TI, Florindo AA. Avaliação da efetividade da promoção da atividade física por agentes comunitários de saúde em visitas domiciliares. Cad Saude Publica. 2015;31(10):2185-98. https://doi.org/10.1590/0102-311X00106014
https://doi.org/10.1590/0102-311X0010601... ,²⁴24. Gomes MA, Duarte MFS. Efetividade de uma intervenção de atividade física em adultos atendidos pela Estratégia Saúde da Família: Programa Ação e Saúde Floripa – Brasil. Rev Bras Ativ Fis Saude. 2008;13(1):44-56. https://doi.org/10.12820/rbafs.v.13n1p44-56
https://doi.org/10.12820/rbafs.v.13n1p44... (44.4%), it was observed the description of pedagogical frameworks structuring the educational approaches, so that different approaches were combined in two studies²²22. Costa EF, Andrade DR, Garcia LM, Ribeiro EH, Santos TI, Florindo AA. Avaliação da efetividade da promoção da atividade física por agentes comunitários de saúde em visitas domiciliares. Cad Saude Publica. 2015;31(10):2185-98. https://doi.org/10.1590/0102-311X00106014
https://doi.org/10.1590/0102-311X0010601... ,²⁶26. Ribeiro EHC, Garcia LMT, Salvador EP, Costa EF, Andrade DR, Latorre MDRDO, et al. Assessment of the effectiveness of physical activity interventions in the Brazilian Unified Health System. Rev Saude Publica. 2017;51:56. https://doi.org/10.1590/s1518-8787.2017051006654
https://doi.org/10.1590/s1518-8787.20170... : the Social Cognitive Theory²⁵25. Meurer ST, Lopes ACS, Almeida FA, Mendonça RD, Benedetti TRB. Effectiveness of the VAMOS strategy for increasing physical activity and healthy dietary habits: a randomized controlled community trial. Health Educ Behav. 2019;46(3):406-16. https://doi.org/10.1177/1090198118820095
https://doi.org/10.1177/1090198118820095... and Paulo Freire’s educational method²⁴24. Gomes MA, Duarte MFS. Efetividade de uma intervenção de atividade física em adultos atendidos pela Estratégia Saúde da Família: Programa Ação e Saúde Floripa – Brasil. Rev Bras Ativ Fis Saude. 2008;13(1):44-56. https://doi.org/10.12820/rbafs.v.13n1p44-56
https://doi.org/10.12820/rbafs.v.13n1p44... (Table 2). Regarding the strategies adopted in the educational processes, counseling was used in eight interventions (88.9%), either through face-to-face meetings¹⁸18. Assunção MCF, Gigante DP, Cardoso MA, Sartorelli DS, Santos IS. Randomized, controlled trial promotes physical activity and reduces consumption of sweets and sodium among overweight and obese adults. Nutr Res. 2010;30(8):541-9. https://doi.org/10.1016/j.nutres.2010.07.006
https://doi.org/10.1016/j.nutres.2010.07... ,¹⁹19. Baba CT, Oliveira IM, Silva AEF, Vieira LM, Cerri NC, Florindo AA, et al. Evaluating the impact of a walking program in a disadvantaged area: using the RE-AIM framework by mixed methods. BMC Public Health. 2017;17:709. https://doi.org/10.1186/s12889-017-4698-5
https://doi.org/10.1186/s12889-017-4698-... ,²¹21. Costa PRF, Assis AMO, Silva MCM, Santana MLP, Dias JC, Pinheiro SMC, et al. Mudança nos parâmetros antropométricos: a influência de um programa de intervenção nutricional e exercício físico em mulheres adultas. Cad Saude Publica. 2009;25(8):1763-73. https://doi.org/10.1590/S0102-311X2009000800012
https://doi.org/10.1590/S0102-311X200900... ,²³23. Ferreira M, Matsudo S, Matsudo V, Braggion G. Effects of an intervention program of physical activity and nutrition orientation on the physical activity level of physically active women aged 50 to 72 years old. Rev Bras Med Esporte. 2005;11(3):172-6. https://doi.org/10.1590/S1517-86922005000300004
https://doi.org/10.1590/S1517-8692200500... ,²⁶26. Ribeiro EHC, Garcia LMT, Salvador EP, Costa EF, Andrade DR, Latorre MDRDO, et al. Assessment of the effectiveness of physical activity interventions in the Brazilian Unified Health System. Rev Saude Publica. 2017;51:56. https://doi.org/10.1590/s1518-8787.2017051006654
https://doi.org/10.1590/s1518-8787.20170... , home visits²²22. Costa EF, Andrade DR, Garcia LM, Ribeiro EH, Santos TI, Florindo AA. Avaliação da efetividade da promoção da atividade física por agentes comunitários de saúde em visitas domiciliares. Cad Saude Publica. 2015;31(10):2185-98. https://doi.org/10.1590/0102-311X00106014
https://doi.org/10.1590/0102-311X0010601... ,²⁴24. Gomes MA, Duarte MFS. Efetividade de uma intervenção de atividade física em adultos atendidos pela Estratégia Saúde da Família: Programa Ação e Saúde Floripa – Brasil. Rev Bras Ativ Fis Saude. 2008;13(1):44-56. https://doi.org/10.12820/rbafs.v.13n1p44-56
https://doi.org/10.12820/rbafs.v.13n1p44... , lectures²⁴24. Gomes MA, Duarte MFS. Efetividade de uma intervenção de atividade física em adultos atendidos pela Estratégia Saúde da Família: Programa Ação e Saúde Floripa – Brasil. Rev Bras Ativ Fis Saude. 2008;13(1):44-56. https://doi.org/10.12820/rbafs.v.13n1p44-56
https://doi.org/10.12820/rbafs.v.13n1p44... , or phone calls²⁰20. Chaves EC, Oyama SM. Abordagem telefônica como estratégia para promoção da saúde. Rev Gaucha Enferm. 2007;28(2):171-9.. Three interventions delivered educational materials²³23. Ferreira M, Matsudo S, Matsudo V, Braggion G. Effects of an intervention program of physical activity and nutrition orientation on the physical activity level of physically active women aged 50 to 72 years old. Rev Bras Med Esporte. 2005;11(3):172-6. https://doi.org/10.1590/S1517-86922005000300004
https://doi.org/10.1590/S1517-8692200500... , while three interventions implemented hands-on activities¹⁹19. Baba CT, Oliveira IM, Silva AEF, Vieira LM, Cerri NC, Florindo AA, et al. Evaluating the impact of a walking program in a disadvantaged area: using the RE-AIM framework by mixed methods. BMC Public Health. 2017;17:709. https://doi.org/10.1186/s12889-017-4698-5
https://doi.org/10.1186/s12889-017-4698-... ,²¹21. Costa PRF, Assis AMO, Silva MCM, Santana MLP, Dias JC, Pinheiro SMC, et al. Mudança nos parâmetros antropométricos: a influência de um programa de intervenção nutricional e exercício físico em mulheres adultas. Cad Saude Publica. 2009;25(8):1763-73. https://doi.org/10.1590/S0102-311X2009000800012
https://doi.org/10.1590/S0102-311X200900... ,²⁶26. Ribeiro EHC, Garcia LMT, Salvador EP, Costa EF, Andrade DR, Latorre MDRDO, et al. Assessment of the effectiveness of physical activity interventions in the Brazilian Unified Health System. Rev Saude Publica. 2017;51:56. https://doi.org/10.1590/s1518-8787.2017051006654
https://doi.org/10.1590/s1518-8787.20170... . In addition, five interventions addressing other health topics in their educational actions, such as nutrition¹⁸18. Assunção MCF, Gigante DP, Cardoso MA, Sartorelli DS, Santos IS. Randomized, controlled trial promotes physical activity and reduces consumption of sweets and sodium among overweight and obese adults. Nutr Res. 2010;30(8):541-9. https://doi.org/10.1016/j.nutres.2010.07.006
https://doi.org/10.1016/j.nutres.2010.07... ,²¹21. Costa PRF, Assis AMO, Silva MCM, Santana MLP, Dias JC, Pinheiro SMC, et al. Mudança nos parâmetros antropométricos: a influência de um programa de intervenção nutricional e exercício físico em mulheres adultas. Cad Saude Publica. 2009;25(8):1763-73. https://doi.org/10.1590/S0102-311X2009000800012
https://doi.org/10.1590/S0102-311X200900... ,²³23. Ferreira M, Matsudo S, Matsudo V, Braggion G. Effects of an intervention program of physical activity and nutrition orientation on the physical activity level of physically active women aged 50 to 72 years old. Rev Bras Med Esporte. 2005;11(3):172-6. https://doi.org/10.1590/S1517-86922005000300004
https://doi.org/10.1590/S1517-8692200500... ,²⁵25. Meurer ST, Lopes ACS, Almeida FA, Mendonça RD, Benedetti TRB. Effectiveness of the VAMOS strategy for increasing physical activity and healthy dietary habits: a randomized controlled community trial. Health Educ Behav. 2019;46(3):406-16. https://doi.org/10.1177/1090198118820095
https://doi.org/10.1177/1090198118820095... ,²⁶26. Ribeiro EHC, Garcia LMT, Salvador EP, Costa EF, Andrade DR, Latorre MDRDO, et al. Assessment of the effectiveness of physical activity interventions in the Brazilian Unified Health System. Rev Saude Publica. 2017;51:56. https://doi.org/10.1590/s1518-8787.2017051006654
https://doi.org/10.1590/s1518-8787.20170... and stress²⁶26. Ribeiro EHC, Garcia LMT, Salvador EP, Costa EF, Andrade DR, Latorre MDRDO, et al. Assessment of the effectiveness of physical activity interventions in the Brazilian Unified Health System. Rev Saude Publica. 2017;51:56. https://doi.org/10.1590/s1518-8787.2017051006654
https://doi.org/10.1590/s1518-8787.20170... were also identified.

