Physical Activity Promotion: A Systematic Review of The Perceptions of Healthcare Professionals

Physical activity (PA) is a cost-effective and non-pharmacological foundation for the prevention and management of chronic and complex diseases. Healthcare professionals could be viable conduits for PA promotion. However, the evidence regarding the effectiveness and benefits of the current forms of PA promotion are inconclusive. Healthcare professionals’ perceptions on key determinants impact on the optimum promotion of PA were explored in this review. Thirty-four (34) studies were identified after systematically searching seven databases for peer-reviewed articles published within the last decade. PA advice or counselling was the most recorded form of PA promotion, limited counselling time was the most reported obstacle while providing incentives was viewed as a key facilitator. There is widespread consensus among healthcare professionals (HCPs) on some aspects of PA promotion. Utilisation of all PA promotional pathways to their full potential could be an essential turning point towards the optimal success of PA promotional goals. Hence, strategies are required to broaden chronic disease treatment methods to include preventive and integrative PA promotion approaches particularly, between frontline HCPs (e.g., GPs) and PA specialists (e.g., EPs). Future studies could explore the functionality of GP to EP referral pathways to determining what currently works and areas requiring further development.


Introduction
Physical activity (PA) has been described as a wonder drug [1]; owing to its positive impacts on physical and mental wellbeing [2,3] and its ability to prevent disability [4] and myriads of chronic diseases [5]. World Health Organization (WHO) defines PA as any bodily movement produced by the skeletal muscles that requires increased energy expenditure above resting requirements and involves household tasks, leisure time activity, and structured physical activity [6]. Despite growing emphasis on the promotion of PA [7,8], the burden of physical inactivity (PI) continues to increase as over 35% of the global population fail to meet the recommended PA guidelines [9] and 5.3 million premature deaths are now directly linked to PI [10]. A 25% reduction in PI could prevent over 1.3 million deaths each year [11].
PA promotional programmes have been developed worldwide since the 1990s and are still utilised in various settings [12][13][14][15][16]. These programmes are typically structured and include PA counselling, advice on behavioural change and/or referral to specialists for an individualised PA programme within a healthcare context [17]. Public health policies are being used to motivate healthcare professionals (HCPs) towards the delivery of behavioural change activities like the promotion of PA to patients [18]. Additionally, measures advocating for the inclusion of PA into patients' treatment plans have been initiated by several policies, and some notable examples include Healthy People 2020 [19] and Exercise is Medicine [20,21].
Various studies have reported PA promotion as an effective intervention in diverse healthcare settings [22][23][24] and that HCPs can be very useful conduits for promoting PA [24]. Successful intervention is attributed to the different levels of one-to-one contact a patient might have with different HCPs during treatment and the significant PA behavioural change that could ensue if PA was promoted at each contact thereby, making every contact count [25,26]. WHO and other agencies have reiterated that HCPs are pivotal to promoting PA and healthcare systems could be key avenues for reducing chronic diseases and PI [8,27,28]. Nonetheless, it has been argued that combined support of the academic and scientific communities would be required in synergy with the efforts of HCPs and policy makers to ultimately achieve the 2013-2020 WHO's global action plan designed to achieve a 10% reduction in PI by 2025 [29].
However, the evidence regarding the key determinant factors that impact on the promotion of PA among HCPs are inconclusive [30,31]. Studies have claimed that several barriers hinder the effective promotion of PA in primary healthcare settings [32][33][34], and that several HCPs miss the opportunities to promote PA to their patients [31,[35][36][37][38][39]. Further claims indicated that these opportunities could have been missed because of the brief and non-specificity of HCPs' advice [40], lack of knowledge and confidence on the effective strategies for promoting PA [41,42], lack of skills, limited time, reimbursements, current workload, and practice barriers [43,44]. Other barriers include lack of training [45,46] and HCPs' beliefs about a patient's readiness to change PA habits [47,48]. If these barriers and the growing prevalence of chronic diseases and PI are not urgently addressed, there could be worsening cases of premature deaths, long-term disabilities, hospitalisation, rehabilitation costs [49], and burden on the healthcare systems [50].
Studies on the key determinants of the effectiveness and long-term sustainability of PA promotional goals from the perspective of HCPs are required [32]. The pressing need for the opinions of key PA stakeholders about key determinants of PA promotion and a sustainable integrated health solution to the growing burden of PI and chronic diseases, highlights the need for a systematic assessment and synthesis of current research on this topic [51][52][53]. This will help identify gaps in the literature and give direction for future research. A thorough review of literature would provide the information that could enhance PA promotional practices, optimise utilization of public health resources, and ultimately improve health outcomes for patients. Consequently, the main objective of this review was to examine relevant primary peer-reviewed articles in order to synthesize the research evidence on PA promotion from the perspective of HCPs. The secondary objective was to explore the key determinants impacting on the optimum achievement of PA promotional goals in healthcare systems.
Considering these objectives and the need to explicitly appraise and synthesize current evidence on the key determinants of effective PA promotion, a systematic review was deemed the most suitable approach for reviewing the literature [51][52][53]. Systematic reviews are studies often conducted for the purpose of identifying, appraising and integrating the evidence pertinent to specific question(s) in order to inform practice, policy, and further research [54,55].
The following questions were addressed by this review: 1.
What are HCPs' perceptions regarding key determinants of PA promotion? 2.
What are HCPs' perceptions about the barriers and facilitators to the achievement of PA promotional goals?

