Blackburn et al. International Journal of Behavioral Nutrition and Physical Activity (2020) 17:53 https://doi.org/10.1186/s12966-020-00957-0 REVIEW Open Access The effectiveness and complexity of interventions targeting sedentary behaviour across the lifespan: a systematic review and meta-analysis Nicole E. Blackburn1*, Jason J. Wilson1, Ilona I. McMullan1, Paolo Caserotti2, Maria Giné-Garriga3,4, Katharina Wirth5,6, Laura Coll-Planas7,8, Sergi Blancafort Alias7,8, Marta Roqué7,8, Manuela Deidda9, Andrew T. Kunzmann10, Dhayana Dallmeier5,11 and Mark A. Tully1,12 Abstract Background: Evidence suggests that sedentary behaviour (SB) is associated with poor health outcomes. SB at any age may have significant consequences for health and well-being and interventions targeting SB are accumulating. Therefore, the need to review the effects of multicomponent, complex interventions that incorporate effective strategies to reduce SB are essential. Methods: A systematic review and meta-analysis were conducted investigating the impact of interventions targeting SB across the lifespan. Six databases were searched and two review authors independently screened studies for eligibility, completed data extraction and assessed the risk of bias and complexity of each of the included studies. Results: A total of 77 adult studies (n=62, RCTs) and 84 studies (n=62, RCTs) in children were included. The findings demonstrated that interventions in adults when compared to active controls resulted in non-significant reductions in SB, although when compared to inactive controls significant reductions were found in both the short (MD -56.86; 95%CI -74.10, -39.63; n=4632; I2 83%) and medium-to-long term (MD -20.14; 95%CI -34.13, -6.16; n=4537; I2 65%). The findings demonstrated that interventions in children when compared to active controls may lead to relevant reductions in daily sedentary time in the short-term (MD -59.90; 95%CI -102.16, -17.65; n=267; I2 86%), while interventions in children when compared to inactive controls may lead to relevant reductions in the short-term (MD -25.86; 95%CI -40.77, -10.96; n=9480; I2 98%) and medium-to-long term (MD -14.02; 95%CI -19.49, -8.55; n=41, 138; I2 98%). The assessment of complexity suggested that interventions may need to be suitably complex to address the challenges of a complex behaviour such as SB, but demonstrated that a higher complexity score is not necessarily associated with better outcomes in terms of sustained long-term changes. (Continued on next page) * Correspondence: ne.blackburn@ulster.ac.uk 1 Centre for Health and Rehabilitation Technologies, Institute of Nursing and Health Research, School of Health Sciences, Ulster University, Newtownabbey, United Kingdom Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Blackburn et al. International Journal of Behavioral Nutrition and Physical Activity (2020) 17:53 Page 2 of 18 (Continued from previous page) Conclusions: Interventions targeting reductions in SB have been shown to be successful, especially environmental interventions in both children and adults. More needs to be known about how best to optimise intervention effects. Future intervention studies should apply more rigorous methods to improve research quality, considering larger sample sizes, randomised controlled designs and valid and reliable measures of SB. Keywords: Sedentary behaviour, Systematic review, Meta-analysis, Complex interventions, Children, Adults Introduction time. Environmental interventions may aim to modify Sedentary behaviour (SB) is defined as any waking be- home, school and/or workplace layouts as well as re- haviour where the energy expenditure is low and the structuring outdoor spaces and/or facilities to reduce predominant posture is sitting, reclining or lying [1]. SB sedentary time [22, 23]. Behavioural interventions focus is a multi-faceted and complex behaviour which is accu- on theory driven approaches that have the potential to mulated in multiple domains such as work, school or influence behavioural determinants to promote healthier home, during transport and leisure time [2]. Accumulat- behaviours [24, 25]. Mixed approach interventions can ing evidence suggests that SB is associated with poor include a combination of both environmental and behav- health outcomes [3, 4]. These relationships appear to re- ioural components [26]. main after statistical adjustment for physical activity While there is limited information about the minimal (PA) levels. However, recent research in adults has indi- amount of SB change required to produce meaningful cated that MVPA can attenuate the risk of all-cause health benefits, a recent systematic review by Peachey mortality of high levels of SB [5, 6]. There remains et al. [27] suggested that a 30-minute per day reduction therefore some debate as to the independence or inter- in SB could be an effective threshold for observing long- dependence of these two behaviours [7]. SB is an estab- term health benefits, such as improving cardiometabolic lished risk factor for cardiovascular disease, type 2 dia- risk biomarkers. One of the main challenges when asses- betes and all-cause mortality [8, 9], as well as an sing the effectiveness of interventions, is addressing the emerging risk factor for several cancers [10, 11]. In the issues that arise when a range of approaches have been UK, it has been estimated that chronic disease associated applied and a variety of components are included in the with SB costs the NHS £0.7bn per annum in direct intervention design to improve the same outcome. The healthcare costs [12]. Medical Research Council (MRC) published