With the exception of the study by Meurer et al. (2019)²⁵25. Meurer ST, Lopes ACS, Almeida FA, Mendonça RD, Benedetti TRB. Effectiveness of the VAMOS strategy for increasing physical activity and healthy dietary habits: a randomized controlled community trial. Health Educ Behav. 2019;46(3):406-16. https://doi.org/10.1177/1090198118820095
https://doi.org/10.1177/1090198118820095... , all the interventions included used questionnaires to assess PA, with higher frequency of use of the IPAQ versions (n = 6)¹⁸18. Assunção MCF, Gigante DP, Cardoso MA, Sartorelli DS, Santos IS. Randomized, controlled trial promotes physical activity and reduces consumption of sweets and sodium among overweight and obese adults. Nutr Res. 2010;30(8):541-9. https://doi.org/10.1016/j.nutres.2010.07.006
https://doi.org/10.1016/j.nutres.2010.07... ,¹⁹19. Baba CT, Oliveira IM, Silva AEF, Vieira LM, Cerri NC, Florindo AA, et al. Evaluating the impact of a walking program in a disadvantaged area: using the RE-AIM framework by mixed methods. BMC Public Health. 2017;17:709. https://doi.org/10.1186/s12889-017-4698-5
https://doi.org/10.1186/s12889-017-4698-... ,²¹21. Costa PRF, Assis AMO, Silva MCM, Santana MLP, Dias JC, Pinheiro SMC, et al. Mudança nos parâmetros antropométricos: a influência de um programa de intervenção nutricional e exercício físico em mulheres adultas. Cad Saude Publica. 2009;25(8):1763-73. https://doi.org/10.1590/S0102-311X2009000800012
https://doi.org/10.1590/S0102-311X200900... . In addition to the questionnaire, two studies also used accelerometers to measure PA¹⁹19. Baba CT, Oliveira IM, Silva AEF, Vieira LM, Cerri NC, Florindo AA, et al. Evaluating the impact of a walking program in a disadvantaged area: using the RE-AIM framework by mixed methods. BMC Public Health. 2017;17:709. https://doi.org/10.1186/s12889-017-4698-5
https://doi.org/10.1186/s12889-017-4698-... ,²⁶26. Ribeiro EHC, Garcia LMT, Salvador EP, Costa EF, Andrade DR, Latorre MDRDO, et al. Assessment of the effectiveness of physical activity interventions in the Brazilian Unified Health System. Rev Saude Publica. 2017;51:56. https://doi.org/10.1590/s1518-8787.2017051006654
https://doi.org/10.1590/s1518-8787.20170... . Samples ranged from 14²⁰20. Chaves EC, Oyama SM. Abordagem telefônica como estratégia para promoção da saúde. Rev Gaucha Enferm. 2007;28(2):171-9. to 291²⁵25. Meurer ST, Lopes ACS, Almeida FA, Mendonça RD, Benedetti TRB. Effectiveness of the VAMOS strategy for increasing physical activity and healthy dietary habits: a randomized controlled community trial. Health Educ Behav. 2019;46(3):406-16. https://doi.org/10.1177/1090198118820095
https://doi.org/10.1177/1090198118820095... participants (Table 3).