Methods
The systematic review was conducted and reported in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) Statement [55].

Inclusion and Exclusion Criteria
The study population consisted of all HCPs (e.g., General Practitioners (GPs), Physicians, Nurses, Physiotherapists, Exercise Physiologists (EPs), Dietitians, Diabetes Health Educators, Pharmacists, Surgeons, Podiatrists, Oncologists, Occupational and Physical Therapists and Healthcare Assistants). There was no restriction on study design however, interventional studies (randomized control design and quasi-experimental designs) were excluded given that the aim of this review was to examine the perceptions of HCPs independent of any intervention. Other requirements for inclusion were that studies must have: 1.
Included adult participants aged 18 years and above.

Considered HCPs' attitudes or perceptions to PA promotion
Articles were excluded if they did not meet the inclusion criteria and/or they: 1. Considered opinions other than those of HCPs (e.g., patients) 2.
Were review papers and 3.
Perceptions of HCPs about PA promotion was not specifically discussed.

Search Strategy
Seven electronic databases comprising, Cinahl, Informit, Medline Ovid, Medline (Pubmed), Scopus, SportDiscus, and The Cochrane Library were searched. Peer reviewed primary articles, written in English and published between February 2010 and February 2020 (a decade of literature) were included in this review. The search was limited to a decade in order to facilitate the evaluation of HCPs' PA promotional practices after the publication of WHO's 2010 global recommendations on PA for health [3]. Text words and indexed terms like "healthcare practitioner, healthcare professionals, healthcare personnel, primary healthcare personnel, physical activity promotion, health promotion, perceptions, views, perspectives, knowledge, beliefs, attitude, inactivity, physical inactivity and chronic diseases" were included in the search terms. The comprehensive search strategy used for this review is presented in Appendix A. Reference lists from previous reviews and included studies were also screened for additional inclusions.

Study Selection
All the identified articles were imported into Endnote X9 software, then titles and abstracts were screened. Two authors (FAA and BSMA) independently screened the titles and abstracts of the retrieved articles and excluded those articles which did not meet the inclusion criteria. Subsequently, full-text articles categorized as potentially eligible for inclusion were jointly screened by the two authors in a consensus meeting and disagreements were resolved in real time until consensus was reached.

Data Synthesis and Analysis
Meta-analysis was not possible, due to the heterogeneous nature of the included articles [55]. A data extraction form was developed and used to collect relevant information from all the included studies. Descriptive data including author, study year, country of study, study design, type of healthcare professional and participant population, gender and mean age were extracted from each of the selected studies. To explore participants' perceptions regarding PA promotion, the following key determinant factors to PA promotion were extracted: HCPs' knowledge of PA, confidence in promoting PA, importance of PA promotion, role in PA promotion, PA assessment, how HCPs currently promote PA, perceived effectiveness of PA promotion, and perceived barriers and facilitators to PA promotion. These factors were adapted from the classifications reported in Fleuren et al. [56] and Chaudoir et al.'s [57] studies on the factors influencing innovations in healthcare.
To categorize the extracted facilitators and barriers from this review, the refined Theoretical Domain Framework (TDF) was adopted [58]. This framework contains 14 domains which are used for coding in behavioral change and implementation research. The TDF domains included: knowledge, skill, social/professional role and identity, beliefs about capabilities, optimism, beliefs about consequences, reinforcement, intentions, goals, memory, attention, decision process, environmental context and resources, social influences, emotion, and behavioral regulation [59]. Two authors (FAA and BSMA) independently extracted and categorized facilitators and barriers from each of the studies. After extracting and categorizing each of these determinants, the two authors met to harmonize the extracted factors as determined by the TDF domain classification. All discrepancies were resolved through discussion and re-examining referenced materials. Identical TDF factors were categorized into sub-themes and domains with multiple themes were deemed crucial TDF domains [60].
For qualitative studies, inductive content analysis was employed [61]. The analysis included three stages of coding, creating categories and abstraction. One author (F.A.A.) extracted data, defined, and developed coding frames for all the key determinant variables in the first stage. Two authors (F.A.A. and B.S.M.A.) designed preliminary categories in the second stage. In the third stage, final categories were developed and labelled by both authors while, all differences were resolved in a consensus meeting. A replication test was used to validate and determine possible extensions to coding frames.