an updated Accordingly, many European countries have now in- framework for the development and evaluation of com- corporated recommendations to reduce SB and break up plex interventions in 2019 [28]. Within this framework, sitting time as part of their PA guidelines [13, 14]. The one of the key considerations is understanding the range SB activities and contexts of primary concern include of effects and how they vary dependent on the context TV viewing and other screen-focused behaviours as well (i.e. among recipients, between sites and over time) and as prolonged sitting within domestic, school, workplace the causes of that variation (i.e. variability in individual and transportation environments [15, 16]. Additionally, level outcomes). In addition, the guidelines consider the throughout the various stages of life, people spend time active components (i.e. variants of a package of care) in different social (i.e. friends, students, colleagues, fam- and complexity of the intervention and how they influ- ily) and organisational environments (i.e. school and ence or impact the effect [28]. One of the novel aspects work) [17], and so SB is age and life stage dependent. SB of this review is that, in addition to establishing effect- at any age may have significant consequences for health iveness, this review aims to understand the causal mech- and well-being [18–20]. It is also influenced by multiple anisms (i.e. something that can explain the observed factors that operate at an individual, social and institu- effect) that produce effective outcomes (i.e. reduce SB) tional level. Consequently, interventions should be that can be applied to intervention development. context-specific and relevant to the population segments Although a number of previous reviews have been con- being targeted [17, 21], and the need to develop and ducted on the effectiveness of SB interventions, most evaluate behaviour-specific, multicomponent, complex focus on specific settings [23] or population groups [27, interventions that incorporate effective strategies to 29, 30]. Interventions in these reviews vary in their com- reduce SB are essential. plexity, but this has not previously been investigated. A variety of strategies and frameworks have been ap- There is therefore a need to comprehensively review the plied to SB interventions including, individualised and full range of interventions by both setting and target, community-based tailoring, incorporating environmen- taking into account both effectiveness and complexity, tal, behavioural or mixed approaches to reducing sitting as these factors contribute to the scaling up of public Blackburn et al. International Journal of Behavioral Nutrition and Physical Activity (2020) 17:53 Page 3 of 18 health programmes to address SB in the population. of disagreement were resolved by a third-party adjudica- Therefore, the aim of this systematic review was to syn- tor, with included studies agreed by consensus. thesise and evaluate the effectiveness of SB interven- tional approaches to reduce sedentary time across the lifespan and establish the relationship between complex- Data Extraction ity and effectiveness. Characteristics of the included studies were independ- ently extracted by two authors (NEB, JJW, IIM, PC, MGG, LCP, KW, SBA and MAT) including: sample size, Methods age of participants, study design, intervention type, set- Study Inclusion Criteria ting, SB outcome, assessment tool, outcome measure, The process of review was reported according to the length of intervention, underlying behavioural theory, PRISMA Statement guidelines [31]. Studies were eligible and details of the control or comparison group. SB data for inclusion if they met the following criteria: [1] any (mean, standard deviation (SD)) were extracted and en- intervention of any length, frequency, and intensity tar- tered into Review Manager (RevMan) (Version 5.3. geting SB; [2] study designs with a control or compari- Copenhagen: The Nordic Cochrane Centre, The Cochrane son group (e.g. usual care, alternative intervention) Collaboration, 2014). where the primary aim was to change the SB of individ- uals assessed by self-report (e.g., questionnaires) or device-based measures (e.g., accelerometer data); [3] Risk of Bias community-dwelling (i.e. not institutional care); [4] SB Authors independently assessed the risk of bias of each was a reported outcome and [5] published in a peer- of the included studies using an adaptation of the reviewed English language journal. Cochrane risk of bias tool [32]. Studies were appraised According to our aim of assessing effectiveness of the based on selection bias (i.e. random sequence gener- interventions, all outcomes relating to SB (self-reported or ation, allocation concealment), detection bias (i.e. blind- device-based measures) such as sedentary time, leisure or ing of study personnel), attrition bias (high is less than occupational sitting time, transport time, screen, media or 70% at follow-up) and the validity of the outcome meas- television time were included. For the assessment of the ure included in the study (i.e. device-based versus self- effectiveness of SB interventions, studies had to include a reported measures). A judgement of ‘low risk’, ‘high risk’, control group. As per Martin et al. [29], we included stud- or ‘unclear risk’ of bias was selected for each of the do- ies with any type of comparator, considering inactive con- mains. We considered that studies had a high risk of bias trols such as; no intervention, waiting list, attention when at least one of the criteria were judged as having a control (e.g. general health information), and usual care high risk of bias in any one of the criteria. Overall risk of (e.g. general lifestyle counselling), as well as active com- bias was assessed as unclear if one or more of the cri- parisons against alternative treatment conditions (e.g. a teria was assessed as unclear, but none were assessed as structured exercise programme). having a high risk of bias. Search Strategy GRADE Assessment Relevant databases were searched using a search strategy The GRADE (Grading of Recommendations, Assess- adapted from previous reviews [29, 30]. A comprehen- ment, Development and Evaluations) is a systematic sive search was performed up to 1 May 2019 using framework developed by Cochrane for rating the cer- MEDLINE, PsycINFO, Web of Science, EMBASE, Phys- tainty of evidence in systematic reviews and other evi- ical Education Index, and SPORTDiscus. Keywords and dence syntheses [33]. Two authors (NEB and IIM) title/abstract words related to exposure (sedentary life- independently assessed the quality of evidence using the style, sitting or lying, screen time, media time, driving) Cochrane GRADE assessment tool. An overall GRADE and intervention (intervention studies, health promotion, quality rating was applied to a body of evidence across health education, behaviour change) were used. The outcomes, usually by taking the lowest quality of evi- search strategy was developed by authors (ATK, MAT dence from all the outcomes that were critical to deci- and NEB) and is provided in Supplement A. Reference sion making. For each of risk of bias, imprecision, lists of the included studies and related systematic re- inconsistency, indirectness, and publication bias, authors views were examined to identify any additional studies. had the option of decreasing their level of certainty one Authors (ATK, NEB, MAT and JJW) independently or two levels based on the evidence available for that reviewed titles and abstracts for inclusion. Two authors outcome. All cases of disagreement were resolved by a (NEB and MAT) then reviewed the full text of the third-party (MR), with the overall certainty of evidence remaining articles to determine final inclusion. All cases agreed by consensus. Blackburn et al. International Journal of Behavioral Nutrition and Physical Activity (2020) 17:53 Page 4 of 18 Complexity Assessment Corp) where r-value and significance (p-value) statistics The Cochrane Collaboration’s intervention Complexity were considered. Assessment Tool for Systematic Reviews was used to as- sess the complexity of the included intervention studies Results [34]. The tool comprises ten dimensions and facilitates Search Results an in-depth, systematic assessment of the complexity of The search of the selected databases returned 24,130 po- interventions. The level of complexity for each of the in- tentially relevant studies, with 9,206 duplicates removed cluded studies was determined based on the assessment using Endnote (vX7.7.1. Toronto Canada: Thomson levels of the core and optional dimensions. Each dimen- Reuters Cord, 2016). A total of 14,924 potentially rele- sion was graded as ‘simple’, ‘moderately complex’ or vant studies remained for title, abstract and key word ‘complex’ based on the criteria for each of the ten com- screening. Following full-text screening and eligibility as- ponents. Studies were grouped based on intervention sessment of 426 studies, 161 studies were deemed as type (i.e. behavioural, environmental or mixed) for inter- relevant and were included in the narrative synthesis, ventions targeting adults (18 years and over) and chil- with 126 included in the meta-analysis. Figure 1 presents dren (aged under 18 years). The global score for each the identification, screening, eligibility and inclusion of included study was calculated by the sum of the individ- studies within this systematic review [31]. ual rating scores (simple = 1, moderately complex = 2, complex = 3). Two authors independently appraised Included Studies intervention complexity of all included studies, with dis- Within the 161 studies included in the narrative synthe- crepancies resolved through discussion. sis, 77 interventions [35–110] related to adults (mean age range: 26-76 years) while 84 interventions [64, 74, Statistical Analysis 108, 111–191] targeted children (mean age range: 2-19 The included studies were grouped depending on inter- years). The adult studies consisted of 62 randomised vention type (behavioural, environmental and mixed), controlled trials (RCTs) of which nine were cluster RCTs length of follow-up (≤6 months, >6 months), age group and five were randomised cross-over trials. In addition, of participants (children and adults), and control (active 15 studies employed a quasi-experimental design, of and inactive). A separate meta-analysis was performed which thirteen controlled before and after trials, one was based on the groupings listed above to calculate the a natural experiment, and one an interrupted time series. pooled effect sizes for SB. The difference between the The studies in children included 62 RCTs of which 23 intervention groups and control/comparison group in were cluster RCTs and two were randomised cross-over the mean change from baseline to post-intervention and trials. A further 22 employed a quasi-experimental de- the comparison at follow-up were used as a measure of sign, of which 16 were controlled trials, five cluster effect size. Separate meta-analyses were conducted for controlled before and after trails, and one natural experi- children and adults as we expected the type, context and ment. The control