Regarding the effects, six interventions resulted in statistically significant data regarding PA in the following indicators: (I) increase in weekly PA volume¹⁸18. Assunção MCF, Gigante DP, Cardoso MA, Sartorelli DS, Santos IS. Randomized, controlled trial promotes physical activity and reduces consumption of sweets and sodium among overweight and obese adults. Nutr Res. 2010;30(8):541-9. https://doi.org/10.1016/j.nutres.2010.07.006
https://doi.org/10.1016/j.nutres.2010.07... ,²³23. Ferreira M, Matsudo S, Matsudo V, Braggion G. Effects of an intervention program of physical activity and nutrition orientation on the physical activity level of physically active women aged 50 to 72 years old. Rev Bras Med Esporte. 2005;11(3):172-6. https://doi.org/10.1590/S1517-86922005000300004
https://doi.org/10.1590/S1517-8692200500... ,²⁵25. Meurer ST, Lopes ACS, Almeida FA, Mendonça RD, Benedetti TRB. Effectiveness of the VAMOS strategy for increasing physical activity and healthy dietary habits: a randomized controlled community trial. Health Educ Behav. 2019;46(3):406-16. https://doi.org/10.1177/1090198118820095
https://doi.org/10.1177/1090198118820095... ,²⁶26. Ribeiro EHC, Garcia LMT, Salvador EP, Costa EF, Andrade DR, Latorre MDRDO, et al. Assessment of the effectiveness of physical activity interventions in the Brazilian Unified Health System. Rev Saude Publica. 2017;51:56. https://doi.org/10.1590/s1518-8787.2017051006654
https://doi.org/10.1590/s1518-8787.20170... - with highlights to the findings of Assunção et al. (2010)¹⁸18. Assunção MCF, Gigante DP, Cardoso MA, Sartorelli DS, Santos IS. Randomized, controlled trial promotes physical activity and reduces consumption of sweets and sodium among overweight and obese adults. Nutr Res. 2010;30(8):541-9. https://doi.org/10.1016/j.nutres.2010.07.006
https://doi.org/10.1016/j.nutres.2010.07... , which showed an increase of 88 minutes a week in the intervention group compared to the control group (p = 0.01), of Meurer et al. (2019)²⁵25. Meurer ST, Lopes ACS, Almeida FA, Mendonça RD, Benedetti TRB. Effectiveness of the VAMOS strategy for increasing physical activity and healthy dietary habits: a randomized controlled community trial. Health Educ Behav. 2019;46(3):406-16. https://doi.org/10.1177/1090198118820095
https://doi.org/10.1177/1090198118820095... , which showed a significant increase of moderate and vigorous PA in the intervention group compared to the control group (Effect size = 0.18), and of Ribeiro et al. (2017)²⁶26. Ribeiro EHC, Garcia LMT, Salvador EP, Costa EF, Andrade DR, Latorre MDRDO, et al. Assessment of the effectiveness of physical activity interventions in the Brazilian Unified Health System. Rev Saude Publica. 2017;51:56. https://doi.org/10.1590/s1518-8787.2017051006654
https://doi.org/10.1590/s1518-8787.20170... , in which, six months after the end of the study, the group that received the educational component showed an increase in the annual exercise score (0.2; 95%CI 0.1-0.4); (II) increase in the index of habitual PA at leisure²⁴24. Gomes MA, Duarte MFS. Efetividade de uma intervenção de atividade física em adultos atendidos pela Estratégia Saúde da Família: Programa Ação e Saúde Floripa – Brasil. Rev Bras Ativ Fis Saude. 2008;13(1):44-56. https://doi.org/10.12820/rbafs.v.13n1p44-56
https://doi.org/10.12820/rbafs.v.13n1p44... ; and, (III) increase in the proportion of women classified as “very active/active”, from 30.4% at baseline to 73.9% at the end of the intervention (Table 3), in Costa et al. (2009)²¹21. Costa PRF, Assis AMO, Silva MCM, Santana MLP, Dias JC, Pinheiro SMC, et al. Mudança nos parâmetros antropométricos: a influência de um programa de intervenção nutricional e exercício físico em mulheres adultas. Cad Saude Publica. 2009;25(8):1763-73. https://doi.org/10.1590/S0102-311X2009000800012
https://doi.org/10.1590/S0102-311X200900... .

