Physical Activity Interventions for Primary Prevention in Adults: A Systematic Review of Randomized Controlled Trial-Based Economic Evaluations

  • Renato MattliEmail author
  • Renato Farcher
  • Maria-Eleni Syleouni
  • Simon Wieser
  • Nicole Probst-Hensch
  • Arno Schmidt-Trucksäss
  • Matthias Schwenkglenks
Systematic Review



Physical inactivity is a worldwide pandemic associated with major chronic diseases. Given limited resources, policy makers are in need of physical activity interventions that provide best value for money.


To summarize evidence from RCT-based economic evaluations of primary prevention physical activity interventions in adult populations outside the workplace setting.


Systematic review of health economic evaluations. Incremental cost-effectiveness ratios (ICERs) in US$ per MET-hour gained were estimated on the basis of mean differences in intervention costs and standardized effects between intervention and control groups.

Data Sources

Identification of relevant studies via systematic searches in electronic databases (MEDLINE, Embase and NHSEED).

Eligibility Criteria

Cost-effectiveness analyses in which all data (except unit costs) came from one RCT investigating physical activity interventions for primary prevention or health promotion in an adult population in high-income countries.


In twelve eligible studies, 22 interventions were investigated. Interventions were based on advice, goal setting and follow-up support, exercise classes, financial incentives or teaching on behavioral change. The ICER varied widely among the interventions and four interventions showed an ICER below the applied benchmark of US$0.44 to US$0.63 per MET-hour gained. These four interventions were based on individualized advice via print or web.


We found evidence from RCTs indicating cost-effectiveness of some physical activity interventions for primary prevention in adults. However, the majority of interventions assessed would not be cost-effective according to the benchmark applied. Furthermore, our study showed that trial-based evidence on cost-effectiveness of physical activity interventions is scarce. Therefore, we recommend that future studies investigating the efficacy or effectiveness of such interventions consider costs as an additional outcome and assess cost-effectiveness.


Author Contributions

RM and MS conceived the design of the study; RM and RF screened the studies; RM and MES extracted the data; RM, MES, SW, AST, MS were involved in the data analysis; RM drafted the manuscript. All authors were involved in the interpretation of the data and commented on and edited the final manuscript.

Compliance with Ethical Standards


No sources of funding were used to assist in the preparation of this article.

Conflict of interest

Renato Mattli, Renato Farcher, Maria-Eleni Syleouni, Simon Wieser, Nicole Probst-Hensch, Arno Schmidt-Trucksäss and Matthias Schwenkglenks declare that they have no conflicts of interest relevant to the content of this review.

Supplementary material

40279_2019_1233_MOESM1_ESM.docx (30 kb)
Supplementary material 1 (DOCX 29 kb)
40279_2019_1233_MOESM2_ESM.doc (121 kb)
Supplementary material 2 (DOC 121 kb)


