Placing Design and Delivery at the Forefront of Physical Activity Intervention

As we move toward the fifth decade of intensive research on how to promote moderate and vigorous physical activity, our behavior change results thus far are very humbling (1). These modest results in behavior change clearly demonstrate room to improve. Past research has been focused highly on the specific content of the intervention — whether it is targeting the benefits and barriers of physical activity or strategies to improve self-regulation. In the current issue of the Journal, Morgan et al. (3) overview a conceptual model that places intervention design and delivery alongside intervention content and suggest that these factors are of equal importance to the success of the intervention because they foster sociocultural relevance. The concepts within the model are not novel, as the authors acknowledge throughout the article. Furthermore, cultural targeting within interventions has been a suggested focus in health behaviors for many years (4). What makes the model potentially useful for future interventions is the culmination of all of these concepts together in a simple integrated form for various phases of intervention testing. The separation of content as only one of four aspects in the model (i.e., from format, facilitator, and pedagogy) also helps position intervention delivery and design as critical factors to the success of intervention outcomes that interact with intervention content. This has direct relevance to the potential limitations of past research efforts, where null results in behavior change often are traced to a failure to change the putative mediator (6). Thus, our current theories, if delivered in a culturally benign format for the target group, are expected not to engender change. Morgan et al. (3) also highlight the critical importance of fieldwork, experience, and pedagogical aspects to intervention design and delivery and how these often are contrary to trial reporting. Indeed, in my experience (and from discussions with other trial researchers), many of the narratives behind the success or failure of a trial involve design and delivery aspects highlighted in the article. These factors often comprise the interesting elements that do not enter into the formal publication yet represent valuable lessons learned. This conceptual model may aid researchers in reporting on these delivery and design features. Despite the helpful integrated model proposed by Morgan et al. (3), there are limits to whether this approach will improve physical activity outcomes. First, as the authors note, the model is built mainly on subjective/experiential lessons learned. Although it seems reasonable to assume that factors such as intervention format and delivery are important to intervention success, the effectiveness of behavior change based on these elements has been relatively underwhelming in the limited research thus far (1). Continued experimental research on program delivery and intervention design is needed. We also need to continue to examine how cultural groups are formed and defined. As Morgan et al. (3) highlight, cultural targeting often is used interchangeably with ethnicity, but shared beliefs and values likely are the critical composites for targeting a group. For example, the very successful Football Fans in Training trial (2), delivered to Scottish soccer fans, demonstrates one possible form of more unconventional targeting. Cultural targeting relevant for engendering physical activity behavior change is a key continued research focus. Finally, although program design and delivery are the prominent features in the model, this does not alleviate the continued improvement needed to understanding physical activity determinants in the form of content. A move away from the more rational approaches to physical activity change, highlighted in traditional social cognitive theories, to more affective and reflexive/automatic bases for behavior change (5) likely is needed no matter how much we top-dress an intervention. Acknowledgments Disclosure of funding: R.E.R. is supported by a Canadian Cancer Society Senior Scientist Award and the Right to Give Foundation with additional funds from the Canadian Cancer Society, the Social Sciences and Humanities Research Council of Canada, and the Canadian Institutes for Health Research.

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