Theory-Based Interventions in Physical Activity: A Systematic Review of Literature in Iran

Lack of physical activity is ranked fourth among the causes of human death and chronic diseases. Using models and theories to design, implement, and evaluate the health education and health promotion interventions has many advantages. Using models and theories of physical activity, we decided to systematically study the educational and promotional interventions carried out in Iran from 2003 to 2013.Three information databases were used to systematically select papers using key words including Iranian Magazine Database (MAGIRAN), Iran Medical Library (MEDLIB), and Scientific Information Database (SID). Twenty papers were selected and studied. Having been applied in 9 studies, The Trans Theoretical Model (TTM) was the most widespread model in Iran (PENDER in 3 studies, BASNEF in 2, and the Theory of Planned Behavior in 2 studies). With regards to the educational methods, almost all studies used a combination of methods. The most widely used Integrative educational method was group discussion. Only one integrated study was done. Behavior maintenance was not addressed in 75% of the studies. Almost all studies used self-reporting instruments. The effectiveness of educational methods was assessed in none of the studies. Most of the included studies had several methodological weaknesses, which hinder the validity and applicability of their results. According to the findings, the necessity of need assessment in using models, epidemiology and methodology consultation, addressing maintenance of physical activity, using other theories and models such as social marketing and social-cognitive theory, and other educational methods like empirical and complementary are suggested.

self-esteem, mood, and reducing the risk of stress and depression are among the benefits of physical activity (WHO, 2013;Pirasteh et al., 2012;Strijk, Proper, van Mechelen, & van der Beek, 2013).
Physical inactivity is common in Iran, particularly in females and in the older age groups (Esteghamati et al., 2011). Koohpayehzadeh et al. (2014) showed that the overall prevalence of physical inactivity in Iran was increased from 15% (2007) to 21.5% (2011) Over the 4 years, 56.4%, 39.2%, and 74.4% of participants were physically inactive at work, commuting and recreation, respectively.
It has been evidently shown that 70-80% of people in Iran lack enough physical activity (Solhi, Ahmadi, Taghdisi, & Haghani, 2011;Hashemi, Rakhshani, Navidian, & Mosavi, 2013) and 65% of youth are far from reaching the recommended levels of physical activity [i.e., 30 min of moderate PA per day, five or more days of the week or vigorous PA at least 20 min per day, three or more days a week] (Saffari, Amini, Ardebili, Mahmoudi, & Sanaeinasab, 2012b).
The world is shifting towards the use of theory-based interventions to increase the level of PA. Glanz and Bishop (2010) stated that, "Increasing evidence suggests that public health and health-promotion interventions that are based on social and behavioral science theories are more effective than those lacking a theoretical base." While little success in changing behavior is documented where no theory was used, theory-based interventions have had significant success in designing effective interventions that are guided by constructs of each theory to change people's behaviors. Theory-based interventions have been associated with larger and longer-term effects than those without an explicit basis in theory (Skaal & Pengpid, 2012). The most common Theories/models in health education/promotion programs are presented in Appendix A.
Several studies have confirmed the effect of education on changing physical behavior (WHO, 2012;Moeini et al., 2010;Saffari, Shojaeezade, Ghofrani Pour, Heydarnia, & Pakporhajiagha, 2012a). To improve the effectiveness of health education programs, it is proposed to use patterns and theories. Each model or theory follows a structural sequence of planning, implementation, and evaluation. Applying these models and theories 1: helps to identify the measurable sequences of the program, 2: reveals how behaviors go through changes, 3: determines the timing of interventions, 4: helps to choose an appropriate combination of strategies, 5: improves the relationship between experts, and 6: improves the programs repetitions and boosts the effectiveness of the program (Saffari et al., 2012a).
In recent years, health education models and theories have been increasingly used in Iran as a framework for designing and implementing interventions. The aim of this review was to critical appraisal of the existing literature reported on the effectiveness of theory-based interventions in physical activity in Iran.

Search Strategy
In order to identify studies in which health education and promotion models and theories were applied, three databases including, MAGIRAN, MEDLIB, and SID were searched. These database publish scientific and peer review studies.
Studies available on these websites were selected according to (1) physical activity (2) health behavior change model (3) health education and promotion models (e.g: BASNEF), (4) the aim of the intervention (e.g: identifying the effectiveness of education), and (5) the type of the study (e.g:clinical trial and PRECEDE).
All studies were performed from 2003 to 2013. Before 2003, there were no articles that used health education and promotion models/theories in physical activity.

Selecting the Studies
The title and the abstract of the studies were saved on an electronic database for future references and reference management .all articles were selected by two authors ,independent of each other .possible disagreement were resolved by discussion and consensus. After an initial list of included studies was developed, the third author, an expert in health education and health promotion reviewed the list for completeness.

Inclusion Criteria
In order for a study to be selected, 5 criteria were defined: Studies that used health education and promotion models and theories.
Studies that aimed to investigate the effect of education using theories and models. Studies that were experimental or a quasi-experimental. www.ccsenet.org/gjhs Global Journal of Health Science Vol. 7, No. 3;2015 217 Studies that yielded physical activity as one of its main outcomes.
Studies that were published in Persian.
No limits were considered for the type of intervention, the duration of intervention, and follow-up activities.

