Built environment correlates of physical activity and sedentary behaviour in older adults: A comparative review between high and low-middle income countries

Feasibility of prevention of type 2 diabetes in low- and middle-income countries

Type 2 diabetes is a leading cause of global mortality and morbidity. Nearly 80% of individuals with diabetes live in low- and middle-income countries (LMICs), where nearly half of those with the condition remain undiagnosed. The majority of known cases have sub-optimal clinical outcomes. Moreover, large populations with impaired glucose tolerance and/or impaired fasting glucose contribute to the rapid increase in type 2 diabetes. Globally, priority should be given to limit the population with diabetes, especially in LMICs, alongside actions to optimise the care of people diagnosed with diabetes. Primary prevention studies in LMICs have generated evidence to show the efficacy and scalability of strategies to fully prevent or delay the development of diabetes in high-risk groups. However, these are mainly limited to certain countries in Asia, particularly China and India. The studies have indicated that prevention policies are effective in populations with a high risk of type 2 diabetes, and they also have long-term benefits, not only for the risk of type 2 diabetes but also for the risk of associated metabolic disorders, such as CVDs. For the effective conduct of national programmes, innovative mechanisms must be implemented, such as the use of information technology, joint efforts of multiple teams implementing similar programmes, and involvement of governmental and non-governmental partnerships. Continuous monitoring and long-term studies are required to assess the utility of these programmes. The effectiveness of such programmes in LMICs has not been proven over the longer term, except in China. Despite the available evidence, the feasibility of prevention strategies for type 2 diabetes in LMICs at population level remains an enigma. There remain challenges in the form of cultural, societal and economic constraints; insufficient infrastructure and healthcare capacity; and the non-fully elucidated natural history and determinants of type 2 diabetes in LMICs.

"We Used to Have Four Seasons, but Now There Is Only One": Perceptions Concerning the Changing Climate and Environment in a Diverse Sample of Israeli Older Persons

Solastalgia is the pain caused by the loss of solace and isolation from one's environment. Solastalgia is contrasted with nostalgia, which is defined as melancholy characterized by homesickness or the distance from one's home. The present study examines the two concepts of solastalgia and nostalgia in the context of climate change among diverse populations of older Israelis. In total, 50 older persons from four different population groups (e.g., veteran Israeli Jews, Israeli Arabs, immigrants from the former Soviet Union, and Ethiopian immigrants) were interviewed. All interviews were transcribed and analyzed thematically. Members of all four groups expressed emotional distress and grief associated with the changing climate, increased environmental pollution, and the disappearance of nature. Perceptions around the undesirability of these changes were quite unanimous, thus leading us to conclude that the outcomes associated with solastalgia and nostalgia are quite similar despite different etiological explanations.

Using Computer Vision to Annotate Video-Recoded Direct Observation of Physical Behavior

Direct observation is a ground-truth measure for physical behavior, but the high cost limits widespread use. The purpose of this study was to develop and test machine learning methods to recognize aspects of physical behavior and location from videos of human movement: Adults (N = 26, aged 18-59 y) were recorded in their natural environment for two, 2- to 3-h sessions. Trained research assistants annotated videos using commercially available software including the following taxonomies: (1) sedentary versus non-sedentary (two classes); (2) activity type (four classes: sedentary, walking, running, and mixed movement); and (3) activity intensity (four classes: sedentary, light, moderate, and vigorous). Four machine learning approaches were trained and evaluated for each taxonomy. Models were trained on 80% of the videos, validated on 10%, and final accuracy is reported on the remaining 10% of the videos not used in training. Overall accuracy was as follows: 87.4% for Taxonomy 1, 63.1% for Taxonomy 2, and 68.6% for Taxonomy 3. This study shows it is possible to use computer vision to annotate aspects of physical behavior, speeding up the time and reducing labor required for direct observation. Future research should test these machine learning models on larger, independent datasets and take advantage of analysis of video fragments, rather than individual still images.

Associations between the built environment and physical activity in children, adults and older people: A narrative review of reviews

BACKGROUND

Physical activity is essential for promoting public health, and it is affected by the built environment at population level. Extensive evidence exists on the associations between the built environment and physical activity, but results are inconclusive for different age groups. Therefore, we conducted a narrative review summarizing existing reviews on the associations between the built environment and physical activity for children, adults and older people and synthesized their findings.

METHODS

We followed the PRISMA 2020 review procedure and searched for systematic reviews published between January 2010 and April 2022 in seven databases (Scopus, Web of Science, Medline, PsycINFO, EMBASE, SocIndex and Cochrane Library) using keywords related to the built environment, urban interventions, physical activity and health.

RESULTS

The selection process yielded 29 reviews with moderate to high quality. From these reviews, we identified 21 built environment characteristics, several of which were positively related to physical activity. For example, children and older people's physical activity was positively associated with pedestrian-friendly features and general safety. Furthermore, adults and older people's physical activity was positively related to the availability and accessibility of shops/commercial services and parks/open spaces. Lastly, the walkability index was positively associated with physical activity in every age group.

