Exploring lay views on physical activity and their implications for public health policy. A case study from East Belfast

Investigating the physical activity, health, wellbeing, social and environmental effects of a new urban greenway: a natural experiment (the PARC study)

BACKGROUND

Evidence for the health benefits of urban green space tends to stem from small, short-term quasi-experimental or cross-sectional observational research, whilst evidence from intervention studies is sparse. The development of an urban greenway (9 km running along 3 rivers) in Northern Ireland provided the opportunity to conduct a natural experiment. This study investigated the public health impact of the urban greenway on a range of physical activity, health, wellbeing, social, and perceptions of the environment outcomes.

METHODS

A repeated cross-sectional household survey of adult residents (aged ≥16 years) who lived ≤1-mile radius of the greenway (intervention sample) and > 1-mile radius of the greenway (control sample) was conducted pre (2010/2011) and 6-months post implementation (2016/2017). We assessed changes in outcomes pre- and post-intervention follow-up including physical activity behaviour (primary outcome measure: Global Physical Activity Questionnaire), quality of life, mental wellbeing, social capital and perceptions of the built environment. Linear regression was used to calculate the mean difference between post-intervention and baseline measures adjusting for age, season, education, car ownership and deprivation. Multi-level models were fitted using a random intercept at the super output area (smallest geographical unit) to account for clustering within areas. The analyses were stratified by distance from the greenway and deprivation. We assessed change in the social patterning of outcomes over time using an ordered logit to make model-based outcome predictions across strata.

RESULTS

The mean ages of intervention samples were 50.3 (SD 18.9) years at baseline (n = 1037) and 51.7 (SD 19.1) years at follow-up (n = 968). Post-intervention, 65% (adjusted OR 0.60, 95% CI 0.35 to 1.00) of residents who lived closest to the greenway (i.e., ≤400 m) and 60% (adjusted OR, 0.64 95% CI 0.41 to 0.99) who lived furthest from the greenway (i.e.,≥1200 m) met the physical activity guidelines - 68% of the intervention sample met the physical activity guidelines before the intervention. Residents in the most deprived quintiles had a similar reduction in physical activity behaviour as residents in less deprived quintiles. Quality of life at follow-up compared to baseline declined and this decline was significantly less than in the control area (adjusted differences in mean EQ5D: -11.0 (95% CI - 14.5 to - 7.4); - 30.5 (95% CI - 37.9 to - 23.2). Significant change in mental wellbeing was not observed despite improvements in some indicators of social capital. Positive perceptions of the local environment in relation to its attractiveness, traffic and safety increased.

CONCLUSIONS

Our findings illustrate the major challenge of evaluating complex urban interventions and the difficulty of capturing and measuring the network of potential variables that influence or hinder meaningful outcomes. The results indicate at this stage no intervention effect for improvements in population-level physical activity behaviour or mental wellbeing. However, they show some modest improvements for secondary outcomes including positive perceptions of the environment and social capital constructs. The public health impact of urban greenways may take a longer period of time to be realised and there is a need to improve evaluation methodology that captures the complex systems nature of urban regeneration.

Individual Characteristics Associated with Active Travel in Low and High Income Groups in the UK

Active travel (AT) has gained increasing attention as a way of addressing low levels of physical activity. However, little is known regarding the relationship between income and AT. The aim of this study was to investigate characteristics associated with undertaking AT in an adult population and by low- and high-income groups. Data collected from the Physical Activity and the Rejuvenation of Connswater (PARC) study in 2017 were used. Participants were categorised into socio-economic groups according to their weekly household income, and were categorised as participating in ‘no’ AT or ‘some’ AT and ‘sufficient’ AT. Multivariable logistic regression explored characteristics associated with AT in the full cohort, and the low- and high-income groups separately. Variables associated with AT in the low-income group were body mass index (BMI), physical activity self-efficacy, marital status, long term illness, difficulty walking and housing tenure. For the high-income group, BMI, marital status, housing tenure and education were associated with AT. For both income groups, there were consistent positive associations with the action/maintenance phase of the stage of change model across all AT categories. The findings suggest that population sub-groups may benefit from targeted initiatives to support engagement in AT and prevent further widening of inequalities.