According to Figure 2, methodological potentialities were observed in the domains “methods used in data collection” and “analysis protocol”, where all studies were classified as having “low” risk of bias. On the other hand, “participant selection” was the domain where a higher frequency of studies assessed as high risk were found, especially due to specificities in four samples (such as overweight/obese people¹⁸18. Assunção MCF, Gigante DP, Cardoso MA, Sartorelli DS, Santos IS. Randomized, controlled trial promotes physical activity and reduces consumption of sweets and sodium among overweight and obese adults. Nutr Res. 2010;30(8):541-9. https://doi.org/10.1016/j.nutres.2010.07.006
https://doi.org/10.1016/j.nutres.2010.07... , people living in regions of high vulnerability¹⁹19. Baba CT, Oliveira IM, Silva AEF, Vieira LM, Cerri NC, Florindo AA, et al. Evaluating the impact of a walking program in a disadvantaged area: using the RE-AIM framework by mixed methods. BMC Public Health. 2017;17:709. https://doi.org/10.1186/s12889-017-4698-5
https://doi.org/10.1186/s12889-017-4698-... ,²⁶26. Ribeiro EHC, Garcia LMT, Salvador EP, Costa EF, Andrade DR, Latorre MDRDO, et al. Assessment of the effectiveness of physical activity interventions in the Brazilian Unified Health System. Rev Saude Publica. 2017;51:56. https://doi.org/10.1590/s1518-8787.2017051006654
https://doi.org/10.1590/s1518-8787.20170... and physically active²¹21. Costa PRF, Assis AMO, Silva MCM, Santana MLP, Dias JC, Pinheiro SMC, et al. Mudança nos parâmetros antropométricos: a influência de um programa de intervenção nutricional e exercício físico em mulheres adultas. Cad Saude Publica. 2009;25(8):1763-73. https://doi.org/10.1590/S0102-311X2009000800012
https://doi.org/10.1590/S0102-311X200900... ,²³23. Ferreira M, Matsudo S, Matsudo V, Braggion G. Effects of an intervention program of physical activity and nutrition orientation on the physical activity level of physically active women aged 50 to 72 years old. Rev Bras Med Esporte. 2005;11(3):172-6. https://doi.org/10.1590/S1517-86922005000300004
https://doi.org/10.1590/S1517-8692200500... ,²⁵25. Meurer ST, Lopes ACS, Almeida FA, Mendonça RD, Benedetti TRB. Effectiveness of the VAMOS strategy for increasing physical activity and healthy dietary habits: a randomized controlled community trial. Health Educ Behav. 2019;46(3):406-16. https://doi.org/10.1177/1090198118820095
https://doi.org/10.1177/1090198118820095... or inactive¹⁹19. Baba CT, Oliveira IM, Silva AEF, Vieira LM, Cerri NC, Florindo AA, et al. Evaluating the impact of a walking program in a disadvantaged area: using the RE-AIM framework by mixed methods. BMC Public Health. 2017;17:709. https://doi.org/10.1186/s12889-017-4698-5
https://doi.org/10.1186/s12889-017-4698-... ,²⁰20. Chaves EC, Oyama SM. Abordagem telefônica como estratégia para promoção da saúde. Rev Gaucha Enferm. 2007;28(2):171-9.,²⁶26. Ribeiro EHC, Garcia LMT, Salvador EP, Costa EF, Andrade DR, Latorre MDRDO, et al. Assessment of the effectiveness of physical activity interventions in the Brazilian Unified Health System. Rev Saude Publica. 2017;51:56. https://doi.org/10.1590/s1518-8787.2017051006654
https://doi.org/10.1590/s1518-8787.20170... people), which limit the generalizability of the original evidence. The domain “intervention integrity” showed seven studies rated as moderate risk of bias²⁰20. Chaves EC, Oyama SM. Abordagem telefônica como estratégia para promoção da saúde. Rev Gaucha Enferm. 2007;28(2):171-9., because they did not report the assessment of consistency of the intervention, and did not mention the risk of contamination between the groups – i.e., the influence caused by the possible proximity of people between the groups, so that those assigned to the control group may also be exposed to the actions conducted to the intervention group.