group participants received one of outcomes of the interventions to differ based on their the following conditions: inactive (i.e. no intervention, life stage. Where study authors reported multiple trial waitlist control) or active (i.e. alternative intervention, arms in a single trial, only the relevant arms were generic health-related advice). Characteristics of the included. It was assumed that there could be much vari- included studies are presented in Supplement B. ation arising from the different populations and study Most included studies measured SB using self- designs. Therefore, prior to data synthesis, the clinical reported tools. Within the adult studies, over 10 homogeneity with respect of the type of intervention, different self-reported measures were used, including type of participants and the similarity of outcomes was validated, and non-validated questionnaires. Within the assessed. Statistical heterogeneity of these groups of in- studies in children, over 20 different self-reported mea- terventions was assessed using the I-squared statistic sures were used, including validated questionnaires, [32]. The meta-analyses were conducted in RevMan non-validated parent-reported tools, and self-reported (Version 5.3. Copenhagen: The Nordic Cochrane Centre, tools. The device-based measures used in adult and chil- The Cochrane Collaboration, 2014). dren studies included: ActivPAL, ActiGraph, and Hookie The association between complexity and effectiveness AM20. Additionally, adult studies included GENEactiv, was assessed through the examination of scatter plots MyWellness Key, and Sensewear armbands. where each studies global score for complexity was plot- Within the meta-analysis, the follow-up length for 37 ted against effect size (Cohen’s D). The strength of asso- of the inactive control studies in adults was less than six ciation between complexity and effectiveness was months of which 20 were behavioural, 10 environmental, assessed using a Spearman’s rank order correlation test and seven were mixed interventions. The remaining 10 (IBM SPSS Statistics software, v23. Armonk, NY: IBM inactive control studies in adults included in the meta- Blackburn et al. International Journal of Behavioral Nutrition and Physical Activity (2020) 17:53 Page 5 of 18 Fig. 1 PRISMA flow diagram [31]. analysis had a follow-up of more than six months of with the mean score being 17.64 (SD 4.14). Results from which included five mixed, four behavioural, and one en- the complexity assessment demonstrated that environ- vironmental intervention. In 15 of the active control mental interventions were less complex in both adult studies in adults, the follow-up was less than six months and children studies. In both adult and children studies, of which nine were behavioural, five mixed, and one mixed and behavioural interventions scored as complex environmental intervention. The remaining four active in relation to two dimensions including, the active com- control studies in adults included in the meta-analysis ponents of the intervention and the behaviours or had a follow-up of more than six months and were actions to which the intervention was directed. Mixed mixed interventions. interventions carried out in children were scored as In 35 of the inactive control studies in children the complex in relation to the degree to which the effects of follow-up was less than six months of which 18 were be- the intervention were changed by recipient or provider havioural, nine were mixed, and eight environmental in- factors. The complexity star chart for intervention stud- terventions. The remaining 24 inactive control studies in ies in adults is presented in Figure 2 and the complexity children included in the meta-analysis had a follow-up star chart for intervention studies in children is of more than six months of which included 16 mixed, presented in Figure 3. six behavioural, and two environmental interventions. In The relationship between complexity and effectiveness 11 of the active control studies in children the follow-up by Cohen’s D effect size are presented in Figures 4 and 5. was less than six months of which four were behavioural A Spearman’s rank-order correlation assessed the relation- and seven were mixed interventions. The remaining ship, resulting in a non-significant relationship (r=-0.23; three active control studies in children included in the p=0.799), suggesting that for these interventions, there meta-analysis had a follow-up of more than six months was no increased effectiveness with more complex of which included two mixed and one behavioural interventions. intervention. Risk of Bias Assessment Complexity Assessment The individual risk of bias assessment is included in Each of the included studies were assessed for the level Supplement C. of complexity of the intervention components using the Cochrane Complexity Assessment Tool [34]. There was Adult Interventions (n=77 studies) significant variety in the level of complexity of the in- Seventeen studies were rated as high risk for selection cluded studies where global scores for complexity ranged bias due to lack of detail regarding the randomisation from 10/30 (least complex) to 30/30 (most complex), process or because they were non-randomised. Three Blackburn et al. International Journal of Behavioral Nutrition and Physical Activity (2020) 17:53 Page 6 of 18 Fig. 2 Complexity Score for Interventions in Adults [34]. studies were rated as unclear due to a lack of informa- how the random sequence was generated. Regarding de- tion regarding how the random sequence was generated. tection bias, 48 studies