Risk of Bias Assessment
Quality Assessment Tool for Studies with Diverse Designs (QATSDD) was used to assess the methodological consistency of the included studies [62]. This tool contains 16 items and is used for examining studies with different research designs. Each of the included studies was graded on a scale of 0 to 3 for each criterion, with 0 = not at all, 1 = very slightly, 2 = moderately, and 3 = complete. To assess the methodological quality of the each of the included studies, the criteria scores were summed and expressed as a percentage of the maximum possible score. The percentage scores were classified into low (<50%), medium (50-80%) or high (>80%) quality evidence for easy identification. The QATSDD criteria included: (1) theoretical framework; (2) aims/objectives; (3) description of research setting; (4) sample size; (5) representative sample of target group; (6) procedure for data collection; (7) rationale for choice of data collection tool(s); (8) detailed recruitment data; (9) assessment of reliability and validity of measurement tool(s) (Quantitative only); (10) fit between research question and method of data collection (Quantitative only); (11) fit between research question and data collection method (Qualitative only); (12) fit between research question and method of analysis; (13) good justification for analytical method selected; (14) reliability of analytical process (Qualitative only); (15) evidence of user involvement in design; (16) strengths and limitations.

Included Studies
One thousand one hundred (1100) articles were identified from all searched databases and imported into Endnote. After screening the titles and abstracts of the articles identified and reviewing 68 full texts, 34 studies met the inclusion criteria for this review (Figure 1).

HCPs' Perceived Confidence in Promoting PA
HCPs expressed their confidence in promoting PA in 32.3% (n = 11) of the 34 included studies (Table 2) [31,69,74,76,79,80,82,89,90,92]. In over half of the studies (n = 6), 68 to 95.3% of participants indicated that they were confident in promoting PA [31,73,74,76,89,90]. In one of the remaining five studies, EPs and physiotherapists were judged to be more confident than other HCPs in providing general and specific PA advice to patients [92]. Another study indicated that confidence was key to PA promotion and equally, found significant associations between confidence and HCPs' PA enquiry and advise habits [70]. Lastly, dietitians indicated that their own personal interest in a particular sport and PA habits enhanced their confidence in promoting PA [82].

HCPs' Perceptions on PA Assessment
Only eight (23.5%) of the included studies recorded HCPs' perceptions about their assessment of patients' PA (Table 2) [53,73,74,83,86,88,90,91]. Across these studies, between 42.5% and 61% of HCPs reportedly assessed patients for PA. However, HCPs in one of the studies indicated that a patient's physical condition (ability to participate in PA), interest in PA, and former PA lifestyle were three factors informing their decision for PA assessment [53].
Some HCPs in a qualitative study, however, indicated that the advice was targeted at the individuals they perceived would be motivated to change PA habits [52], others claimed they promoted PA based on their experience of a particular sport [82] while three HCPs in a cross-sectional study indicated that they advised their clients not to do PA for unstated reasons [65]. In another study, sport medicine physicians revealed that those who promoted PA by giving written PA prescriptions recorded better improvements in their patients PA levels [88]. In 14.8% (n = 4) of these studies, 73-93.4% of physiotherapists noted that they promoted PA by providing some form of written material [64,73,75,76]. In three different cross-sectional studies, respectively, 24% of physiotherapists [90] and 40% of GPs [67] indicated that they provided written materials to patients while some HCPs stated that giving out written materials was most feasible for them in the third study [92]. HCPs (the majority of which were GPs) across five studies (18.5%) referred patients to exercise specialists for PA intervention [51,63,68,73,86].
Across another five studies, HCPs managed the risk factors (promoting PA via other means outside advice/counselling, providing writing materials and referral to exercise specialists) [69,73,84,86,88]. This group consisted of mainly physiotherapists [69,73,84] and physicians [86,88]. Among the studies that patients were referred to exercise specialists, only in one study did 40% of HCPs indicate that they referred clients to physiotherapists [63], others did not specify the specialists they referred their clients to. Across the five studies reporting the views of HCPs who managed their client's risks factors, two stated that, about 26% of the HCPs provided written PA prescription [86,88], interventions to change behavior in one study [73], PA seminars in another study [69] while structured gym sessions, group exercises, and recreational sports activities were conducted by physiotherapists in the last study [84].