CONCLUSION

Our findings provide valuable information on creating health-promoting urban environments for practitioners. Further research is needed to understand which characteristics make urban environments age friendly for physical activity. Special attention should be paid to less explored promising characteristics such as street lighting and the quality of green spaces.

Long-term ambient air pollution exposure and prospective change in sedentary behaviour and physical activity in individuals at risk of type 2 diabetes in the UK

BACKGROUND

Air pollution may be a risk factor for physical inactivity and sedentary behaviour (SED) through discouraging active lifestyles, impairing fitness and contributing to chronic diseases with potentially important consequences for population health.

METHODS

Using generalized estimating equations, we examined the associations between long-term particulate matter with diameter ≤2.5 μm (PM2.5), ≤10 μm (PM10) and nitrogen dioxide (NO2) and annual change in accelerometer-measured SED, moderate-to-vigorous physical activity (MVPA) and steps in adults at risk of type 2 diabetes within the Walking Away from Type 2 Diabetes trial. We adjusted for important confounders including social deprivation and measures of the built environment.

RESULTS

From 808 participants, 644 had complete data (1605 observations; 64.7% men; mean age 63.86 years). PM2.5, NO2 and PM10 were not associated with change in MVPA/steps but were associated with change in SED, with a 1 ugm-3 increase associated with 6.38 (95% confidence interval: 0.77, 12.00), 1.52 (0.49, 2.54) and 4.48 (0.63, 8.34) adjusted annual change in daily minutes, respectively.

CONCLUSIONS

Long-term PM2.5, NO2 and PM10 exposures were associated with an annual increase in SED: ~11-22 min/day per year across the sample range of exposure (three standard deviations). Future research should investigate whether interventions to reduce pollution may influence SED.

Prioritizing a research agenda on built environments and physical activity: a twin panel Delphi consensus process with researchers and knowledge users

BACKGROUND

The growth of urban dwelling populations globally has led to rapid increases of research and policy initiatives addressing associations between the built environment and physical activity (PA). Given this rapid proliferation, it is important to identify priority areas and research questions for moving the field forward. The objective of this study was to identify and compare research priorities on the built environment and PA among researchers and knowledge users (e.g., policy makers, practitioners).

METHODS

Between September 2022 and April 2023, a three-round, modified Delphi survey was conducted among two independent panels of international researchers (n = 38) and knowledge users (n = 23) to identify similarities and differences in perceived research priorities on the built environment and PA and generate twin 'top 10' lists of the most important research needs.

RESULTS

From a broad range of self-identified issues, both panels ranked in common the most pressing research priorities including stronger study designs such as natural experiments, research that examines inequalities and inequities, establishing the cost effectiveness of interventions, safety and injuries related to engagement in active transportation (AT), and considerations for climate change and climate adaptation. Additional priorities identified by researchers included: implementation science, research that incorporates Indigenous perspectives, land-use policies, built environments that support active aging, and participatory research. Additional priorities identified by knowledge users included: built environments and PA among people living with disabilities and a need for national data on trip chaining, multi-modal travel, and non-work or school-related AT.

CONCLUSIONS

Five common research priorities between the two groups emerged, including (1) to better understand causality, (2) interactions with the natural environment, (3) economic evaluations, (4) social disparities, and (5) preventable AT-related injuries. The findings may help set directions for future research, interdisciplinary and intersectoral collaborations, and funding opportunities.

Correlates of physical activity and sedentary behavior in adults living with overweight and obesity: A systematic review

Overweight and obesity are consistently associated with lower physical activity (PA) levels and greater sedentary behavior (SB) in population studies. To date, no review has evaluated the factors associated with these behaviors in the specific population who have developed obesity/overweight. The aim of this systematic review was to identify the correlates/determinants of SB and PA in adults with overweight and obesity. Five databases were searched for studies, which reported factors or outcomes relating to PA or SB in adults living with overweight/obesity, published from 1980 to 2021. The factors were categorized using a socioecological model, strength, and direction of association. Of 34,058 articles retrieved, 45 studies were included, and 155 factors were identified. Self-efficacy, intrinsic motivation, exercise enjoyment, self-perceived good health, and social support were consistently associated with higher levels of PA. Consistent negative correlations were married females, increased BMI, obesity severity, pain, number of comorbidities, lack of time, energy, and willpower, and hilly terrain. Few studies (n = 12) examined SB, and no evidence for consistent associations were found. This review identified several correlates specific to PA in this population. Further studies are required to identify directionality and distal correlates for PA and all correlate levels of SB.

Does the built environment influence location- and trip-based sedentary behaviors? Evidence from a GPS-based activity space approach of neighborhood effects on older adults

OBJECTIVE

Evidence on the influence of built environments on sedentary behaviors remains unclear and is often contradictory. The main limitations encompass the use of self-reported proxies of sedentary time (ST), the scarce consideration of the plurality of sedentary behaviors, and environmental exposures limited to the residential neighborhood. We investigated the relationships between GPS-based activity space measures of environmental exposures and accelerometer-based ST measured in total, at the place of residence, at all locations, and during trips.