Exclusion Criteria
Studies that were descriptive and cross-sectional.
Studies that used health education and promotion models/theories to simply investigate effective factors and determinants in physical activity.

Data Collection, Data Analysis, and Classification
To collect required data, 1) selected studies were scrutinized(rough plan, the duration of the study, etc.), 2) the features of the population were evaluated(job characteristics, etc.) and 3) the focus of the study (physical activity promotion), and 4) the way of measuring outcomes were studied (self reporting, using the instruments, etc.).

Quality Assessment Tool
We adapted methodological quality assessment for the included studies from CONSORT (Brooks, Higgins & Webster, 2010) and Chen et al , s check list(2014) .A total Methodological quality score was calculated by summing up all "yes" .studies that met 70% of the criteria ,were rated as having high methodological quality (

Results
All studies except for one case (Tabatabaei et al., 2010) showed that target intervention was effective in the promotion of physical activity. The most commonly used model in physical activity was the trans theoretical model (TTM) which was used in 9 studies. Other models and theories which were applied in the studies were the PENDER model (3 studies), the PRECEDE model (2studies), the theory of planned behavior (2 studies), the BANSEF model (2 studies), the self regulation theory (1 study), and the health belief model [HBM] (1 study).
Regarding the type of the study, all studies were experimental, except for 8 quasi-experimental studies (Table 1).
Of 20 trials, only 3 trials provided evidence of high quality. The sample size varied in different studies, ranging from 25 to 300 people. Five studies addressed maintenance of physical activity (performed in different periods of time) [Hazavehei et al,2009;Shakeri et al.,2012;Farmanbar et al, 2011;Peyman et al, 2012& Noroozi et al, 2011. Approximately 65% of the studies explained the background and their reasons for selecting the model (Table 3). With regards to the educational methods, almost all studies used a combination of methods; 65%used lectures and 35% used pamphlets. The peer education method and motivational interviewing were used in only one study (Solhi et al., 2012). As for the experiential methods, role playing was used in five and workshop in one study. The most important integrative method used in the studies was group discussion (14 studies). None of the studies measured the effectiveness of the educational method (Tables 1 and 2).

Discussion
The present review investigated the theory based intervention in PA in Iran and the effect of these interventions.

Main Results
Approximately all the studies conducted in Iran focused on the individual or intrapersonal level, and individuals were the primary target audience of the health education materials.
All studies except for one case stated that target intervention was effective in the promotion of physical activity.
The studies were heterogeneous and had different sample sizes (ranging from 25-300). All the studies relied on self-reporting. The interventions differed in target populations, duration of intervention, and settings. Of 20 trials, only 3 provided evidence of high quality.
Almost all studies used a combination of methods. PA maintenance was not addressed in 75% of the studies.

Summary of the Lessons Learned From This Review
Most of the studies that conducted in Iran had methodological weaknesses.
In30-40% of the studies, the reasons for choosing the theories/models were not specified.
The social and ecological models were not addressed, Although social marketing and social-cognitive theory are applicable models/theories in physical activity, we could not find any records that were designed and implemented based on these models/theories in Iran.

Theoretical Basis for Intervention
Of nine studies based on TTM, all reported positive results in the treatment group. When compared to the control group, the treatment group had a significant progress during the stages of change and TTM constructs (Table 1).
Of two studies based on TPB, Tabatabaee et al. (2010) reported that TPB did not lead to an increase in physical activity. Azjen and Fishbein (2004) showed that the predictability of TPB differed from behavior to behavior and from population to population.
In Iran, only three studies had the inclusion criteria of PENDER.all of these studies had some positive results.
In studies performed by Saffari et al. Only two studies contained BASNEF inclusion criteria. They did not deal with the application of BASNEF model in physical activity studies,but the maintenance of physical activity was addressed in studies by Hazavehei et al. (2009),4 months after the interventions and Shakeri et al(2012),6 weeks after the intervention.

Overall Completeness and Applicability of Evidence
Of twenty trials, 7 were conducted in the school/university and 3 in the workplace. the others were conducted in clinical settings .Most studies included promotion of PA as a main objective. All of them provided multiple sessions. One trial focused on elderly people. Almost all studies used a combination of methods.
Methods are the means or ways that we use to deliver the material to our clients. In a classification, educational methods are divided into three categories: 1) reinforcement methods 2) integrative methods and 3) experiential methods (Saffari et al, 2012a). Most educators agree that reinforcement methods such as lectures are necessary (Saffari et al., 2012a;Tyler et al., 2009), but they believe that they should be limited in number and well delivered. It is important to give the learners the opportunities to apply and reflect on lecture material during course time.Our findings showed that the most important educational methods that were used in the studies were the reinforcement method (65% used lectures). Lectures are efficient ways of delivering information. but the weaknesses of lecture should be considered.
Traditionally, small groups consist of 8-12 participants. Small groups can take on a variety of different tasks, including problem solving, role play, discussion, brainstorming, debate, workshops, and presentations. In our study, the most widely used integrative educational method was group discussion.
The main advantages of small group learning are that it encourages active learning and develops communication and teamwork skills.
The peer education method and motivational interviewing were used in only one study.