B10; F3
Perception of limited role in PA promotion: [84] Professional collaboration among HCPs: [68,83] Lack of cooperation among HCP's: [69,83] HCPs physical active lifestyles: [52] TDF domain 4: beliefs about capabilities (This is the honest and rational acceptance of a particular talent or expertise that can be useful to an individual) B10; F(Non) Language barrier: [64] Not indicated Lack of motivational skills to encourage participants: [64] Lack of confidence in promoting PA: [77] TDF domain 5: optimism (This is the conviction that an event will occur, or an expected aim will be achieved)

Assessment of Methodological Quality
QATSDD assessment indicated that 67.6% (n = 23) of the included studies were medium quality studies [51][52][53]63,[65][66][67]69,71,[73][74][75][76]78,79,81,82,[85][86][87][88]90,92], 17.6% (n = 6) were high quality studies [64,70,77,80,83,84], and 14.7% (n = 5) were low quality studies [31,68,72,89,91] (Table 4). Individual scores ranged from 35.7 to 83.3%. All except one [70] of the top-quality studies were qualitative and were judged to be explicit in their methodology while all the low-quality studies were quantitative and some of the weaknesses identified from these studies included: lack of theoretical framework, inadequate sample sizes and poor reliability. Five out of the six high quality studies recorded the opinions of homogenous groups of HCPs including three physiotherapists studies [64,83,84] and one each of physician [71] and GP studies [78]. The findings across the high quality studies indicated that though HCPs (mostly physiotherapists, physicians, and GPs) currently promote PA, additional training and support are required to effectively promote PA and including patients in the structuring and implementation of PA interventions could enhance the achievement of PA promotional goals. The five low quality studies included two physician studies [72,89], two heterogenous HCP studies [31,91], and one GP study [68]. There was no notable difference between the findings from the high and low quality studies.