METHODS

This study is part of the CURHA project, based on 471 older adults residing in Luxembourg, who wore a GPS receiver and a tri-axial accelerometer during 7 days. Daily ST was computed in total, at the residence, at all locations and during trips. Environmental exposures included exposure to green spaces, walking, biking, and motorized transportation infrastructures. Associations between environments and ST were examined using linear and negative binomial mixed models, adjusted for demographics, self-rated health, residential self-selection, weather conditions and wear time.

RESULTS

Participants accumulated, on average, 8 h and 14 min of ST per day excluding sleep time. ST spent at locations accounted for 83 % of the total ST. ST spent at the residence accounted for 87 % of the location-based ST and 71 % of the total ST. Trip-based ST represents 13 % of total ST, and 4 % remained unclassified. Higher street connectivity was negatively associated with total ST, while the density of parking areas correlated positively with total and location-based ST. Stronger associations were observed for sedentary bouts (uninterrupted ST over 20 and 30 min).

CONCLUSION

Improving street connectivity and controlling the construction of new parking, while avoiding the spatial segregation of populations with limited access to public transport, may contribute to limit ST. Such urban planning interventions may be especially efficient in limiting the harmful uninterrupted bouts of ST among older adults.

A Qualitative Study of Food Choice in Urban Coastal Esmeraldas, Ecuador

Background

Constraints on food choice increase risk of malnutrition worldwide. Residents of secondary cities within low- and middle-income countries are a population of particular concern because they often face high rates of food insecurity and multiple nutritional burdens. Within this context, effective and equitable interventions to support healthy diets must be based on an understanding of the lived experience of individuals and their interactions with the food environment.

Objectives

The primary objectives of this study were to describe considerations that drive household decision making around food choice in the city of Esmeraldas, Ecuador; to identify trade-offs between these considerations; and to understand how an evolving urban environment influences these trade-offs.

Methods

Semistructured interviews were conducted with 20 mothers of young children to explore drivers in food choice throughout the purchase, preparation, and consumption chain. Interviews were transcribed and coded to identify key themes.

Results

Personal preference, economic access (costs), convenience, and perceptions of food safety were key influencers of decision making related to food. In addition, concerns about personal safety in the urban environment limited physical access to food. This, combined with the need to travel long distances to obtain desirable foods, increased men's participation in food purchasing. Women's increasing engagement in the workforce also increased men's participation in food preparation.

Conclusions

Policies to promote healthy food behavior in this context should focus on increasing access to health foods, such as affordable fresh produce, in convenient and physically safe locations. CurrDev Nutr 2023;x:xx.

An Umbrella Review of the Best and Most Up-to-Date Evidence on the Built Environment and Physical Activity in Older Adults ≥60 Years

Objectives: To present the best and most up-to-date evidence on associations between built environment (BE) attributes and overall and specific domains of physical activity (PA) (i.e., leisure, transport, walking, and cycling) in older adults (≥60 years).

Methods: An umbrella review was undertaken to compile evidence from systematic reviews using the Joanna Briggs Institute methodology. A comprehensive search (updated 16 August 2022), inclusion/exclusion of articles via title/abstract and full-text reviews, data extraction, and critical appraisal were completed. Only reviews with a good critical appraisal score were included.

Results: Across three included systematic reviews, each BE attribute category was positively associated with ≥1 PA outcome. A larger number of significant associations with BE attributes were reported for transport walking (13/26), total walking (10/25), and total PA (9/26), compared to leisure walking (4/34) and transport cycling (3/12). Fewer associations have been examined for leisure cycling (1/2).

Conclusion: Although the causality of findings cannot be concluded due to most primary studies being cross-sectional, these best and most up-to-date findings can guide necessary future longitudinal and experimental studies for the (re)design of age-friendly communities.

Impact of environmental interventions based on social programs on physical activity levels: A systematic review

Background

The design of social programs at the environmental level such as in schools, parks, bicycle paths, or workspaces generates changes in the behavior of individuals and modifies lifestyles by increasing physical activity (PA) levels.

Objective

To determine the effectiveness of environmental interventions based on social programs by changing the population's level of PA.

Methodology

Natural experiment studies that involved environmental intervention programs at a social level were included. The primary outcome was PA levels with consideration of both objective and subjective measurements. An electronic search was carried out in Medline/Pubmed, SCIENCE DIRECT, WEB OF SCIENCE, and CINAHL databases up to January 2022 with two reviewers screening titles and abstracts and selecting studies for full-text reading. Two reviewers also acquired relevant data and evaluated study quality using the ROBINS I tool. A qualitative analysis was performed.

Results

Three thousand eight hundred and sixty-five articles were found in the 4 consulted databases. After eliminating duplication (200), two reviewers screened 3,665 titles and abstracts and excluded 3,566 that did not meet the inclusion criteria, leaving 99 articles to be read in full text. The 99 full texts were reviewed of which 24 papers met the eligibility criteria. All were natural experiments published between 2011 and 2020 and all evaluated environmental social programs revealing that social programs at the environmental level promoted PA in various populations at the community level worldwide.