DISCUSSION

Based on data from nine interventions conducted in six Brazilian cities, from three regions of the country, the current synthesis pointed out positive results in three different PA indicators: (I) increase in weekly PA volume¹⁸18. Assunção MCF, Gigante DP, Cardoso MA, Sartorelli DS, Santos IS. Randomized, controlled trial promotes physical activity and reduces consumption of sweets and sodium among overweight and obese adults. Nutr Res. 2010;30(8):541-9. https://doi.org/10.1016/j.nutres.2010.07.006
https://doi.org/10.1016/j.nutres.2010.07... ,²³23. Ferreira M, Matsudo S, Matsudo V, Braggion G. Effects of an intervention program of physical activity and nutrition orientation on the physical activity level of physically active women aged 50 to 72 years old. Rev Bras Med Esporte. 2005;11(3):172-6. https://doi.org/10.1590/S1517-86922005000300004
https://doi.org/10.1590/S1517-8692200500... ,²⁵25. Meurer ST, Lopes ACS, Almeida FA, Mendonça RD, Benedetti TRB. Effectiveness of the VAMOS strategy for increasing physical activity and healthy dietary habits: a randomized controlled community trial. Health Educ Behav. 2019;46(3):406-16. https://doi.org/10.1177/1090198118820095
https://doi.org/10.1177/1090198118820095... ,²⁶26. Ribeiro EHC, Garcia LMT, Salvador EP, Costa EF, Andrade DR, Latorre MDRDO, et al. Assessment of the effectiveness of physical activity interventions in the Brazilian Unified Health System. Rev Saude Publica. 2017;51:56. https://doi.org/10.1590/s1518-8787.2017051006654
https://doi.org/10.1590/s1518-8787.20170... ; (II) increase in leisure time PA index²⁴24. Gomes MA, Duarte MFS. Efetividade de uma intervenção de atividade física em adultos atendidos pela Estratégia Saúde da Família: Programa Ação e Saúde Floripa – Brasil. Rev Bras Ativ Fis Saude. 2008;13(1):44-56. https://doi.org/10.12820/rbafs.v.13n1p44-56
https://doi.org/10.12820/rbafs.v.13n1p44... ; and (III) increase in the proportion of women ranked as “very active/active”²¹21. Costa PRF, Assis AMO, Silva MCM, Santana MLP, Dias JC, Pinheiro SMC, et al. Mudança nos parâmetros antropométricos: a influência de um programa de intervenção nutricional e exercício físico em mulheres adultas. Cad Saude Publica. 2009;25(8):1763-73. https://doi.org/10.1590/S0102-311X2009000800012
https://doi.org/10.1590/S0102-311X200900... . Despite the great heterogeneity among pedagogical frameworks that supported the educational processes, counseling practice was the strategy most often adopted by the interventions, regardless of their format and the content approached, also highlighting approaches in other health-related topics, such as nutrition and stress.

Given the growth of academic production related to PA and health topic in Brazil²⁷27. Ramires VV, Becker LA, Sadovsky ADI, Zago AM, Bielemann RM, Guerra PH. Evolução da pesquisa epidemiológica em atividade física e comportamento sedentário no Brasil: atualização de uma revisão sistemática. Rev Bras Ativ Fis Saude. 2014;19(5):529-30. https://doi.org/10.12820/rbafs.v.19n5p529
https://doi.org/10.12820/rbafs.v.19n5p52... , the number of interventions can be considered to be low. However, this scarcity may be justified by the current context of cuts of budget for research in Brazil²⁸28. Jucá B. Cortes de verbas desmontam ciência brasileira e restringem pesquisa a mais ricos. El País (Brasil). 9 set 2020 [cited 2020 Oct 10. Available from: https://brasil.elpais.com/brasil/2019/09/03/politica/1567542296_718545.htm
https://brasil.elpais.com/brasil/2019/09... ,²⁹29. Norte DB. Cortes e mais cortes: o que será da ciência e da pesquisa no Brasil? VocêS/A. 9 mar 2020 [cited 2020 Oct 10]. Available from: https://vocesa.abril.com.br/carreira/cortes-bolsas-pesquisa-ciencia/
https://vocesa.abril.com.br/carreira/cor... , besides the fact that intervention studies demands longer time to be developed, as well as more funding and larger teams. Even so, regarding the results, what was observed in this synthesis supports the evidence of Heath et al. (2012)¹³13. Heath GW, Parra DC, Sarmiento OL, Andersen LB, Owen N, Goenka S, et al. Evidence-based intervention in physical activity: lessons from around the world. Lancet. 2012;380(9838):272-81. https://doi.org/10.1016/S0140-6736(12)60816-2
https://doi.org/10.1016/S0140-6736(12)60... and Hoehner et al. (2013)¹⁴14. Hoehner CM, Ribeiro IC, Parra DC, Reis RS, Azevedo MR, Hino AA, et al. Physical activity interventions in Latin America: expanding and classifying the evidence. Am J Prev Med. 2013;44(3):e31-40. https://doi.org/10.1016/j.amepre.2012.10.026
https://doi.org/10.1016/j.amepre.2012.10... regarding the effects of educational processes on interventions aimed at increasing the PA levels. The positive results observed in interventions conducted in PHC-SUS settings are also worth noticing²⁴24. Gomes MA, Duarte MFS. Efetividade de uma intervenção de atividade física em adultos atendidos pela Estratégia Saúde da Família: Programa Ação e Saúde Floripa – Brasil. Rev Bras Ativ Fis Saude. 2008;13(1):44-56. https://doi.org/10.12820/rbafs.v.13n1p44-56
https://doi.org/10.12820/rbafs.v.13n1p44... ,²⁶26. Ribeiro EHC, Garcia LMT, Salvador EP, Costa EF, Andrade DR, Latorre MDRDO, et al. Assessment of the effectiveness of physical activity interventions in the Brazilian Unified Health System. Rev Saude Publica. 2017;51:56. https://doi.org/10.1590/s1518-8787.2017051006654
https://doi.org/10.1590/s1518-8787.20170... . International studies recommend interventions in PHC settings, considering the greater possibility of dissemination of a given strategy⁹9. Sanchez A, Bully P, Martinez C, Grandes G. Effectiveness of physical activity promotion interventions in primary care: a review of reviews. Prev Med. 2015;76 Suppl:S56-67. https://doi.org/10.1016/j.ypmed.2014.09.012
https://doi.org/10.1016/j.ypmed.2014.09.... ,¹⁰10. Garrett S, Elley CR, Rose SB, O’Dea D, Lawton BA, Dowell AC. Are physical activity interventions in primary care and the community cost-effective? A systematic review of the evidence. Br J Gen Pract. 2011;61(584):e125-33. https://doi.org/10.3399/bjgp11X561249
https://doi.org/10.3399/bjgp11X561249... ,³⁰30. Orrow G, Kinmonth AL, Sanderson S, Sutton S. Effectiveness of physical activity promotion based in primary care: systematic review and meta-analysis of randomised controlled trials. BMJ. 2012;344:e1389. https://doi.org/10.1136/bmj.e1389
https://doi.org/10.1136/bmj.e1389... .