Discussion
This systematic review explored and synthesized the perceptions of HCPs about key factors influencing effective promotion of PA. This review has highlighted pertinent issues including increased workload and time pressure on frontline HCPs such as GPs in the promotion of PA. The underutilization of the services of PA specialists such as EPs is also highlighted though, these specialists are more suitable for specific and top-level PA support services which majority of the population perhaps seek when specialist PA requirements are indicated. This is evident from the insights provided by the HCPs in relation to how they promote PA with most HCPs viewing inadequate counselling time as a major barrier to PA promotion. These findings corroborate the work of other studies [52,93]. For example, Hebert et al. [93] indicated that HCPs are open to the view of PA promotion, however, personal, and organizational obstacles might prevent effective integration of PA promotion into primary care. This was further reiterated by Din et al. [52], who concluded that barriers to PA promotion including expertise and time limitations should be resolved in order to facilitate HCPs' ability to promote PA. Given that patients value the advice of HCPs, a concise and strategic behavioral change intervention delivered by HCPs might be useful in enhancing PA and reducing inactivity [94]. Consequently, continuous training for HCPs, the adoption of PA prescription and referral programmes as universal standard treatments and the integration of PA and healthcare services might enhance individual levels of PA and help meet the WHO goals for the reduction of inactivity, morbidity, and mortality [95].
HCPs' reported knowledge of PA and its promotion pathways were quite varied, and this could be an indication that more awareness and training may be required. This finding was evident in the study by Cantwell et al. [63] who indicated that HCPs can provide crucial PA prompts to patients but may lack the requisite knowledge to give explicit PA advice. Given that the findings from this review include an assortment of HCPs' opinions, it therefore provides an extension to the work of Cantwell and colleagues who explored the perceptions of mainly oncology specialists. Factors making up three domains of TDF (knowledge, skills, and reinforcement) signaled the major impact knowledge has on HCP's propensity to promote PA. Jones et al. [96] suggested that ongoing training and the employment of evidenced-based practice to promote PA or refer cases to PA specialists could be helpful.
Despite the divergence in knowledge, there were optimistic views from HCPs about the importance of promoting PA, their effectiveness and confidence in promoting it. For example, the majority of physicians, psychologists and physiotherapists from a cross-sectional study, indicated that they were confident in promoting PA and perceived PA to be effective. Additionally, all except psychologists considered PA to be important for their patients. The low perception of the importance of PA among psychologists could be due to paucity of knowledge about the benefits of PA among this group of HCPs required to inform positive behavioral change towards PA promotion [74,97]. HCPs' views regarding their assessment for PA were inconclusive. Their views suggested that several factors impacted on their decision for PA assessment, and as a result there might be a need for consensus on standard PA assessment procedures [98]. This could enhance evidence-based practice, inform the need for timely PA intervention for chronic diseases, and improve the quality of care and outcome for patients' conditions.
The majority of HCPs viewed PA promotion to be part of their role. Despite this overwhelming agreement, some HCPs in a qualitative study thought their role was limited and the number of nurses viewing PA promotion as part of their role were less compared to other HCPs across the included studies. When asked about whose role is best suited for promoting PA, HCPs in a cross-sectional study ranked physiotherapists highest and the least were other unspecified PA specialists. However, Williams et al. [84] argued that physiotherapists failed to promote PA because they viewed it outside their role. Possible reasons for this could be because PA promotion is not an integral component of most physiotherapists practice and these specialists now practice with a wider scope which perhaps leads to more divergence in their PA promotional roles [76,99]. Another group of eligible PA specialist who could be best suited for this role are EPs, although their valuable skills in PA promotion are probably underutilized [100,101]. EPs emerge as the best option by virtue of their training in the delivery of clinical PA interventions for the prevention and management of chronic and complex disease conditions [102]. Contrary to expectation, only one of the included studies explored the perceptions of EPs. This could be because exercise physiology is still an evolving profession and EPs are not within the context of the healthcare systems in most countries. Hence, some HCPs like GPs might have limited understanding of how to refer to EPs [103]. Consolidating the valuable access of frontline HCPs like GPs with the PA expertise and extended consultation time of PA specialists like physiotherapists and EPs, could perhaps be the catalyst for the achievement of PA goals [102]. For the wider public without chronic or complex diseases or with limited accessibility to PA specialists, ongoing community-based PA support programmes could be helpful. Hence, further studies into the effectiveness of PA promotional interventions provided by EPs, the functionality of community-based PA support programmes and reasons for weak referral pathways between key healthcare gatekeepers such as GPs and PA specialists such as EPs will be highly valuable.
HCPs' perceptions about the factors within the TDF domains for barriers and facilitators to PA promotion revealed that achievement of PA promotion goals could be improved by minimizing identified obstacles and boosting the enabling factors. The obstacles included inadequate consultation time and paucity of knowledge about the importance of PA and its promotional pathways, while the facilitators were incentives for key frontline HCPs, providing further training on PA and access to PA educational materials. Addressing these factors, therefore, could enhance HCPs' knowledge, effectiveness, readiness, and confidence in promoting PA [96]. HCPs viewed "limited consultation time" as the greatest barrier within the environmental context and resources domain of TDF. Based on this result, referral of identified clients to PA specialists for prolonged and effective PA consultations could be a remedy [100,104]. For example, one of the significant findings from the study by Freene et al. [92] and echoed by O'Brien et al. [105], indicated that physiotherapists and EPs were more confident in providing PA advice to patients. Hence, indicating that these PA specialists can be key players in interventions designed to combat complex and chronic diseases. In view of the perceived facilitating TDF factors, the gains of PA promotion could be enhanced if all the potential pathways for PA promotion are utilized to their full capacity.
In summary, the general perceptions of HCPs about key determinants of PA promotion are encouraging. Current PA promotion practices could be made more efficient if fundamental obstacles such as limited consultation time, underutilization of PA referral services and the lack of PA knowledge and resources are addressed.