Conclusion

The 24 reviewed studies suggest innovative proposals for social programs that seek to increase PA and promote healthy lifestyles related to public activity policies developed in the countries in which they were generated. Environmental social programs can positively impact PA levels among children and adults.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=229718, identifier: CRD42021229718.

Aging in Rural Communities

Purpose of Review

Population aging is occurring worldwide, particularly in developed countries such as the United States (US). However, in the US, the population is aging more rapidly in rural areas than in urban areas. Healthy aging in rural areas presents unique challenges. Understanding and addressing those challenges is essential to ensure healthy aging and promote health equity across the lifespan and all geographies. This review aims to present findings and evaluate recent literature (2019-2022) on rural aging and highlight future directions and opportunities to improve population health in rural communities.

Recent Findings

The review first addresses several methodological considerations in measuring rurality, including the choice of measure used, the composition of each measure, and the limitations and drawbacks of each measure. Next, the review considers important concepts and context when describing what it means to be rural, including social, cultural, economic, and environmental conditions. The review assesses several key epidemiologic studies addressing rural-urban differences in population health among older adults. Health and social services in rural areas are then discussed in the context of healthy aging in rural areas. Racial and ethnic minorities, indigenous peoples, and informal caregivers are considered as special populations in the discussion of rural older adults and healthy aging. Lastly, the review provides evidence to support critical longitudinal, place-based research to promote healthy aging across the rural-urban divide is highlighted.

Summary

Policies, programs, and interventions to reduce rural-urban differences in population health and to promote health equity and healthy aging necessitate a context-specific approach. Considering the cultural context and root causes of rural-urban differences in population health and healthy aging is essential to support the real-world effectiveness of such programs, policies, and interventions.

A hierarchy of correlates for objectively measured physical activity, sedentary time, and physical fitness in older adults: A CHAID analysis

The aging process reflects, in many cases, not only a decline in physical activity (PA) and physical fitness (PF), but also an increase in overall levels of sedentary time (ST). In order to hierarchically identify the most powerful correlates related to low and high levels of objectively assessed PA, ST, and PF during the late adulthood, a total of 2666 older adults were cross-sectionally evaluated. Multidimensional correlates were obtained through interview. Using chi-squared automatic detection analysis to identify the cluster of correlates with most impact on PA (<21.4 min/day), ST (≥8 h/day), and PF (<33.3th percentile), was found that the most likely subgroup to be physically inactive consisted of widowers not owning a computer and sport facilities in the neighbourhood (94.7%), while not being widowed, reporting to have a family that exercises and a computer at home (54.3%) represented the subgroup less likely to be inactive. Widowers without sidewalks in the neighbourhood were the most sedentary group (91.0%), while being a married woman and reporting to have space to exercise at home (40%) formed the most favourable group of correlates regarding ST. Men reporting a financial income <500€ and physical problems frequently formed the group with the lowest PF level (70.3%). In contrast, the less likely subgroup to have low levels of PF level consisted of having a financial income ≥1000€ and a computer at home (3.4%). Future interventions should target widowers with limited accessibility to computer and urban/sport-related infrastructures, as well as impaired older adults with low financial income.HighlightsChi-squared automatic interaction detection was used to identify and hierarchise correlates of objectively measured physical activity, sedentary time, and fitness.Widowers not having a computer at home and sport facilities in the neighbourhood were the most likely to be physically inactive, while not being widowed, having a family that exercises and a computer at home represented the subgroup less likely to be physically inactive.The most likely to be classified as sedentary were widowers without sidewalks in the neighbourhood, while the most favourable group of correlates regarding ST was formed by married women and reporting to have space to exercise at home.Individuals with a low financial income and physical problems comprised the population subgroup with the lowest PF levels, while having a medium-high financial income and a computer at home represented the less likely subgroup to have low levels of PF.

Systematic review and critical methodological appraisal of community-based falls prevention economic models

BACKGROUND

Falls impose significant health and economic burdens on community-dwelling older persons. Decision modelling can inform commissioning of alternative falls prevention strategies. Several methodological challenges arise when modelling public health interventions including community-based falls prevention. This study aims to conduct a systematic review (SR) to: systematically identify community-based falls prevention economic models; synthesise and critically appraise how the models handled key methodological challenges associated with public health modelling; and suggest areas for further methodological research.

METHODS

The SR followed the 2021 PRISMA reporting guideline and covered the period 2003-2020 and 12 academic databases and grey literature. The extracted methodological features of included models were synthesised by their relevance to the following challenges: (1) capturing non-health outcomes and societal intervention costs; (2) considering heterogeneity and dynamic complexity; (3) considering theories of human behaviour and implementation; and (4) considering equity issues. The critical appraisal assessed the prevalence of each feature across models, then appraised the methods used to incorporate the feature. The methodological strengths and limitations stated by the modellers were used as indicators of desirable modelling practice and scope for improvement, respectively. The methods were also compared against those suggested in the broader empirical and methodological literature. Areas of further methodological research were suggested based on appraisal results.