Most studies did not report the pedagogical frameworks that supported the educational approaches. Considering that some of the strategies were conducted in the context of the PHC-SUS, which is grounded in premises of health promotion, this is an important gap, including for understanding their alignment with the main national policies, the paths of strategies, and the role of players involved throughout the implementation process. The four studies²²22. Costa EF, Andrade DR, Garcia LM, Ribeiro EH, Santos TI, Florindo AA. Avaliação da efetividade da promoção da atividade física por agentes comunitários de saúde em visitas domiciliares. Cad Saude Publica. 2015;31(10):2185-98. https://doi.org/10.1590/0102-311X00106014
https://doi.org/10.1590/0102-311X0010601... ,²⁴24. Gomes MA, Duarte MFS. Efetividade de uma intervenção de atividade física em adultos atendidos pela Estratégia Saúde da Família: Programa Ação e Saúde Floripa – Brasil. Rev Bras Ativ Fis Saude. 2008;13(1):44-56. https://doi.org/10.12820/rbafs.v.13n1p44-56
https://doi.org/10.12820/rbafs.v.13n1p44... with available information based their interventions on different frameworks, either grouped or isolated, thus limiting more in-depth comparisons.

In view of the limitations perceived in the information-based approaches, it is suggested that future interventions also incorporate knowledge from Behavioral Economics³¹31. Loch MR, Dias DF, Castro ASR, Guerra PH. Controle remoto ou remoto controle? A economia comportamental e a promoção de comportamentos saudáveis. Rev Panam Salud Publica. 2019;43:e18. https://doi.org/10.26633/RPSP.2019.18
https://doi.org/10.26633/RPSP.2019.18... , particularly regarding its notion that knowledge, although important, is insufficient in most cases since it disregards the action of non-conscious processes that determine our choices³²32. Marteau TM. Changing minds about changing behaviour. Lancet. 2018;391(10116):116-7. https://doi.org/10.1016/S0140-6736(17)33324-X
https://doi.org/10.1016/S0140-6736(17)33... .

Furthermore, it is worth mentioning the importance of ecological or socio-ecological approaches and models, which include several factors from different “levels” that influence human behavior, in a perspective that goes beyond the understanding of health as a mere state of absence of disease³³33. Martins L, Dionor GA, El-Hani CN, Carvalho GS. Construtos teóricos e práticos da saúde: as abordagens biomédica e socioecológica. In: Anais do 10. Encontro Nacional de Pesquisa em Educação em Ciências –ENPEC; 24 - 27 nov 2015; Águas de Lindóia, SP. São Paulo: ABRAPEC; 2015. p.1-8.. Although educational strategies may play an important role in promoting PA levels, one should not lose sight of the fact that these should be implemented in parallel with the approach of many other factors³¹31. Loch MR, Dias DF, Castro ASR, Guerra PH. Controle remoto ou remoto controle? A economia comportamental e a promoção de comportamentos saudáveis. Rev Panam Salud Publica. 2019;43:e18. https://doi.org/10.26633/RPSP.2019.18
https://doi.org/10.26633/RPSP.2019.18... .