Implementing community-based health promotion in socio-economically disadvantaged areas: a qualitative study

BACKGROUND

There is a gradient relationship between socio-economic status and health. We investigated the views and perceptions of health promotion service providers regarding factors that affect lack of engagement in public health initiatives by residents in socio-economically disadvantaged (SED) communities.

METHODS

We conducted semi-structured interviews with a purposive sample of key providers (n = 15) of community-based health promotion services to elicit their views about engagement-related factors and their experiences of the provision, delivery and impact of health promotion in SED areas. Interviews were analysed using thematic analysis.

RESULTS

Failure to (i) recognise within SED communities, socio-cultural norms of health-related behaviour and (ii) communicate to local residents an understanding of complex lifestyle influences appeared to affect adversely service engagement and contribute to the development of negative attitudes towards health promotion. Engagement is more likely when services are delivered within familiar settings, peer support is available, initiatives are organized within existing groups, external incentives are offered and there are options regarding times and locations. Collaborative working between providers and communities facilitates efficient, context-sensitive service delivery.

CONCLUSIONS

Knowledge of a local community and its socio-environmental context alongside a collaborative, facilitative and tailored approach to delivery are required to ensure successful engagement of SED communities in health promotion.

Multimodal imaging interpreted by graders to detect re-activation of diabetic eye disease in previously treated patients: the EMERALD diagnostic accuracy study

BACKGROUND

Owing to the increasing prevalence of diabetes, the workload related to diabetic macular oedema and proliferative diabetic retinopathy is rising, making it difficult for hospital eye services to meet demands.

OBJECTIVE

The objective was to evaluate the diagnostic performance, cost-effectiveness and acceptability of a new pathway using multimodal imaging interpreted by ophthalmic graders to detect reactivation of diabetic macular oedema/proliferative diabetic retinopathy in previously treated patients.

DESIGN

This was a prospective, case-referent, cross-sectional diagnostic study.

SETTING

The setting was ophthalmic clinics in 13 NHS hospitals.

PARTICIPANTS

Adults with type 1 or type 2 diabetes with previously successfully treated diabetic macular oedema/proliferative diabetic retinopathy in one/both eyes in whom, at the time of enrolment, diabetic macular oedema/proliferative diabetic retinopathy could be active or inactive.

METHODS

For the ophthalmic grader pathway, review of the spectral domain optical coherence tomography scans to detect diabetic macular oedema, and seven-field Early Treatment Diabetic Retinopathy Study/ultra-wide field fundus images to detect proliferative diabetic retinopathy, by trained ophthalmic graders. For the current standard care pathway (reference standard), ophthalmologists examined patients face to face by slit-lamp biomicroscopy for proliferative diabetic retinopathy and, in addition, spectral domain optical coherence tomography imaging for diabetic macular oedema.

OUTCOME MEASURES

The primary outcome measure was sensitivity of the ophthalmic grader pathway to detect active diabetic macular oedema/proliferative diabetic retinopathy. The secondary outcomes were specificity, agreement between pathways, cost-consequences, acceptability and the proportion of patients requiring subsequent ophthalmologist assessment, unable to undergo imaging and with inadequate quality images/indeterminate findings. It was assumed for the main analysis that all patients in whom graders diagnosed active disease or were 'unsure' or images were 'ungradable' required examination by an ophthalmologist.