did not report whether the study Regarding detection bias, 26 studies did not report personnel were blinded to the intervention and were whether the study personnel were blinded to the inter- rated to be unclear risk for detection bias. Seventeen vention and were rated to be unclear risk for detection studies were blinded and rated as low risk, with the bias. Twenty-six studies were blinded and rated as low remaining 19 studies rated as high risk as there was no risk, with the remaining 25 studies rated as high risk as allocation concealment. Fifteen studies were rated as there was no allocation concealment. Eight studies were high risk of attrition bias. The validity of the outcome rated as a high risk of attrition bias, two studies were measure included in the study was assessed for risk of rated as unclear as they gave no indication of the num- bias. Forty-nine studies included self-reported measures ber of participants returning for post-intervention and were rated as high risk, with the remaining 35 stud- follow-up. The validity of the outcome measure included ies rated as low risk due to the inclusion of device-based in the study was also assessed for risk of bias. Thirty measures. The largest risk of bias for the children inter- studies included self-reported measures of SB and were ventions came from the validity of the outcome measure, rated as high risk, with the remaining 47 studies rated as with almost 60% of studies including self-reported mea- low risk due to the inclusion of device-based measures. sures of SB. A summary of the risk of bias assessment in The largest risk of bias for the adult interventions came children is shown in Figure 7. from the validity of the outcome measure, with almost 40% of studies including self-reported measures of SB. A summary of the risk of bias assessment in adults is Effectiveness shown in Figure 6. Of the 161 studies included in the review, 126 studies provided data for inclusion in the meta-analysis. Studies Children Interventions (n=84 studies) were excluded from the meta-analysis due to insufficient Seventeen studies were rated as high risk for selection data provided (i.e. did not provide a measure of bias as they were non-randomised. Seven studies were variance) or the study’s SB outcome measures were rated as unclear due to a lack of information regarding inappropriate data types for meta-analyses. Blackburn et al. International Journal of Behavioral Nutrition and Physical Activity (2020) 17:53 Page 7 of 18 Fig. 3 Complexity Score for Interventions in Children [34]. Fig. 4 Relationship Between Complexity and Effectiveness of Interventions in Adults* Blackburn et al. International Journal of Behavioral Nutrition and Physical Activity (2020) 17:53 Page 8 of 18 Fig. 5 Relationship Between Complexity and Effectiveness of Interventions in Children**Line represents linear best fit line Effects of Adult Interventions adult studies demonstrated moderate to high heterogen- Studies in adults were pooled according to the type of eity at both short and medium-term across both active intervention (i.e. behavioural, environmental or mixed), and inactive control comparators. Results for the reduc- the length of follow up (≤6 months or >6 months) and tions in percentage of daily time in SB were not robust type of control (active or inactive). The results from the due to the scarcity of data. meta-analysis of the adult studies is presented in Tables 1 and 2. Effects of Children Interventions The findings from the adult interventions that in- Studies in children were pooled according to the type of cluded an inactive control demonstrated a clinically intervention (i.e. behavioural, environmental or mixed), meaningful effect in the short-term i.e. ≤6 months [24]. the length of follow up (≤6 months or >6 months) and The findings from the environmental and mixed inter- type of control (active or inactive). The results from the ventions in the medium-term demonstrated a moderate meta-analysis of the children studies is presented in but relevant reduction in daily SB. The results from the Tables 3 and 4. Fig. 6 Risk of Bias - Interventions in Adults Blackburn et al. International Journal of Behavioral Nutrition and Physical Activity (2020) 17:53 Page 9 of 18 Fig. 7 Risk of Bias - Interventions in Children The findings from the analyses of the children’s studies when compared to inactive controls became non- demonstrated moderate reductions in daily SB with be- significant in the short term (-23.13; 95%CI -66.47, havioural, environmental and mixed interventions that 20.21; n=3678; I2 37%). included an inactive control, in the short-term. Results for the reductions in percentage SB time were not very GRADE Assessment robust due to the scarcity of data. Furthermore, findings The GRADE approach was used to assess the certainty for behavioural and mixed in the medium-term were in- in evidence across all outcomes. The overall GRADE conclusive due to the lack of studies included in this quality rating and scoring for risk of bias, imprecision, outcome. The results from the children studies demon- inconsistency, indirectness, and publication bias are pre- strated extreme heterogeneity in behavioural interven- sented in Supplement D. Due to the high heterogeneity tions at short-term and mixed interventions at medium- across the outcomes, the majority were ranked as having term across the inactive control comparator outcomes. a very low to low certainty of evidence. Within the active control outcomes, extreme heterogen- eity was demonstrated in mixed interventions at short- Discussion term. In a sensitivity analysis, studies