Implications for Practice and Research
The evidence from this review could inform future research on improving the integrative health promotional practice in healthcare settings. It could also be translated into evidence-based practice for PA promotion in healthcare settings. To facilitate the translation of research into practice, stakeholder networks could be established to train, encourage and enforce PA promotional goals for sustainable and enhanced patient health outcomes. The key PA determinants identified in this review can be used to educate and enhance the PA knowledge of frontline HCPs like GPs. Particularly, the unique expertise of different PA specialists and the varied roles they can play in the effective delivery of optimum healthcare services can be further emphasized. Stakeholders can also utilize the findings in this review to plan, implement and evaluate PA promotional interventions in healthcare settings. Future studies that focus on modifying HCPs' PA habits and promotion practices as well as strengthening referral pathways between key healthcare gatekeepers such as GPs and PA specialists will be helpful. Given that QATSDD assessment indicated that most of the included studies lacked theoretical framework, future studies could be structured to relevant theoretical framework in order to enhance the quality of the study.

Strength and Limitation
This is the first systematic review on PA promotion that explored the perceptions of varied HCPs regarding key determinants to PA promotion. The results from this review could strengthen the evidence-base for research on ways to enhance sustainable PA promotion among HCPs. Employing the TDF behavioral domain framework and assessing the quality of the included studies, further strengthened the evidence in this systematic review. QATSDD assessment indicated that almost two-thirds of the studies were medium quality studies. The studies were judged to be strong in their aims and objectives and the methods used for recruitment, collection and the analysis of data. The studies, however, lacked or failed to explicitly describe relevant theoretical frameworks, research questions and sample sizes. Other limitations of this review include the heterogeneity of the included studies and the exclusion of some relevant studies due to pre-set inclusion criteria such as the selection of English language studies only. The distinction in the training programmes, role description, and expertise of various HCP professions across the globe might have impacted on study results as well.

Conclusions
The findings of this review revealed that the optimum utilization of all PA promotion pathways (Advice/counselling, provision of PA resources or prescription, and the onward referral to PA specialists such as EPs) and addressing key TDF domain factors could be the potential turning point in a bid for sustainable solutions to the success of PA promotional goals. There is an accessible PA expertise for the non-pharmacological prevention and treatment of chronic diseases within healthcare systems, though this pathway is currently underutilized. Hence, an effective framework for HCPs' behavioral modification and the enhancement of collaborative interdisciplinary care for chronic and complex disease management will be invaluable. This was echoed by the WHO, where they indicated that HCPs are crucial to the success of PA promotion. Ultimately, development of functional stakeholder networks for training, promotion, implementation, and the evaluation of PA promotional goals could offer sustainable solutions and improved health outcomes for patients. Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or notfor-profit sectors.

Conflicts of Interest:
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Appendix A. Study Search Terms
"primary care" OR "primary healthcare" OR "Integrated health*" OR "primary healthcare p*" OR "patient car*" OR "healthcare p*" OR "general practi*" OR "family doctor*" OR doctor* Or gp* OR physician* OR surgeon* OR nurse* OR "physical therapist*" OR physio* OR "exercise physiologist*" OR "health p*" OR dietitian* OR "occupational therapist*" OR chiropractor* OR podiatrist* OR "allied health p*" AND perception* OR know* OR inform* OR perspective* OR view* OR believe* OR opinion* OR idea* OR impression* OR proficiency OR "uptake and knowledge" OR behaviour AND "physical activit*" OR exercise* OR sport* OR walk* OR run* OR "physical fitness" OR "exercise on referral" OR "physical activity on prescription" OR "exercise on prescription" OR "exercise is medicine" OR "green prescription" OR "exercise referral scheme" OR "physical activity promotion" OR "health promotion" AND inactiv* OR "chronic disease*" OR disease* OR sedentary OR "sedentary behaviour*" OR "lifestyle disease*" OR "life style, sedentary" OR "life style change*" Appendix B.   QATSDD criteria: This row shows a list of all the Quality Assessment Tool for Studies with Diverse Designs (QATSDD) item employed in this review. The QATSDD item were numbered from one to sixteen. The interpretation of the numbers includes: (1) theoretical framework; (2) aims/objectives; (3) description of research setting; (4) sample size; (5) representative sample of target group; (6) procedure for data collection; (7) rationale for choice of data collection tool(s); (8) detailed recruitment data; (9) assessment of reliability and validity of measurement tool(s) (Quantitative only); (10) fit between research question and method of data collection (Quantitative only); (11) fit between research question and data collection method (Qualitative only); (12) fit between research question and method of analysis; (13) good justification for analytical method selected; (14) reliability of analytical process (Qualitative only); (15) evidence of user involvement in design; (16)