RESULTS

46 models were identified. Comprehensive incorporation of non-health outcomes and societal intervention costs was infrequent. The assessments of heterogeneity and dynamic complexity were limited; subgroup delineation was confined primarily to demographics and binary disease/physical status. Few models incorporated heterogeneity in intervention implementation level, efficacy and cost. Few dynamic variables other than age and falls history were incorporated to characterise the trajectories of falls risk and general health/frailty. Intervention sustainability was frequently based on assumptions; few models estimated the economic/health returns from improved implementation. Seven models incorporated ethnicity- and severity-based subgroups but did not estimate the equity-efficiency trade-offs. Sixteen methodological research suggestions were made.

CONCLUSION

Existing community-based falls prevention models contain methodological limitations spanning four challenge areas relevant for public health modelling. There is scope for further methodological research to inform the development of falls prevention and other public health models.

Role of Built Environments on Physical Activity and Health Promotion: A Review and Policy Insights

As urbanization and motorization continue worldwide, various health issues have emerged as a burden between individuals, families and governments at all levels. Under the prevalence of chronic disease, this review synthesizes research on the impact of the various built environments on the multiple health outcomes from a methodological and mechanistic perspective. Besides, it attempts to provide useful planning and policy implications to promote physical activity and health benefits. The finds show that: (1) Current literature has used a variety of dataset, methods, and models to examine the built environment-health benefit connections from the perspective of physical activity; (2) The prevalence of chronic diseases is inextricably linked to the built environment, and policy interventions related to physical activity and physical and mental wellbeing of urban residents should be emphasized; (3) The impact of the built environment on health is manifested in the way various elements of the physical environment guide the lifestyle of residents, thereby influencing physical activity and travel; (4) Given the changes that have occurred in the built environment during the current urban expansion, the link between urban planning and the public health sector should be strengthened in the future, and the relevant authorities should actively pursue policies that promote urban public health in order to improve the health of residents. Finally, it proposes potential policy insights for urban planning and development toward a healthier city and society.

The Role of Urban Environments in Promoting Active and Healthy Aging: A Systematic Scoping Review of Citizen Science Approaches

Promoting active and healthy aging in urban spaces requires environments with diverse, age-friendly characteristics. This scoping review investigated the associations between urban characteristics and active and healthy aging as identified by citizen science (CS) and other participatory approaches. Using a systematic scoping review procedure, 23 articles employing a CS or participatory approach (participant age range: 54-98 years) were reviewed. An inductive and deductive thematic analysis was completed to (a) identify local urban barriers and facilitators and (b) map them against the World Health Organization (WHO) Checklist of Essential Features of Age-Friendly Cities. A new Citizen Science Appraisal Tool (CSAT) was developed to evaluate the quality of CS and other participatory approaches included in the reviewed articles. A range of interconnected urban barriers and facilitators was generated by residents across the personal (e.g. perceived safety), environmental (e.g. unmaintained infrastructure), socio-cultural (e.g. cross-cultural activities), economic (e.g. affordable housing) and political (e.g. governmental support to migrant communities) domains. Mapping the barriers and facilitators to the WHO age-friendly checklist underscored the checklist's relevance and elucidated the need to explore barriers for migrant and cross-cultural communities and neighborhood development and alterations. The CSAT demonstrated strengths related to active engagement of residents and study outcomes leading to real-world implications. To advance the potential of CS to enrich our understanding of age-friendly environments, employing co-production to enhance relevance and sustainability of outcomes is an important strategy. Overall, employing CS highlighted the value of systematically capturing the experiences of older adults within studies aimed at promoting active and healthy aging.

The Effect of Built Environment on Older People Leisure-Time Walking and Physical Activity in Different Sex Groups in the City of Ningbo, China

The aim of this study was to examine the effect of built environment (BE) elements on older people’s (OP) leisure-time physical activity (LTPA) and leisure-time walking (LTW) level in the city of Ningbo. Older participants numbering 312 were randomly recruited using cross-sectional survey in 2019. International Physical Activity Questionnaire-short version (IPAQ-S) and Neighborhood Environment Walkability Scale—abbreviated (NEWS-A)—were used to gather LTPA data and the perceive scores of BE, respectively. Liner regression analysis was performed to investigate the association relationship between the perceived scores of BE and OP’s LTW and LTPA. The study’s results showed that, when not considering different sex groups, OP’s LTW was significantly related with the perceived scores of access to services (AE, p = 0.045), walking/cycling facilities (W/CF, p = 0.007), aesthetics, and land use mix diversity (LUMD, p = 0.04). OP’s LTPA was significantly related with AE (p = 0.04) and aesthetics (p < 0.001). The association relationships of BE with LTW and LTPA varied in different sex groups. Three elements (AE, W/CF, and LUMD) and one element (pedestrian/traffic safety and P/TS) of BE were found be related with older male and older female’s LTW, respectively. One element (aesthetics) and two elements (aesthetics, LUMD) of BE were found be related with older male and older female’s LTPA, respectively. The results indicated that the effects of BE on OP’s LTW and the effects of BE on OP’s LTPA were different. The effect also varied in different sex groups. More studies are needed to confirm the effect of BE on OP’s LTW and LTPA in different sex groups to globally enrich the scientific data base.