including children The findings of the review have shown that behavioural aged less than five were removed as potentially their en- and environmental interventions in adults resulted in a vironments may differ. Mixed interventions in children significant short-term (≤6 months) reduction in SB and Table 1 Effectiveness of SB Interventions in Adults Compared to an Inactive Control Subgroup 1: Behavioural Studies (n=) I (n=) C (n=) I2 MD (95%CI) Outcome 1: SB min/day (≤6mo) 19 1179 1015 83% -60.57 [-86.67, -34.46] Outcome 2: SB min/day (>6mo) 4 701 501 63% -7.30 [-28.98, 14.38] Outcome 3: SB percentage (≤6mo) 1 56 63 N/A -1.02 [-3.03, 0.99] Subgroup 2: Environmental Studies (n=) I (n=) C (n=) I2 MD (95%CI) Outcome 1: SB min/day (≤6mo) 8 181 167 86% -64.05 [-104.64, -23.46] Outcome 2: SB min/day (>6mo) 1 222 264 N/A -35.20 [-80.94, 10.54] Outcome 3: SB % (≤6mo) 2 52 49 0% -13.95 [-15.33, -12.56] Subgroup 3: Mixed Studies (n=) I (n=) C (n=) I2 MD (95%CI) Outcome 1: SB min/day (≤6mo) 7 552 526 87% -42.63 [-77.62, -7.63] Outcome 2: SB min/day (>6mo) 5 1797 1052 72% -30.25 [-52.92, -7.58] Overall Results Studies (n=) I (n=) C (n=) I2 MD (95%CI) Outcome 1: SB min/day (≤6mo) 34 1912 1708 83% -56.86 [-74.10, -39.63] Outcome 2: SB min/day (>6mo) 10 2720 1817 65% -20.14 [-34.13, -6.16] Outcome 3: SB % (≤6mo) 3 108 112 98% -9.80 [-10.94, -8.65] Blackburn et al. International Journal of Behavioral Nutrition and Physical Activity (2020) 17:53 Page 10 of 18 Table 2 Effectiveness of SB Interventions in Adults Compared to an Active Control Subgroup 1: Behavioural Studies (n=) I (n=) C (n=) I2 MD (95%CI) Outcome 1: SB min/day (≤6mo) 9 404 384 87% -36.69 [-76.23, 2.86] Outcome 2: SB min/day (>6mo) 4 145 152 69% -3.77 [-20.95, 13.41] Subgroup 2: Environmental Studies (n=) I (n=) C (n=) I2 MD (95%CI) Outcome 1: SB min/day (≤6mo) 1 15 16 N/A 2.58 [-57.81, 62.97] 2 Subgroup 3: Mixed Studies(n=) I(n=) C(n=) I MD (95%CI) Outcome 1: SB min/day (≤6mo) 3 88 97 0% -11.13 [-35.60, 13.33] Outcome 2: SB min/day (>6mo) 1 24 12 N/A -29.60 [-72.36, 13.16] Outcome 3: SB percentage (≤6mo) 2 35 36 0% -1.29 [-4.01, 1.43] 2 Overall Results Studies (n=) I (n=) C (n=) I MD (95%CI) Outcome 1: SB min/day (≤6mo) 13 507 497 81% -25.89 [-53.51, 1.73] Outcome 2: SB min/day (>6mo) 5 169 164 62% -6.49 [-22.34, 9.37] Outcome 3: SB percentage (≤6mo) 2 35 36 0% -1.29 [-4.01, 1.43] interventions using a mix of strategies resulted in a sta- is not without limitations. The tool is designed to be ap- tistically significant reduction in SB. In both the short plied in reviews including a group of very similar inter- and medium-term. The heterogeneity of the results was ventions. However, interventions included within the high in all cases, reducing the confidence in the current review varied in terms of the active components, consistency of the findings, in addition, the GRADE as- the degree of tailoring and the nature of the causal path- sessment demonstrated very low certainty of evidence ways between the intervention and outcome. In order to against the relevant outcomes. In children, SB interven- avoid poor reporting, interventions were grouped based tions with short-term follow-up (≤6 months) resulted in on their type (i.e. behavioural, environmental or mixed), a statistically significant difference in favour of the inter- whether the intervention included an active or inactive vention. Overall, there was high heterogeneity and the control and the length of follow-up. These steps were GRADE certainty of evidence assessment was rated low. taken in order to avoid misinterpretation of data and For both adult and children studies, the complexity as- promote comparison between similar studies as the tool sessment revealed no association between effect size and intends. One of the main benefits of using this tool is complexity of the intervention, suggesting that complex- that it facilitates an in-depth, systematic assessment of ity has no impact on the effectiveness of interventions. It the complexity of interventions, leading to an increased is important to recognise that the complexity assessment understanding of how complex interventions work [34]. Table 3 Effectiveness of SB Interventions in Children Compared to an Inactive Control Subgroup 1: Behavioural Studies (n=) I (n=) C (n=) I2 MD (95%CI) Outcome 1: SB min/day (≤6mo) 18 2490 2632 99% -27.20 [-46.99, -7.40] Outcome 2: SB min/day (>6mo) 6 1629 1567 87% -6.20 [-26.42, 14.02] Subgroup 2: Environmental Studies (n=) I (n=) C (n=) I2 MD (95%CI) Outcome 1: SB min/day (≤6mo) 8 255 237 77% -18.57 [-40.12, 2.99] Outcome 2: SB min/day (>6mo) 2 41 41 0% -8.75 [-17.18, -0.32] Subgroup 3: Mixed Studies (n=) I (n=) C (n=) I2 MD (95%CI) Outcome 1: SB min/day (≤6mo) 6 1941 1925 37% -27.41 [-51.18, -3.63] Outcome 2: SB min/day (>6mo) 15 18710 19150 99% -17.54 [-24.15, -10.92] Outcome 3: SB % (≤6mo) 3 627 435 0% -1.70 [-2.93, -0.48] Overall Results Studies (n=) I (n=) C (n=) I2 MD (95%CI) Outcome 1: SB min/day (≤6mo) 32 4686 4794 98% -25.86 [-40.77, -10.96] Outcome 2: SB min/day (>6mo) 23 20380 20758 98% -14.02 [-19.49, -8.55] Outcome 3: SB % (≤6mo) 3 627 435 0% -1.70 [-2.93, -0.48] Blackburn et al. International Journal of Behavioral Nutrition and Physical Activity (2020) 17:53 Page 11 of 18 Table 4 Effectiveness of SB Interventions in Children Compared to an Active Control Subgroup 1: Behavioural Studies (n=) I (n=) C (n=) I2 MD (95%CI) Outcome 1: SB min/day (≤6mo) 4 87 90 0% -48.26 [-69.83, -26.69] Outcome 2: SB min/day (>6mo) 1 255 176 N/A -4.00 [-13.16, 5.16] 2 Subgroup 3: Mixed Studies (n=) I (n=) C (n=) I MD (95%CI) Outcome 1: SB min/day (≤6mo) 4 46 44 