RESULTS

Eligible participants with active and inactive diabetic macular oedema (152 and 120 participants, respectively) and active and inactive proliferative diabetic retinopathy (111 and 170 participants, respectively) were recruited. Under the main analysis, graders had a sensitivity of 97% (142/147) (95% confidence interval 92% to 99%) and specificity of 31% (35/113) (95% confidence interval 23% to 40%) to detect diabetic macular oedema. For proliferative diabetic retinopathy, graders had a similar sensitivity and specificity using seven-field Early Treatment Diabetic Retinopathy Study [sensitivity 85% (87/102), 95% confidence interval 77% to 91%; specificity 48% (77/160), 95% confidence interval 41% to 56%] or ultra-wide field imaging [sensitivity 83% (87/105), 95% confidence interval 75% to 89%; specificity 54% (86/160), 95% confidence interval 46% to 61%]. Participants attending focus groups expressed preference for face-to-face evaluations by ophthalmologists. In the ophthalmologists' absence, patients voiced the need for immediate feedback following grader's assessments, maintaining periodic evaluations by ophthalmologists. Graders and ophthalmologists were supportive of the new pathway. When compared with the reference standard (current standard pathway), the new grader pathway could save £1390 per 100 patients in the review of people with diabetic macular oedema and, depending on the imaging modality used, between £461 and £1189 per 100 patients in the review of people with proliferative diabetic retinopathy.

CONCLUSIONS

For people with diabetic macular oedema, the ophthalmic grader pathway appears safe and cost saving. The sensitivity of the new pathway to detect active proliferative diabetic retinopathy was lower, but may still be considered acceptable for patients with proliferative diabetic retinopathy previously treated with laser. Suggestions from focus group discussions should be taken into consideration if the new pathway is introduced to ensure its acceptability to users.

LIMITATIONS

Lack of fundus fluorescein angiography to confirm diagnosis of active proliferative diabetic retinopathy.

FUTURE WORK

Could refinement of the new pathway increase its sensitivity to detect proliferative diabetic retinopathy? Could artificial intelligence be used for automated reading of images in this previously treated population?

TRIAL REGISTRATION

Current Controlled Trials ISRCTN10856638 and ClinicalTrials.gov NCT03490318.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology AssessmentVol. 25, No. 32. See the NIHR Journals Library website for further project information.

Network methods to support user involvement in qualitative data analyses: an introduction to Participatory Theme Elicitation

BACKGROUND

While Patient and Public Involvement (PPI) is encouraged throughout the research process, engagement is typically limited to intervention design and post-analysis stages. There are few approaches to participatory data analyses within complex health interventions.

METHODS

Using qualitative data from a feasibility randomised controlled trial (RCT), this proof-of-concept study tests the value of a new approach to participatory data analysis called Participatory Theme Elicitation (PTE). Forty excerpts were given to eight members of a youth advisory PPI panel to sort into piles based on their perception of related thematic content. Using algorithms to detect communities in networks, excerpts were then assigned to a thematic cluster that combined the panel members' perspectives. Network analysis techniques were also used to identify key excerpts in each grouping that were then further explored qualitatively.

RESULTS

While PTE analysis was, for the most part, consistent with the researcher-led analysis, young people also identified new emerging thematic content.

CONCLUSIONS

PTE appears promising for encouraging user led identification of themes arising from qualitative data collected during complex interventions. Further work is required to validate and extend this method.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT02455986 . Retrospectively Registered on 21 May 2015.

'Keeping your body and mind active': an ethnographic study of aspirations for healthy ageing

OBJECTIVE

To describe and explore perceptions, practices and motivations for active living in later life.

DESIGN

Qualitative study with semistructured interviews and 'semistructured' participant observations of participant-selected activities, such as exercise classes, private or organised walks, shopping and gardening.

PARTICIPANTS

27 participants (65-80 years) from the European Prospective Investigation into Cancer Norfolk study, purposefully selected by gender, age, occupational class, living status and residential location; 19 of the participants agreed to be accompanied for observed activities.

SETTING

Participants' homes, neighbourhoods, places of leisure activities and workplaces in Norfolk, England.

RESULTS

All participants regarded a positive attitude as important for healthy ageing; this included staying active, both physically and mentally through sedentary activities such as reading and crosswords. 'Getting out of the house', being busy, or following a variety of interests were regarded as both important motivators and descriptions of their 'activeness'. Purposeful activities formed an important part of this, for example, still being engaged in paid or voluntary work, having caring responsibilities, or smaller incidental activities such as helping neighbours or walking for transport. Many also reported adapting previous, often lifelong, activity preferences and habits to their ageing body, or replacing them altogether with lower impact activities such as walking. This included adapting to the physical limitations of partners and friends which dictated the intensity and frequency of shared activities. The social context of activities could thus form a barrier to active living, but could also encourage it through companionship, social responsibilities and social pressures.