Developing a Complex Understanding of Physical Activity in Cardiometabolic Disease from Low-to-Middle-Income Countries-A Qualitative Systematic Review with Meta-Synthesis

Physical activity behaviour is complex, particularly in low-resource settings, while existing behavioural models of physical activity behaviour are often linear and deterministic. The objective of this review was to (i) synthesise the wide scope of factors that affect physical activity and thereby (ii) underpin the complexity of physical activity in low-resource settings through a qualitative meta-synthesis of studies conducted among patients with cardiometabolic disease living in low-to-middle income countries (LMIC). A total of 41 studies were included from 1200 unique citations (up to 15 March 2021). Using a hybrid form of content analysis, unique factors (n = 208) that inform physical activity were identified, and, through qualitative meta-synthesis, these codes were aggregated into categories (n = 61) and synthesised findings (n = 26). An additional five findings were added through deliberation within the review team. Collectively, the 31 synthesised findings highlight the complexity of physical activity behaviour, and the connectedness between person, social context, healthcare system, and built and natural environment. Existing behavioural and ecological models are inadequate in fully understanding physical activity participation in patients with cardiometabolic disease living in LMIC. Future research, building on complexity science and systems thinking, is needed to identify key mechanisms of action applicable to the local context.

Leisure sedentary time and physical activity are higher in neighbourhoods with denser greenness and better built environments: An analysis of the Canadian Longitudinal Study on Aging

Associations of environmental variables with physical activity and sedentary time using data from the Canadian Longitudinal Study on Aging, and the Canadian Urban Environment Research Consortium (Canadian Active Living Environments (Can-ALE) dataset, and Normalized Difference Vegetation Index (NDVI, greenness) dataset) were assessed. The main outcome variables were physical activity and sedentary time as measured by a modified version of the Physical Activity for Elderly Scale. The sample consisted of adults aged 45 and older (n = 36,580, mean age 62.6±10.2, 51% female). Adjusted ordinal regression models consistently demonstrated that those residing in neighbourhoods in the highest Can-ALE category (most well-connected built environment) reported more physical activity and sedentary time. For example, males aged 75+ in the highest Can-ALE category had 1.9 times higher odds of reporting more physical activity (OR = 1.9, 95%CI = 1.1-3.4) and 1.8 higher odds of reporting more sedentary time (OR = 1.8, 95%CI = 1.0-3.4). Neighbourhoods with higher greenness scores were also associated with higher odds of reporting more physical activity and sedentary time. It appears that an environment characterized by higher Can-ALE and higher greenness may facilitate physical activity, but it also facilitates more leisure sedentary time in older adults; research using device measured total sedentary time, and consideration of the types of sedentary activities being performed is needed. Novelty: ●Middle-aged and older adults living in neighbourhoods with higher Can-ALE scores and more greenness report more physical activity and leisure sedentary time ●Greenness is important for physical activity and sedentary time in middle-aged adults.

Neighborhood Urban Design and Outdoor Later Life: An Objective Assessment of Out-of-Home Time and Physical Activity Among Older Adults in Barcelona

This study explores how older adults' time out-of-home and physical activity (PA) are associated with the provision of urban open spaces (green spaces, plazas, and boulevards) and microelements (street trees and benches) in their neighborhoods. The authors used data from 103 residents in Barcelona and matched it to official geospatial data. The authors adjusted a set of mixed-effects linear regressions, both for the entire sample and also stratified by age and gender. For the entire sample, the percentage of green spaces showed a positive association with neighborhood time out-of-home and PA, while participants' PA also showed a positive association with the presence of benches. Outdoor time among older women was not associated with any of the measured exposures. For men, the provision of green spaces and benches was positively associated with time out-of-home and PA. These results could inform the design of urban spaces that aim to encourage outdoor activity among older adults.

A systematic review of empirical and simulation studies evaluating the health impact of transportation interventions

Urban transportation is an important determinant of health and environmental outcomes, and therefore essential to achieving the United Nation's Sustainable Development Goals. To better understand the health impacts of transportation initiatives, we conducted a systematic review of longitudinal health evaluations involving: a) bus rapid transit (BRT); b) bicycle lanes; c) Open Streets programs; and d) aerial trams/cable cars. We also synthesized systems-based simulation studies of the health-related consequences of walking, bicycling, aerial tram, bus and BRT use. Two reviewers screened 3302 unique titles and abstracts identified through a systematic search of MEDLINE (Ovid), Scopus, TRID and LILACS databases. We included 39 studies: 29 longitudinal evaluations and 10 simulation studies. Five studies focused on low- and middle-income contexts. Of the 29 evaluation studies, 19 focused on single component bicycle lane interventions; the rest evaluated multi-component interventions involving: bicycle lanes (n = 5), aerial trams (n = 1), and combined bicycle lane/BRT systems (n = 4). Bicycle lanes and BRT systems appeared effective at increasing bicycle and BRT mode share, active transport duration, and number of trips using these modes. Of the 10 simulation studies, there were 9 agent-based models and one system dynamics model. Five studies focused on bus/BRT expansions and incentives, three on interventions for active travel, and the rest investigated combinations of public transport and active travel policies. Synergistic effects were observed when multiple policies were implemented, with several studies showing that sizable interventions are required to significantly shift travel mode choices. Our review indicates that bicycle lanes and BRT systems represent promising initiatives for promoting population health. There is also evidence to suggest that synergistic effects might be achieved through the combined implementation of multiple transportation policies. However, more rigorous evaluation and simulation studies focusing on low- and middle-income countries, aerial trams and Open Streets programs, and a more diverse set of health and health equity outcomes is required.