  1. 1.
    Ding D, Kolbe-Alexander T, Nguyen B, Katzmarzyk PT, Pratt M, Lawson KD. The economic burden of physical inactivity: a systematic review and critical appraisal. Br J Sports Med. 2017;51(19):1392–409. Scholar
  2. 2.
    Ding D, Lawson KD, Kolbe-Alexander TL, Finkelstein EA, Katzmarzyk PT, van Mechelen W, et al. The economic burden of physical inactivity: a global analysis of major non-communicable diseases. Lancet. 2016;388(10051):1311–24. Scholar
  3. 3.
    Lee IM, Shiroma EJ, Lobelo F, Puska P, Blair SN, Katzmarzyk PT. Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. Lancet. 2012;380(9838):219–29. Scholar
  4. 4.
    Blondell SJ, Hammersley-Mather R, Veerman JL. Does physical activity prevent cognitive decline and dementia? A systematic review and meta-analysis of longitudinal studies. BMC Public Health. 2014;14:510. Scholar
  5. 5.
    Schuch FB, Vancampfort D, Firth J, Rosenbaum S, Ward PB, Silva ES, et al. Physical activity and incident depression: a meta-analysis of prospective cohort studies. Am J Psychiatry. 2018;175(7):631–48. Scholar
  6. 6.
    Shiri R, Falah-Hassani K. Does leisure time physical activity protect against low back pain? Systematic review and meta-analysis of 36 prospective cohort studies. Br J Sports Med. 2017;51(19):1410–8. Scholar
  7. 7.
    Foster C, Hillsdon M, Thorogood M, Kaur A, Wedatilake T. Interventions for promoting physical activity. Cochrane Database Syst Rev. 2005(1).
  8. 8.
    Buxton MJ, Drummond MF, Van Hout BA, Prince RL, Sheldon TA, Szucs T, et al. Modelling in economic evaluation: an unavoidable fact of life. Health Econ. 1997;6(3):217–27.CrossRefGoogle Scholar
  9. 9.
    Ramsey S, Willke R, Briggs A, Brown R, Buxton M, Chawla A, et al. Good research practices for cost-effectiveness analysis alongside clinical trials: the ISPOR RCT-CEA task force report. Value Health. 2005;8(5):521–33. Scholar
  10. 10.
    Brennan A, Akehurst R. Modelling in health economic evaluation. What is its place? What is its value? Pharmacoeconomics. 2000;17(5):445-59.Google Scholar
  11. 11.
    Sculpher MJ, Claxton K, Drummond M, McCabe C. Whither trial-based economic evaluation for health care decision making? Health Econ. 2006;15(7):677–87. Scholar
  12. 12.
    Rittenhouse B. Uses of models in economic evaluations of medicines and other health technologies. London: Office of Health Economics; 1996.Google Scholar
  13. 13.
    Drummond M, Sculpher M. Common methodological flaws in economic evaluations. Med Care. 2005;43(7 Suppl):5–14.PubMedGoogle Scholar
  14. 14.
    Abu-Omar K, Rutten A, Burlacu I, Schatzlein V, Messing S, Suhrcke M. The cost-effectiveness of physical activity interventions: a systematic review of reviews. Prev Med Rep. 2017;8:72–8. Scholar
  15. 15.
    Davis JC, Verhagen E, Bryan S, Liu-Ambrose T, Borland J, Buchner D, et al. 2014 consensus statement from the first Economics of Physical Inactivity Consensus (EPIC) conference (Vancouver). Br J Sports Med. 2014;48(12):947–51. Scholar
  16. 16.
    Foster C, Richards J, Thorogood M, Hillsdon M. Remote and web 2.0 interventions for promoting physical activity. Cochrane Database Syst Rev. 2013(9).
  17. 17.
    Wu S, Cohen D, Shi Y, Pearson M, Sturm R. Economic analysis of physical activity interventions. Am J Prev Med. 2011;40(2):149–58. Scholar
  18. 18.
    Thielen FW, Van Mastrigt G, Burgers LT, Bramer WM, Majoie H, Evers S, et al. How to prepare a systematic review of economic evaluations for clinical practice guidelines: database selection and search strategy development (part 2/3). Expert Rev Pharmacoecon Outcomes Res. 2016;16(6):705–21. Scholar
  19. 19.
    van Mastrigt GA, Hiligsmann M, Arts JJ, Broos PH, Kleijnen J, Evers SM, et al. How to prepare a systematic review of economic evaluations for informing evidence-based healthcare decisions: a five-step approach (part 1/3). Expert Rev Pharmacoecon Outcomes Res. 2016;16(6):689–704. Scholar
  20. 20.
    Wijnen B, Van Mastrigt G, Redekop WK, Majoie H, De Kinderen R, Evers S. How to prepare a systematic review of economic evaluations for informing evidence-based healthcare decisions: data extraction, risk of bias, and transferability (part 3/3). Expert Rev Pharmacoecon Outcomes Res. 2016;16(6):723–32. Scholar
  21. 21.
    World Bank. World Bank country and lending groups. 2018. Accessed 10 Nov 2018.
  22. 22.