Regarding counseling, which was the most used educational strategy among the studies included, there are records on its positive influence on behavioral change stages³⁴34. Häfele V; Siqueira FV. Aconselhamento para atividade física e mudança de comportamento em Unidades Básicas de Saúde. Rev Bras Ativ Fis Saude. 2017;21(6):581-92. https://doi.org/10.12820/rbafs.v.21n6p581-592
https://doi.org/10.12820/rbafs.v.21n6p58... , as well as its effect on increasing PA levels³⁵35. Lin JS, O’Connor E, Whitlock EP, Beil TL. Behavioral counseling to promote physical activity and a healthful diet to prevent cardiovascular disease in adults: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med. 2010;153(11):736-50. https://doi.org/10.7326/0003-4819-153-11-201012070-00007
https://doi.org/10.7326/0003-4819-153-11... . A nationwide study indicates that PA counseling is a practice used by most physicians and nurses working in PHC³⁶36. Florindo AA, Mielke GI, Gomes GAO, Ramos LR, Bracco MM, Parra DC, et al. Physical activity counseling in primary health care in Brazil: a national study on prevalence and associated factors. BMC Public Health. 2013;13:794. https://doi.org/10.1186/1471-2458-13-794
https://doi.org/10.1186/1471-2458-13-794... , even though many of them have little technical knowledge on PA-related issues.

As with the issue of pedagogical references, most of the studies included in the synthesis did not report important elements of the counseling processes, such as: concepts and topics approached, sequential logic subjects, as well as actions aimed at the broader concept of “PA promotion”, involving elements of identification and overcoming of barriers to the practice, for example. This finding reinforces the results found by Gagliardi et al. (2015)³⁷37. Gagliardi AR, Faulkner G, Ciliska D, Hicks A. Factors contributing to the effectiveness of physical activity counselling in primary care: a realist systematic review. Patient Educ Couns. 2015;98(4):412-9. https://doi.org/10.1016/j.pec.2014.11.020
https://doi.org/10.1016/j.pec.2014.11.02... and, since the continuous offer of counseling is associated with maintaining high levels of PA in the long term, it is important to design strategies (such as training courses and guidelines) for the different professionals working in PHC³⁸38. Florindo AA, Andrade DR, Guerra PH, Mota J, Crone D, Mafra ACCN, et al. Physical activity promotion by health practitioners: a distance-learning training component to improve knowledge and counseling. Prim Health Care Res Dev. 2018;19(2):140-50. https://doi.org/10.1017/S1463423617000676
https://doi.org/10.1017/S146342361700067... , in order to provide suitable theoretical and practical subsidies for strengthening it as a public health strategy³⁹39. Siqueira FV, Nahas MV, Facchini LA, Silveira DS, Piccini RX, Tomasi E, et al. Aconselhamento para a prática de atividade física como estratégia de educação à saúde. Cad Saude Publica. 2009;25(1):203-13. https://doi.org/10.1590/S0102-311X2009000100022
https://doi.org/10.1590/S0102-311X200900... .

On the other hand, it should be emphasized that the practice of counseling - and any other strategy conducted alone - may be not enough to improve PA indicators: these themes need to be more present in people’s lives, either through information or other forms of interventions³³33. Martins L, Dionor GA, El-Hani CN, Carvalho GS. Construtos teóricos e práticos da saúde: as abordagens biomédica e socioecológica. In: Anais do 10. Encontro Nacional de Pesquisa em Educação em Ciências –ENPEC; 24 - 27 nov 2015; Águas de Lindóia, SP. São Paulo: ABRAPEC; 2015. p.1-8.. In other words, beyond the implementation of specific and/or isolated strategies, it is important that the “PA theme” be more present in people’s lives, since PA promotion is a cross-sector theme by nature.

In this spectrum, we highlight the importance of consistent planning of the built environment of cities, in order to expand people’s access to PA practice rooms. We could mention the opening of bike lanes which, besides physical demarcation of public roads, require traffic laws to ensure cyclists’ safety, as well as improvements in safety and lighting on public roads, favoring active transportation at different times of the day.

On the other hand, considering that most of the interventions included were developed in PHC-SUS settings, counseling for PA may be interconnected with the demands of other healthcare professionals, in the sense of more comprehensive guidance focused on healthy lifestyle habits, and the corresponding improvement of health conditions of a given person or group of people³⁹39. Siqueira FV, Nahas MV, Facchini LA, Silveira DS, Piccini RX, Tomasi E, et al. Aconselhamento para a prática de atividade física como estratégia de educação à saúde. Cad Saude Publica. 2009;25(1):203-13. https://doi.org/10.1590/S0102-311X2009000100022
https://doi.org/10.1590/S0102-311X200900... . This suggestion is emphasized by this synthesis, since interventions were implemented by different specialists, not only by Physical Education professionals.