91% -74.73 [-152.36, 2.90] Outcome 2: SB min/day (>6mo) 1 22 22 N/A 19.14 [-3.46, 41.74] Outcome 4: SB % (>6mo) 1 39 37 N/A 3.17 [-7.60, 13.94] Overall Results Studies (n=) I (n=) C (n=) I2 MD (95%CI) Outcome 1: SB min/day (≤6mo) 8 133 134 86% -59.90 [-102.16, -17.65] Outcome 2: SB min/day (>6mo) 2 277 198 71% 5.17 [-17.01, 27.35] Outcome 4: SB % (>6mo) 1 39 37 N/A 3.17 [-7.60, 13.94] Adult Interventions CI -20 to -2) [192]. Similarly, the current study found Our findings are supported by previous systematic re- greater reductions in SB were evident at short-term views in adults [23, 27, 29, 30], demonstrating that the compared to medium-term across all outcomes with the interventions had a positive effect on reducing SB. In exception of mixed interventions including an active line with the findings from Peachey et al. which included control. However, this outcome only considered one studies published up to July 2017 [27], the findings from study with a small sample size (n=36). this review demonstrated the greatest reduction in sit- In terms of determining whether these reductions in ting time from environmental interventions. These find- daily SB are clinically meaningful, Healy and colleagues ings are interesting considering that the global have modelled the impact of reallocating two daily hours complexity scores in environmental interventions were of sitting to standing or to stepping on cardio-metabolic considerably lower than that of behavioural and mixed risk factors in adults [193]. This two-hour reduction is interventions. This suggests that within certain contexts in line with recommendations from Public Health where there is more control (i.e. workplace settings), less England and the Active Working Community Interest complex interventions targeting environmental determi- Company for office-based workers [194]. They found nants may be required. This finding is supported by a significant associations with sitting-to-standing realloca- previous review by Gardner and colleagues [24] focusing tions included small-to-medium reductions in fasting on behaviour change strategies used in SB reduction in- plasma glucose (2%), triglycerides (11%) and total/HDL- terventions among adults, where interventions based on cholesterol ratio (6%) while sitting-to-stepping realloca- environmental restructuring, persuasion, or education tions were significantly associated with medium reduc- were the most promising in terms of reducing SB. They tions in body mass index (11%), waist circumference also highlighted the most promising behaviour change (7.5cm), triglycerides (14%) and two-hour plasma glu- techniques were self-monitoring, problem solving, and cose (11%) [193]. Despite the comparatively smaller re- restructuring the social or physical environment [24]. ductions in SB time found in our review, these changes Many of the environmental interventions included in in SB could still have a clinically meaningful impact on the current review were based in the workplace and adult’s health as a 30-minute per day reduction in daily mainly involved adding height-adjustable desks or stand- sitting time has been suggested as an effective target for ing tables. However, most provided few details to indi- observing long-term health benefits in another system- viduals on how to effectively use the new apparatus atic review [27]. which could account for the lack of change in daily SB Although this review appears to demonstrate the time. Additionally, individuals may have needed extra potential utility of SB-reducing interventions in adults in behavioural elements to sustain the change (e.g. educa- the medium-term (i.e. >6 months), stronger evidence tion on the benefits of reducing sitting in the long-term exists for SB-reducing interventions in the short-term or activity trackers to provide feedback on progress to- (≤6 months). There is a need for more high-quality stud- wards goals). A systematic review of interventions for re- ies to fully consider how to effectively reduce daily SB ducing non-occupational SB in adults and older adults time in the months and years after interventions have found that interventions could reduce leisure sitting time been implemented. Findings demonstrate that SB inter- in adults in the medium-term (-30 min/day; 95% CI -58 ventions are effective, with environmental interventions to -2), and TV viewing in the short-term (-61 min/day; demonstrating a window for opportunity. A range of 95% CI -79 to -43) and medium-term (-11 min/day; 95% theoretical frameworks were implemented across the SB Blackburn et al. International Journal of Behavioral Nutrition and Physical Activity (2020) 17:53 Page 12 of 18 interventions including, social cognitive theory, self- interventions, incorporating both behavioural and envir- determination theory and the theory of planned behav- onmental components, may increase the likelihood of re- iour. A recent systematic review described the behaviour ducing sitting time in children. A review of reviews change strategies used within interventions that sought examining interventions designed to reduce SB among to reduce SB [195]. In support of the current study, au- children and adolescents was conducted in 2013 [203]. thors concluded that interventions based on environ- Authors found that all reviews concluded some level of mental restructuring, persuasion or education were most effectiveness in reducing time spent in SB, with most effective. In addition, self-monitoring, problem solving presenting a small but significant reduction in sedentary and restructuring the social or physical environment time. Effective