    McGowan J, Sampson M, Salzwedel DM, Cogo E, Foerster V, Lefebvre C. PRESS Peer review of electronic search strategies: 2015 guideline statement. J Clin Epidemiol. 2016;75:40–6. Scholar
  23. 23.
    Evers S, Goossens M, de Vet H, van Tulder M, Ament A. Criteria list for assessment of methodological quality of economic evaluations: Consensus on Health Economic Criteria. Int J Technol Assess Health Care. 2005;21(2):240–5.CrossRefGoogle Scholar
  24. 24.
    Higgins JPT, Green S. Cochrane handbook for systematic reviews of interventions version 5.1.0 [updated March 2011]. The Cochrane Collaboration; 2011.Google Scholar
  25. 25.
    Laine J, Kuvaja-Kollner V, Pietila E, Koivuneva M, Valtonen H, Kankaanpaa E. Cost-effectiveness of population-level physical activity interventions: a systematic review. Am J Health Promot. 2014;29(2):71–80. Scholar
  26. 26.
    Canning KL, Brown RE, Jamnik VK, Salmon A, Ardern CI, Kuk JL. Individuals underestimate moderate and vigorous intensity physical activity. PLoS One. 2014;9(5):e97927. Scholar
  27. 27.
    Cerin E, Cain KL, Oyeyemi AL, Owen N, Conway TL, Cochrane T, et al. Correlates of agreement between accelerometry and aelf-reported physical activity. Med Sci Sports Exerc. 2016;48(6):1075–84. Scholar
  28. 28.
    Van Holle V, De Bourdeaudhuij I, Deforche B, Van Cauwenberg J, Van Dyck D. Assessment of physical activity in older Belgian adults: validity and reliability of an adapted interview version of the long International Physical Activity Questionnaire (IPAQ-L). BMC Public Health. 2015;15:433. Scholar
  29. 29.
    Drummond M, Weatherly H, Claxton K, Ferguson B, Godfrey C, Rice N, et al. Assessing the challenges of applying standard methods of economic evaluation to public health interventions. York: Public Health Research Consortium; 2008.Google Scholar
  30. 30.
    World Bank. PPP conversion factor, GDP (LCU per international $). 2019. Accessed 20 Feb 2019.
  31. 31.
    Federal Reserve Bank of St. Louis. Consumer price index: Total all items for the United States, index 2015 = 100, annual, not seasonally adjusted. 2019. Accessed 03 Jun 2019.
  32. 32.
    WHO. Global recommendations on physical activity for health. Geneva, Switzerland. 2010.Google Scholar
  33. 33.
    Mattli R, Wieser S, Probst-Hensch N, Schmidt-Trucksass A, Schwenkglenks M. Physical inactivity caused economic burden depends on regional cultural differences. Scand J Med Sci Sports. 2019;29(1):95–104. Scholar
  34. 34.
    Federal Statistical Office. Kosten und Finanzierung des Gesundheitswesens seit 1960. 2019. Accessed 20 Jun 2019.
  35. 35.
    Federal Statistical Office. Swiss wage index: index and variation on the base of 2010 = 100 (NOGA08). 2019. Accessed 20 Jun 2019.
  36. 36.
    Elley CR, Garrett S, Rose SB, O’Dea D, Lawton BA, Moyes SA, et al. Cost-effectiveness of exercise on prescription with telephone support among women in general practice over 2 years. Br J Sports Med. 2011;45(15):1223–9.CrossRefGoogle Scholar
  37. 37.
    Elley CR, Kerse N, Arroll B, Swinburn B, Ashton T, Robinson E. Cost-effectiveness of physical activity counselling in general practice. N Z Med J. 2004;117(1207):U1216.PubMedGoogle Scholar
  38. 38.
    Leung W, Ashton T, Kolt GS, Schofield GM, Garrett N, Kerse N, et al. Cost-effectiveness of pedometer-based versus time-based green prescriptions: the healthy steps study. Aust J Prim Health. 2012;18(3):204–11. Scholar
  39. 39.
    Harris T, Kerry S, Victor C, Iliffe S, Ussher M, Fox-Rushby J, et al. A pedometer-based walking intervention in 45- to 75-year-olds, with and without practice nurse support: the PACE-UP three-arm cluster RCT. Health Technol Assess. 2018;22(37):1–273. Scholar
  40. 40.
    Iliffe S, Kendrick D, Morris R, Masud T, Gage H, Skelton D, et al. Multicentre cluster randomised trial comparing a community group exercise programme and home-based exercise with usual care for people aged 65 years and over in primary care. Health Technol Assess. 2014;18(49):1–105. Scholar
  41. 41.
    Isaacs AJ, Critchley JA, Tai SS, Buckingham K, Westley D, Harridge SDR, et al. Exercise evaluation randomised trial (EXERT): a randomised trial comparing GP referral for leisure centre-based exercise, community-based walking and advice only. Health Technol Assess. 2007;11(10):104.CrossRefGoogle Scholar
  42. 42.