Limitations and Quality of the Evidence
Of 20 trials, only 3 provided evidence of high quality (Table 3). www.ccsenet.org/gjhs Global Journal of Health Science Vol. 7, No. 3; All the studies reviewed here relied on self-reporting (except for Moeini et al, 2010). The reliability of self-reporting is questionable .Because of social desirability and other types of information bias, self report is not the most reliable indicator of behavior (Lopez, Tolley, Grimes, Chen, & Stockton, 2013).
Choosing a theory should start with a "thorough assessment of the situation: the units of analysis or change, the topic, and the type of behavior to be addressed" (WHO, 2012). We found that, some studies specifically stated their reasons for selecting the theory/model, while, many studies did not provide sufficient information about the assessment of the situation.
Sample size calculation was poorly reported. Only one trial provided blinding of participants (Tabatabaei et al., 2010). The flow of participants was reported in none of the studies .Randomization details were frequently unclear.
Because of the variation in the duration of intervention(ranging from immediately to 24 week) the studies that conducted in Iran does not provide enough evidence on the optimal duration of most effective intervention for promoting physical activity. This is consistent with a systematic review performed by Chen and Wilkosz (2014).
Effectiveness may be limited when the theory/model is partially implemented (Lopez et al., 2013). Peyman et al. (2012), used only two components of the self-regulation theory (SRT), e.g. setting goals and perusing goals.
Other components of SRT were not addressed in their study.As Saffari et al. (2012b) mentioned, some stages of PRECEDE (such as genetic diagnosis) could be ignored. Estebsari et al. (2010), evaluated the stages of educational diagnosis (predisposing, enabling, reinforcing).
Constructs such as awareness, perceived susceptibility, perceived severity, perceive benefits, and perceived barriers were evaluated in a study by Abedi et al. (2011). A recent addition to the HBM is the concept of self-efficacy, which was added to the model in 1980. Bendura reported that self-efficacy was one of the most important structures in such behaviors as physical activity (Moeini et al., 2010;Jallilian et al., 2013). In the study by Abedi et al. (2011), self-efficacy was not evaluated.

TTM
Our Findings show that TTM is frequently used in physical activity studies in Iran. In spite of its popularity, TTM has its own limitations. First, the reliability of self-reporting is questionable. All the studies reviewed here relied on self-reporting. Only Moeini et al. (2010) used Ergo line bicycle to evaluate the physical strength in the sample population. Second, the TTM lacks predictability. It has not been addressed in the studies published in Iran. Some scholars, however, consider this model as a descriptive, not a predictive one (Sharma & Romas, 2008).
Our systematic review revealed that several questionnaires were used to measure the constructs of the TTM.For example, Jalilian et al (2013) used 5 questionnaires. Being economical is considered as one of the characteristics of a good theory or model and the TTM is not an economical model (Saffari et al., 2012a). Another limitation of the TTM is that people can easily pass stages or return to the previous stages. No study in Iran ever dealt with the issue of returning to previous stages.

TPB
One of the limitations of TPB is that it assumes that perceived behavioral control can predict actual behavior control. It is confirmed by the decrease in perceived behavior control observed in the study performed by Tabatabaei et al (2010). Measurement of intention requires measurement of its predictors which in the context of TPB is most commonly inferred from questionnaire responses and measuring behavior using self-reporting is another limitation of TPB. Self-reporting has been used as a measure in TPB-based studies in Iran. Ajzen and Fishbein (2004) reported that "such behaviors as physical activity were time-consuming and expensive to study" (Saffari et al., 2012a).

PENDER
One of the main disadvantages of this model is that it contains too many constructs, and is not economical. For example, Teimori et al (2007) used 7 questionnaires. It does not seem economical or easy to control. It is also quite time-consuming (Saffari et al, 2012a).
One of the main challenges in health education and promotion is the maintenance of the behavior which was considered in only 5 studies in different periods of time without any explanation on the reason.

Conclusion
This review can be used to design and implement theory/model based interventions in physical activity, but the methodological weaknesses among the studies (e.g lack of sample size adequacy, variation in the duration of intervention, lack of rationale for selecting models/theories, etc …) should be considered. Limitations and weaknesses listed above could affect the validity and applicability of the results of these studies.
Considering the findings of the study, the authors suggest that: Maintenance in PA and integrating models in the field of physical activity should be addressed; Future researches should include long term follow ups, longer intervention periods, and larger sample sizes to evaluate the effectiveness of theory -based interventions in PA.
Health promotion programs are more effective when planners consider multiple levels of influence on health problem .Lack of addressing interpersonal and community levels in Iranian trials is important and should be included in future research. Moreover, epidemiology methodology consultation is necessary.
The reliability and validity of assessment tools in Iranian studies must be one of the important priorities. Some other effective social and ecological models in the field of physical activity are social marketing and social-cognitive theory which were not performed in Iran. It is suggested that future studies include these models.