Longitudinal Association of Built Environment Pattern with Physical Activity in a Community-Based Cohort of Elderly Hong Kong Chinese: A Latent Profile Analysis

A large number of studies have focused on the associations between single built environment (BE) characteristics and physical activity (PA). Combinations of BE characteristics offer a more comprehensive approach to identify the BE–PA associations. We aimed to examine the BE–PA associations in a cohort of elderly Hong Kong Chinese. Between 2001 and 2003, 3944 participants (65–98 years of age) were recruited and followed for a mean of 7.8 years. BE characteristics were assessed via geographic information system. PA levels were obtained using the Physical Activity Scale for the Elderly questionnaire at baseline and three follow-ups. Latent profile analysis was first conducted to classify the BE characteristics, and linear mixed-effects models were then used to explore the longitudinal associations between the BE classes and changes in the PA levels. Three classes of BE were identified. Class 3 (characterized by greater green space and sky view factor) demonstrated a significant decline in household PA (β = −1.26, 95% confidence interval: −2.20, −0.33) during the study period, and a slower decline in walking PA (1.19 (0.42, 1.95)) compared with Class 2 (characterized by a greater proportion of residential land use). Our results indicate that BE patterns characterized by high green space and a sky view factor may help promote the walking PA level.

Urban environments and objectively-assessed physical activity and sedentary time in older Belgian and Chinese community dwellers: potential pathways of influence and the moderating role of physical function

BACKGROUND

Many studies have examined neighbourhood environmental correlates of older adults' physical activity (PA) but only a few focused on sedentary time (ST). Only a small proportion of these studies used objective measures of PA/ST, such as accelerometer-assessed PA/ST, and only a couple employed accelerometer cut-points appropriate for older adults. Furthermore, although older adults experience declines in physical function as they age, there is a dearth of information on the impact of the neighbourhood environment on PA/ST in individuals with different levels of physical function.

METHODS

We used data from two extant cross-sectional studies conducted in Hong Kong (China) and Ghent (Belgium) (N = 829). Participants were recruited from pre-selected administrative units stratified by socio-economic status and walkability. Moderate-to-vigorous PA (MVPA) and ST were assessed for 7 days using accelerometers and cut-points developed for older adults. Objective neighbourhood environmental attributes within 400 m and 1 km buffers surrounding participants' homes were quantified using Geographic Information Systems data. Lower extremity physical function was objectively assessed. Socio-demographic information was collected via interviews. Total, direct and indirect (mediated) effects of environmental attributes on MVPA and ST were estimated using generalised additive mixed models and the joint-significant test.

RESULTS

Commercial/civic destination density and number of parks within 1 km from home showed positive total and direct effects on MVPA, and public transport density showed negative total and direct effects on ST, which were consistent across cities and physical function levels. The total and direct effects of residential density on MVPA depended on physical function, and those of residential density on ST differed by city. A complex network of potential inconsistent pathways linking all environmental attributes to MVPA and ST in the whole sample or in subgroups of participants was revealed.

DISCUSSION

Access to parks and commercial/civic destinations appear to support older adults' MVPA in different geographical and cultural contexts and irrespective of their physical function level. By supporting MVPA, these characteristics also contribute to a reduction in ST. The potential effects of public transport, recreational facilities and residential density are less straightforward and point at inconsistent effects that may depend on the geographical context and level of physical function.

E. M. Browning M, Rigolon A. Noncommunicable Diseases, Park Prescriptions, and Urban Green Space Use Patterns in a Global South Context: The Case of Dhaka, Bangladesh

Urban green space use is often associated with improved physical and mental health and lower noncommunicable disease (NCDs) burdens. Factors that influence green space visits have been documented in cities of the Global North, but evidence of urban green space use patterns for cities in the Global South is scarce. The aim of this study is to investigate factors influencing urban green space use patterns in Dhaka, Bangladesh, a megacity of the Global South, with a particular focus on how poor health condition and healthcare professionals' prescriptions to exercise outdoors (park prescriptions-ParkRx) impact the green space use of middle-aged adults. We collected green space characteristics and use factors (i.e., availability, accessibility, attractiveness, and attachment), health condition, ParkRx, and urban green space use intensity (i.e., frequency and duration) via a self-reported questionnaire from 169 middle-aged residents of Dhaka. We used multivariate modeling to estimate the association of green space characteristics, health condition, and ParkRx with use intensity. We further applied a mediation analysis to determine the influence of ParkRx on the relationship between residents' poor health conditions and use intensity. We found that green space availability and accessibility did not significantly influence use intensity, but attractiveness was negatively associated with use intensity. Green space use intensity was significantly and positively associated with attachment to the green space, poor health condition (i.e., having noncommunicable diseases), and ParkRx. ParkRx significantly mediated the relationship between health condition and use intensity. We observed limited supply, poor access, and low attractiveness when studying the urban green spaces in Dhaka, but these qualities did not affect use intensity, as found in many case studies in the Global North. In contrast, urban green space use intensity in our case study is mostly dependent on poor health condition and park prescriptions.