strategies identified from the analysis re- were particularly promising behaviour change tech- vealed that involving the family, incorporating behaviour niques. Future studies should consider theory-driven SB change techniques and including environmental compo- interventions delivered in the work-place as they could nents all positively supported the intervention effect. result in benefits for both the individual and the em- Consequently, future research should consider non- ployer, high-quality studies need to be conducted to school settings such as home or community settings or confirm these effects. seek to change curricular activity and SB policy to illicit benefits. Children Interventions A body of evidence recognises that SB in childhood may Conclusions have significant consequences for poor health outcomes The primary aim of this review was to synthesise and in adulthood [19], making the development of effective evaluate the complexity and effectiveness of current SB interventions an important public health concern [196]. interventional approaches to reduce sedentary time The current review included 84 studies in children across the lifespan. The findings of this review demon- (mean age 2-19 years) of which 62% [52] were carried strated that interventions may lead to relevant reduc- out in a school setting. All interventions with the excep- tions in daily sedentary time. However, the heterogeneity tions of those that were mixed including an active con- in reported outcomes, intervention components, and trol in the medium-term demonstrated reductions in SB. control arms (active versus inactive) prevented us from A recent systematic review of interventions to reduce SB drawing firmer conclusions from the evidence provided. in 0-5 year olds found overall mean reductions in SB of The complexity assessment also suggested that interven- -18.91 min/day; 95% CI -33.31 to -4.51 [197]. This find- tions may need to be more complex to address the ing suggests that interventions of ≥6 months duration multi-faceted nature of SB, but a higher complexity and those conducted in community settings were more score is not necessarily associated with better outcomes effective. The findings within the current review demon- in terms of sustained change. strated stronger evidence for effectiveness in the short- term, however due to a lack of studies included in the Supplementary information medium-term analysis it is difficult to compare findings Supplementary information accompanies this paper at https://doi.org/10. between the follow-up periods, and hence make conclu- 1186/s12966-020-00957-0. sions on the available evidence. Additional file 1: Supplement A. Search Strategy Studies of SB interventions targeting children are Additional file 2: Supplement B. Characteristics of Included Studies mainly carried out within a school setting due to ease of Additional file 3: Supplement C. Risk of Bias access to the target population, with a large proportion Additional file 4. Supplement D. Meta-Analysis and GRADE of their week days, during term time spent in school Assessment [198–200]. Furthermore, evidence supporting the effect of school-based interventions which target out-of-school Abbreviations activity (i.e. changes to screen time) or overall activity ATK: Andrew T. Kunzmann; GRADE: Grading of Recommendations, are varied with most finding no effect [198–200], and Assessment, Development and Evaluations; IIM: Ilona I. McMullan; JJW: Jason J. Wilson; KW: Katharina Wirth; LCP: Laura Coll-Planas; MAT: Mark A. Tully; some showing that changes are possible where curricu- MGG: Maria Giné-Garriga; MR: Marta Roqué; MRC : Medical Research Council; lum changes can be made [201]. In a systematic review NEB: Nicole E. Blackburn; PA: Physical activity; PC: Paolo Caserotti; of school-based interventions, Hegarty and colleagues RCT: Randomised controlled trial; SB: Sedentary behaviour; SBA: Sergi Blancafort Alias; SD: Standard deviation [202] demonstrated that multicomponent interventions may be an effective method for reducing device-based Acknowledgements measured SB in the short-to-medium term. In line with The work described in this publication was supported and funded by the the current review, multi-component interventions were European Union program Horizon 2020 (H2020-Grant 634270). Consortium members of the participating organisations of the SITLESS project include: most promising in terms of effectively reducing SB in Antoni Salvà Casanovas, Àlex Domingo, Marta Roqué and Laura Coll-Planas: children. These findings would suggest that mixed Health and Ageing Foundation of the Autonomous University of Barcelona, Blackburn et al. International Journal of Behavioral Nutrition and Physical Activity (2020) 17:53 Page 13 of 18 Spain; Maria Giné-Garriga, Miriam Guerra-Balic, Carme Martin-Borràs, Javier Received: 16 January 2020 Accepted: 13 April 2020 Jerez-Roig, Guillermo R Oviedo, Marta Santiago-Carrés, Oriol Sansano and Guillermo Varela: Faculty of Psychology, Education and Sport Sciences Blan- querna, Ramon Llull University, Barcelona, Spain; Emma McIntosh and Man- uela Deidda: Health Economics and Health Technology Assessment, References University of Glasgow, UK; Dietrich Rothenbacher, Michael Denkinger, Kathar- 1. Tremblay MS, Aubert S, Barnes JD, Saunders TJ, Carson V, Latimer-Cheung ina Wirth, Dhayana Dallmeier and Jochen Klenk: Institute of Epidemiology AE, Chastin SFM, Altenburg TM, Chinapaw MJM, Terminology Consensus and Medical Biometry, Ulm University, Germany; Frank Kee: Centre for Public Project Participants SBRN. 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