    Finkelstein EA, Brown DS, Brown DR, Buchner DM. A randomized study of financial incentives to increase physical activity among sedentary older adults. Prev Med. 2008;47(2):182–7. Scholar
  43. 43.
    Sevick MA, Dunn AL, Morrow MS, Marcus BH, Chen GJ, Blair SN. Cost-effectiveness of lifestyle and structured exercise interventions in sedentary adults. Results of project ACTIVE. Am J Prev Med. 2000;19(1):1–8. Scholar
  44. 44.
    Sevick MA, Napolitano MA, Papandonatos GD, Gordon AJ, Reiser LM, Marcus BH. Cost-effectiveness of alternative approaches for motivating activity in sedentary adults: results of project STRIDE. Prev Med. 2007;45(1):54–61. Scholar
  45. 45.
    Golsteijn RHJ, Peels DA, Evers SMAA, Bolman C, Mudde AN, de Vries H, et al. Cost-effectiveness and cost-utility of a web-based or print-delivered tailored intervention to promote physical activity among adults aged over fifty: an economic evaluation of the Active Plus intervention. Int J Behav Nutr Phys Act. 2014;11(1):1–17. Scholar
  46. 46.
    van Keulen HM, Bosmans JE, van Tulder MW, Severens JL, de Vries H, Brug J, et al. Cost-effectiveness of tailored print communication, telephone motivational interviewing, and a combination of the two: results of an economic evaluation alongside the Vitalum randomized controlled trial. Int J Behav Nutr Phys Act. 2010. Scholar
  47. 47.
    Ewald B, Stacey F, Johnson N, Plotnikoff RC, Holliday E, Brown W, et al. Physical activity coaching by Australian Exercise Physiologists is cost effective for patients referred from general practice. Aust N Z J Public Health. 2018;42(1):12–5. Scholar
  48. 48.
    Wendel-Vos GC, Schuit AJ, Saris WH, Kromhout D. Reproducibility and relative validity of the short questionnaire to assess health-enhancing physical activity. J Clin Epidemiol. 2003;56(12):1163–9.CrossRefGoogle Scholar
  49. 49.
    Stewart AL, Gillis D, Grossman M, Castrillo M, Pruitt L, McLellan B, et al. Diffusing a research-based physical activity promotion program for seniors into diverse communities: CHAMPS III. Prev Chronic Dis. 2006;3(2):A51.PubMedPubMedCentralGoogle Scholar
  50. 50.
    Arroll B, Jackson R, Beaglehole R. Validation of a 3-month physical activity recall questionnaire with a 7-day food intake and physical activity diary. Epidemiology. 1991;2(4):296–9.CrossRefGoogle Scholar
  51. 51.
    McLean G, Tobias M. The New Zealand Physical Activity Questionnaires: report on the validation and use of the NZPAQ-LF and NZPAQ-SF self-report physical activity survey instruments. Wellington, New Zealand: Sport and Recreation New Zealand (SPARC). 2004.Google Scholar
  52. 52.
    Resnicow K, McCarty F, Blissett D, Wang T, Heitzler C, Lee RE. Validity of a modified CHAMPS physical activity questionnaire among African–Americans. Med Sci Sports Exerc. 2003;35(9):1537–45. Scholar
  53. 53.
    Sallis JF, Haskell WL, Wood PD, Fortmann SP, Rogers T, Blair SN, et al. Physical activity assessment methodology in the Five-City Project. Am J Epidemiol. 1985;121(1):91–106. Scholar
  54. 54.
    Hillsdon M, Thorogood M, White I, Foster C. Advising people to take more exercise is ineffective: a randomized controlled trial of physical activity promotion in primary care. Int J Epidemiol. 2002;31(4):808–15. Scholar
  55. 55.
    James EL, Ewald B, Johnson N, Brown W, Stacey FG, McElduff P, et al. Efficacy of GP referral of insufficiently active patients for expert physical activity counseling: protocol for a pragmatic randomized trial (The NewCOACH trial). BMC Fam Pract. 2014;15:218. Scholar
  56. 56.
    James EL, Ewald BD, Johnson NA, Stacey FG, Brown WJ, Holliday EG, et al. Referral for expert physical activity counseling: a pragmatic RCT. Am J Prev Med. 2017;53(4):490–9. Scholar
  57. 57.
    Peels DA, Bolman C, Golsteijn RH, De Vries H, Mudde AN, van Stralen MM, et al. Differences in reach and attrition between web-based and print-delivered tailored interventions among adults over 50 years of age: clustered randomized trial. J Med Internet Res. 2012;14(6):e179. Scholar
  58. 58.
    Kolt GS, Schofield GM, Kerse N, Garrett N, Ashton T, Patel A. Healthy steps trial: pedometer-based advice and physical activity for low-active older adults. Ann Fam Med. 2012;10(3):206–12. Scholar
  59. 59.
    Rose SB, Lawton BA, Elley CR, Dowell AC, Fenton AJ. The ‘Women’s Lifestyle Study’, 2-year randomized controlled trial of physical activity counselling in primary health care: rationale and study design. BMC Public Health. 2007;7:166. Scholar