It is also worth mentioning the interventions that addressed other health themes, such as nutrition¹⁸18. Assunção MCF, Gigante DP, Cardoso MA, Sartorelli DS, Santos IS. Randomized, controlled trial promotes physical activity and reduces consumption of sweets and sodium among overweight and obese adults. Nutr Res. 2010;30(8):541-9. https://doi.org/10.1016/j.nutres.2010.07.006
https://doi.org/10.1016/j.nutres.2010.07... ,²¹21. Costa PRF, Assis AMO, Silva MCM, Santana MLP, Dias JC, Pinheiro SMC, et al. Mudança nos parâmetros antropométricos: a influência de um programa de intervenção nutricional e exercício físico em mulheres adultas. Cad Saude Publica. 2009;25(8):1763-73. https://doi.org/10.1590/S0102-311X2009000800012
https://doi.org/10.1590/S0102-311X200900... ,²³23. Ferreira M, Matsudo S, Matsudo V, Braggion G. Effects of an intervention program of physical activity and nutrition orientation on the physical activity level of physically active women aged 50 to 72 years old. Rev Bras Med Esporte. 2005;11(3):172-6. https://doi.org/10.1590/S1517-86922005000300004
https://doi.org/10.1590/S1517-8692200500... ,²⁵25. Meurer ST, Lopes ACS, Almeida FA, Mendonça RD, Benedetti TRB. Effectiveness of the VAMOS strategy for increasing physical activity and healthy dietary habits: a randomized controlled community trial. Health Educ Behav. 2019;46(3):406-16. https://doi.org/10.1177/1090198118820095
https://doi.org/10.1177/1090198118820095... ,²⁶26. Ribeiro EHC, Garcia LMT, Salvador EP, Costa EF, Andrade DR, Latorre MDRDO, et al. Assessment of the effectiveness of physical activity interventions in the Brazilian Unified Health System. Rev Saude Publica. 2017;51:56. https://doi.org/10.1590/s1518-8787.2017051006654
https://doi.org/10.1590/s1518-8787.20170... and stress²⁶26. Ribeiro EHC, Garcia LMT, Salvador EP, Costa EF, Andrade DR, Latorre MDRDO, et al. Assessment of the effectiveness of physical activity interventions in the Brazilian Unified Health System. Rev Saude Publica. 2017;51:56. https://doi.org/10.1590/s1518-8787.2017051006654
https://doi.org/10.1590/s1518-8787.20170... . Recognizing the emergence of the use of electronic appliances as an auxiliary tool to healthcare⁴⁰40. Lee M, Lee H, Kim Y, Kim J, Cho M, Jang J, et al. Mobile app-based health promotion programs: a systematic review of the literature. Int J Environ Res Public Health. 2018;15(12):2838. https://doi.org/10.3390/ijerph15122838
https://doi.org/10.3390/ijerph15122838... , it can be suggested that future national studies test the introduction of applications with educational content and/or digital counseling under the prism of PHC. It is worth mentioning the promising results of interventions that use digital counseling for reducing systolic blood pressure⁴¹41. Stogios N, Kaur B, Huszti E, Vasanthan J, Nolan RP. Advancing digital health interventions as a clinically applied science for blood pressure reduction: a systematic review and meta-analysis. Can J Cardiol. 2020;36(5):764-74. https://doi.org/10.1016/j.cjca.2019.11.010
https://doi.org/10.1016/j.cjca.2019.11.0... .

Even if it was not the objective of the study, but a gap perceived during the process of reading and extracting original data, it is recommended that future interventions report more deeply important internal and external elements such as adoption, scope, effectiveness, implementation and maintenance, as recommended by the RE-AIM instrument⁴²42. Glasgow RE, Vogt TM, Boles SM. Evaluating the public health impact of health promotion interventions: the RE-AIM framework. Am J Public Health. 1999;89(9):1322-7. https://doi.org/10.2105/AJPH.89.9.1322
https://doi.org/10.2105/AJPH.89.9.1322... . It is recognized that processes of consistent implementation, which articulate different health professionals with different levels of experience, allow greater generalization, and greater possibility of using this information in decision-making⁴²42. Glasgow RE, Vogt TM, Boles SM. Evaluating the public health impact of health promotion interventions: the RE-AIM framework. Am J Public Health. 1999;89(9):1322-7. https://doi.org/10.2105/AJPH.89.9.1322
https://doi.org/10.2105/AJPH.89.9.1322... . A previous systematic review suggests the weakness of reports on the Brazilian school-based interventions in the domains of adoption, implementation, and maintenance⁴³43. Silva JA, Gonçalves ECA, Silva DAS, Silva KS. Programas de intervenção para atividade física nas escolas brasileiras: revisão com base no modelo RE-AIM. Cienc Saude Coletiva. 2019;24(9):3443-56. https://doi.org/10.1590/1413-81232018249.23502017
https://doi.org/10.1590/1413-81232018249... .

Recognizing that the effectiveness of an intervention is directly related to how it is implemented, future studies are recommended to evaluate, in a broader perspective, the process of delivering these strategies, not disregarding the specificities of the SUS PHC settings. Thus, some starting points may be listed, such as: (I) prior recognition of the territories and their respective health needs, by approaching residents and community health agents; (II) permanent dialogue with the many PHC actors, in order to acknowledge the different possibilities of action, and encourage the articulated engagement of the multiprofessional team, from the initial proposal negotiations to the evaluation process; and, (III) expanded health approaches beyond the “AF theme”, developed in groups and complying with the logic of PHC.

This review has some limitations, such as (I) the little conceptual report of the elements that make up the intervention, (II) the congruence of strategies developed in SUS spaces with national policies on PHC, as well as the use of different (III) intervention designs, (IV) populations and contexts, and (V) PA indicators. Given these heterogeneities, we chose not to conduct the meta-analysis. On the other hand, as a major strength, it may be highlighted the more specific focus on educational strategies, which allowed the identification of important gaps, such as absence of reports on the pedagogical guidelines of the interventions, and on the consonance of protocols with the ideals of health promotion in Brazil.

Finally, the available set of Brazilian interventions suggests that the educational approaches produced some positive effects on different PA indicators, highlighting counseling as the main strategy used, and the approaches that involved other health themes, such as nutrition and stress. However, considering the several determinants of PA in Brazil, it is important that future interventions be conducted in different locations of the country, so as to comprehensively evaluate their processes of implementation and articulation with the different professionals working in PHC.

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