Built environment correlates of physical activity in low- and middle-income countries: A systematic review

Insufficient physical activity (PA) is the fourth major risk factor for many non-communicable diseases and premature mortality worldwide. Features of the built environment (BE) play a considerable role in determining population PA behaviors. The majority of evidence for PA-BE relationships comes from high-income countries and may not be generalizable to low- and middle-income countries (LMICs). We aim to systematically review the literature and assess the associations between perceived and/or objective BE characteristics and PA domains in LMICs. This review adopted a systematic search strategy for English language articles published between January 2000 and June 2019 from four electronic databases-Medline, Embase, Web of Science and PubMed-adhering to the PRISMA guidelines. Studies addressing the associations between self-reported and/or objective BE and PA were only included if they were conducted in LMICs, according to the World Bank classification list. Articles investigating PA-BE relationships across any age groups were included, and all study designs were eligible, except for qualitative studies and reviews. Thirty-three studies were included for evidence synthesis. Cross-sectional studies were the most prevailing study design (97%), revealing a notable gap in longitudinal PA-BE research in LMICs. A majority of the BE factors were not associated with different PA domains while others (e.g., density, proximity to services, aesthetics) exhibited an inconsistent association. Land-use mix diversity was positively associated with transport PA and the presence of recreation facilities resulted in an increase in PA during leisure-time. Increased safety from crime at night consistently increased total PA and walking levels. Research exploring the associations between BE attributes and PA behaviors in LMICs appears to be limited and is primarily cross-sectional. Longitudinal research studies with objective measures are needed for inferring well-grounded PA-BE causal relationships and informing the design of evidence-based environmental interventions for increasing PA levels in LMICs.

Commercial app use linked with sustained physical activity in two Canadian provinces: a 12-month quasi-experimental study

Background

Top tier commercial physical activity apps rarely undergo peer-reviewed evaluation. Even fewer are assessed beyond six months, the theoretical threshold for behaviour maintenance. The purpose of this study was to examine whether a multi-component commercial app rewarding users with digital incentives for walking was associated with an increase in physical activity over one year.

Methods

This 12-month quasi-experimental study was conducted in two Canadian provinces (n = 39,113 participants). Following a two-week baseline period, participants earned digital incentives ($0.04 CAD/day) every day they reached a personalized daily step goal. Mixed-effects models estimated changes in weekly mean daily step count between the baseline period and the last two recorded weeks. Models were fit for several engagement groups and separately by baseline physical activity status within engagement groups.

Results

Nearly half of participants (43%) were categorized as physically inactive at baseline (fewer than 5000 daily steps), and 60% engaged with the app for at least six months [‘Regular’ (24–51 weeks of step data) or ‘Committed’ sub-groups (52 weeks)]. Weekly mean daily step count increased for physically inactive users regardless of engagement status (P < .0001). The increase was largest for ‘Regular’ and ‘Committed’ participants—1215 and 1821 steps/day, respectively. For physically active participants, step count increases were only observed in the ‘Committed’ sub-group (P < .0001). Effect sizes were modest-to-medium depending on the sub-group analyzed.

Conclusions

A commercial app providing small but immediate digital incentives for individualized goals was associated with an increased weekly mean daily step count on a population-scale over one year. This effect was more evident for physically inactive and more engaged participants.

"I Would Never Come Here Because I've Got My Own Garden": Older Adults' Perceptions of Small Urban Green Spaces

Green spaces are known to improve health and wellbeing via several mechanisms, such as by reducing stress and facilitating physical activity. However, little is known about the impact of the smaller green spaces typically found in urban environments on wellbeing, especially for older adults. This study investigated experiences in adults (5 males and 10 females) aged 60 years and over of small urban green spaces in a large UK city. Fifteen older adults were interviewed using semi-structured walk-along interviews and photo elicitation methods in Old Moat, Greater Manchester. Twelve of the participants lived in Old Moat at the time of the study, and the remaining three participants previously lived in Old Moat and were frequent visitors. Transcribed interviews were analyzed using Thematic Analysis. Smaller urban green spaces were perceived differently to large green spaces, and participants were more likely to use larger green spaces such as parks. The smaller green spaces were perceived as belonging to other people, which discouraged the older adults from using them. The older adults also emphasized the importance of taking care of small urban green spaces and preventing them from becoming overgrown. Urban planners should consider these factors, since they indicate that the size and type of urban green spaces may influence whether they improve health and wellbeing. Further research should investigate in more detail which types of urban green space are most conducive to facilitating physical activity and improving wellbeing.