CONCLUSIONS

Promoting and maintaining physical activity among older people may require more attention to activeness as an attitude and way of life as well as to its social context, and initiatives encouraging broader activity habits rather than discrete activities.

Individual factors and perceived community characteristics in relation to mental health and mental well-being

BACKGROUND

It has been argued that though correlated with mental health, mental well-being is a distinct entity. Despite the wealth of literature on mental health, less is known about mental well-being. Mental health is something experienced by individuals, whereas mental well-being can be assessed at the population level. Accordingly it is important to differentiate the individual and population level factors (environmental and social) that could be associated with mental health and well-being, and as people living in deprived areas have a higher prevalence of poor mental health, these relationships should be compared across different levels of neighbourhood deprivation.

METHODS

A cross-sectional representative random sample of 1,209 adults from 62 Super Output Areas (SOAs) in Belfast, Northern Ireland (Feb 2010 - Jan 2011) were recruited in the PARC Study. Interview-administered questionnaires recorded data on socio-demographic characteristics, health-related behaviours, individual social capital, self-rated health, mental health (SF-8) and mental well-being (WEMWBS). Multi-variable linear regression analyses, with inclusion of clustering by SOAs, were used to explore the associations between individual and perceived community characteristics and mental health and mental well-being, and to investigate how these associations differed by the level of neighbourhood deprivation.

RESULTS

Thirty-eight and 30 % of variability in the measures of mental well-being and mental health, respectively, could be explained by individual factors and the perceived community characteristics. In the total sample and stratified by neighbourhood deprivation, age, marital status and self-rated health were associated with both mental health and well-being, with the 'social connections' and local area satisfaction elements of social capital also emerging as explanatory variables. An increase of +1 in EQ-5D-3 L was associated with +1SD of the population mean in both mental health and well-being. Similarly, a change from 'very dissatisfied' to 'very satisfied' for local area satisfaction would result in +8.75 for mental well-being, but only in the more affluent of areas.

CONCLUSIONS

Self-rated health was associated with both mental health and mental well-being. Of the individual social capital explanatory variables, 'social connections' was more important for mental well-being. Although similarities in the explanatory variables of mental health and mental well-being exist, socio-ecological interventions designed to improve them may not have equivalent impacts in rich and poor neighbourhoods.

Demand response to improved walking infrastructure: A study into the economics of walking and health behaviour change

Walking is the most common form of moderate-intensity physical activity among adults, is widely accessible and especially appealing to obese people. Most often policy makers are interested in valuing the effect on walking of changes in some characteristics of a neighbourhood, the demand response for walking, of infrastructure changes. A positive demand response to improvements in the walking environment could help meet the public health target of 150 min of at least moderate-intensity physical activity per week. We model walking in an individual's local neighbourhood as a 'weak complement' to the characteristics of the neighbourhood itself. Walking is affected by neighbourhood characteristics, substitutes, and individual's characteristics, including their opportunity cost of time. Using compensating variation, we assess the economic benefits of walking and how walking behaviour is affected by improvements to the neighbourhood. Using a sample of 1209 respondents surveyed over a 12 month period (Feb 2010-Jan 2011) in East Belfast, United Kingdom, we find that a policy that increased walkability and people's perception of access to shops and facilities would lead to an increase in walking of about 36 min/person/week, valued at £13.65/person/week. When focussing on inactive residents, a policy that improved the walkability of the area would lead to guidelines for physical activity being reached by only 12.8% of the population who are currently inactive. Additional interventions would therefore be needed to encourage inactive residents to achieve the recommended levels of physical activity, as it appears that interventions that improve the walkability of an area are particularly effective in increasing walking among already active citizens, and, among the inactive ones, the best response is found among healthier, younger and wealthier citizens.