  60. 60.
    van Keulen HM, Mesters I, Brug J, Ausems M, Campbell M, Resnicow K, et al. Vitalum study design: RCT evaluating the efficacy of tailored print communication and telephone motivational interviewing on multiple health behaviors. BMC Public Health. 2008;8:216. Scholar
  61. 61.
    Marcus BH, Napolitano MA, King AC, Lewis BA, Whiteley JA, Albrecht AE, et al. Examination of print and telephone channels for physical activity promotion: rationale, design, and baseline data from Project STRIDE. Contemp Clin Trials. 2007;28(1):90–104. Scholar
  62. 62.
    Elley CR, Kerse N, Arroll B, Robinson E. Effectiveness of counselling patients on physical activity in general practice: cluster randomised controlled trial. BMJ. 2003;326(7393):793. Scholar
  63. 63.
    Dunn AL, Garcia ME, Marcus BH, Kampert JB, Kohl HW, Blair SN. Six-month physical activity and fitness changes in Project Active, a randomized trial. Med Sci Sports Exerc. 1998;30(7):1076–83.CrossRefGoogle Scholar
  64. 64.
    Dunn AL, Marcus BH, Kampert JB, Garcia ME, Kohl HW 3rd, Blair SN. Comparison of lifestyle and structured interventions to increase physical activity and cardiorespiratory fitness: a randomized trial. JAMA. 1999;281(4):327–34.CrossRefGoogle Scholar
  65. 65.
    Kohl HW 3rd, Dunn AL, Marcus BH, Blair SN. A randomized trial of physical activity interventions: design and baseline data from project active. Med Sci Sports Exerc. 1998;30(2):275–83.CrossRefGoogle Scholar
  66. 66.
    Muller-Riemenschneider F, Reinhold T, Willich SN. Cost-effectiveness of interventions promoting physical activity. Br J Sports Med. 2009;43(1):70–6. Scholar
  67. 67.
    U.S. Department of Health and Human Services. Physical activity guidelines for Americans, 2nd edition. 2018.Google Scholar
  68. 68.
    Wolfenstetter SB, Wenig CM. Economic evaluation and transferability of physical activity programmes in primary prevention: a systematic review. Int J Environ Res Public Health. 2010;7(4):1622–48. Scholar
  69. 69.
    Husereau D, Drummond M, Petrou S, Carswell C, Moher D, Greenberg D, et al. Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement. Value Health. 2013;16(2):e1–5. Scholar
  70. 70.
    Reis RS, Salvo D, Ogilvie D, Lambert EV, Goenka S, Brownson RC. Scaling up physical activity interventions worldwide: stepping up to larger and smarter approaches to get people moving. Lancet. 2016;388(10051):1337–48. Scholar
  71. 71.
    van Dongen JM, Proper KI, van Wier MF, van der Beek AJ, Bongers PM, van Mechelen W, et al. A systematic review of the cost-effectiveness of worksite physical activity and/or nutrition programs. Scand J Work Environ Health. 2012;38(5):393–408. Scholar
  72. 72.
    Cavill N, Kahlmeier S, Rutter H, Racioppi F, Oja P. Economic analyses of transport infrastructure and policies including health effects related to cycling and walking: a systematic review. Transp Policy (Oxf). 2008;15(5):291–304. Scholar
  73. 73.
    Lewis C, Ubido J, Holford R, Scott-Samuel A. Prevention programmes cost-effectiveness review: physical activity. Liverpool. 2010.Google Scholar
  74. 74.
    Chen IJ, Chou CL, Yu S, Cheng SP. Health services utilization and cost utility analysis of a walking program for residential community elderly. Nurs Econ. 2008;26(4):263–9.PubMedGoogle Scholar
  75. 75.
    Munro JF, Nicholl JP, Brazier JE, Davey R, Cochrane T. Cost effectiveness of a community based exercise programme in over 65 year olds: cluster randomised trial. J Epidemiol Community Health. 2004;58(12):1004–10. Scholar
  76. 76.
    Schulz DN, Smit ES, Stanczyk NE, Kremers SP, de Vries H, Evers SM. Economic evaluation of a web-based tailored lifestyle intervention for adults: findings regarding cost-effectiveness and cost-utility from a randomized controlled trial. J Med Internet Res. 2014;16(3):e91. Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Institute of Pharmaceutical Medicine (ECPM)University of BaselBaselSwitzerland
  2. 2.Winterthur Institute of Health EconomicsZurich University of Applied SciencesWinterthurSwitzerland
  3. 3.Swiss Tropical and Public Health InstituteBaselSwitzerland
  4. 4.University of BaselBaselSwitzerland
  5. 5.Division of Sports and Exercise Medicine, Department of Sport, Exercise and HealthUniversity of BaselBaselSwitzerland

Personalised recommendations