The challenges of evaluating environmental interventions to increase population levels of physical activity: the case of the UK National Cycle Network

Using an Intervention Mapping Approach to Develop a Program for Preventing High Blood Pressure in a Marginalized Afro-Colombian Population: A Community-Based Participatory Research

The prevention of high blood pressure (HBP) is an important public health initiative worldwide, since HBP is the main risk factor for cardiovascular diseases and increases the damage caused by coronavirus disease 2019 (COVID-19). We designed, implemented, and evaluated a program to identify effective and sustainable interventions for preventing HBP in a marginalized black population. Our study was conducted in Quibdó, a city in Colombia with the highest poverty rate and located in the Pacific coast, a subregion in Colombia with the highest prevalence of HBP. We followed an intervention mapping framework using a community-based participatory research approach. Focus groups, photovoice, literature reviews, and cross-sectional quantitative surveys were used for data collection. The community chose the time, place, and type of physical activity; led the physical activities; and strengthened their skills in seeking resources in their community to sustain the program. The evaluation was aimed at determining whether the interventions were able to achieve the program’s primary aim. We used a before (September 2016) and after (December 2017) design for the evaluation. To decrease the selection bias and allow comparisons between homogeneous groups, we used a propensity score matching technique. The steps required to create a self-sustaining physical activity program were provided in detail. The pre-post test showed a decrease of the HBP (systolic, 13.4% points; p = 0.018; diastolic, 6.5% points; p = 0.002). The program may be an effective and self-sustaining intervention, and it can be replicated by policymakers and implemented in other population groups.

Towards better evidence-informed global action: lessons learnt from the Lancet series and recent developments in physical activity and public health

In the past few decades, the field of physical activity has grown and evolved in scope, depth, visibility and impact around the world. Global progress has been observed in research and practice in physical activity regarding surveillance, health outcomes, correlates/determinants, interventions, translation and policy. The 2012 and 2016 Lancet series on physical activity provide some of the most comprehensive global analysis on various topics within physical activity. Based on the Lancet series and other key developments in the field, literature searches, and expert group meetings and consultation, we provide a global summary on the progress of, gaps in and future directions for physical activity research in the following areas: (1) surveillance and trends, (2) correlates and determinants, (3) health outcomes and (4) interventions, programmes and policies. Besides lessons learnt within each specific area, several recommendations are shared across areas of research, including improvement in measurement, applying a global perspective with a growing emphasis on low-income and middle-income countries, improving inclusiveness and equity in research, making translation an integral part of research for real-world impact, taking an 'upstream' public health approach, and working across disciplines and sectors to co-design research and co-create solutions. We have summarised lessons learnt and recommendations for future research as 'roadmaps' in progress to encourage moving the field of physical activity towards achieving population-level impact globally.

Physical Activity and Commuting to School in Spanish Nine-Year-Old Children: Differences by Gender and by Geographical Environment

Children’s health status is related to their physical activity levels. Active commuting is associated with higher physical activity and reduced risk of all-cause mortality, cardiovascular disease incidence, and diabetes. The objective of this research was to study the levels of physical activity and the commuting to school (active vs. passive) in Spanish nine-year-old children, analyzing the differences by gender and by the geographical environment where they live (rural or urban environment). Accelerometry was used for the measurement of physical activity: Sedentary time (min/day), vigorous physical activity (min/day), moderate to vigorous physical activity (min/day), intensity (counts/min), steps (number). The questionnaire of the European Youth Heart Study (EYHS) was used to determine the geographical environment (city/urban, residential area/outside city, rural/village) and the modes of transport (active: Walking and bicycle, passive: Car, motorcycle, public transport). A total of 455 Spanish nine-year-old children (247 girls and 208 boys) belonging to the EYHS participated in this study. The results showed that boys were significantly more physically active than girls (p ≤ 0.001). Results also showed that active commuting to school was positively correlated with the levels of physical activity (r = 0.324, p ≤ 0.001). The geographical environment influenced the way in which children went to school, being active commuting to school significantly (p ≤ 0.001) less frequent in those children who lived in a rural environment (22.4%) than in those who lived in the city (57.1%) or in a residential area (62.7%). As active commuting to school means increasing levels of physical activity in both sexes, strategies should be implemented in order to encourage active commuting to schools, contributing at the same time to better health and sustainability of future generations.

Closing the loop: short term impacts on physical activity of the completion of a loop trail in Sydney, Australia

BACKGROUND

In Australia, an estimated 57% of the population do not meet physical activity recommendations for health. The built environment is important for active living, and recreational trails provide safe and pleasant settings for this purpose. However, evidence for positive impacts on physical activity from real world natural experiments is sparse. We describe the impact of transforming a recreational trail into a loop on usage by cyclists and pedestrians and users' physical activity levels.

METHOD

We conducted time series analyses of pre and post-completion (November 2013-July 2015) counts taken from infrared electronic counters of pedestrians and cyclists on two established sections of the trail adjusted for underlying trend, trend change, weather, holidays and trail closures. Chi-square analyses of pre and post-completion visual counts examined change in the distribution of pedestrian/cyclist, adult/child, and male/female users. Descriptive and bivariate analyses of post-completion intercept survey data of 249 trail users were conducted to examine user characteristics and impact on physical activity.

RESULTS

Pedestrian and cyclist counts on established trail sections increased by between 200 and 340% from pre to post-completion. Visual count data showed a significant 7% increase in children (vs adults) using the trail at one site pre to post (p = 0.008). Of previous users, 48% reported doing more physical activity at the trail and this was additional to (not replacing) physical activity done elsewhere. Those users not meeting physical activity recommendations were more likely to report increased total physical activity since the loop was created (55.5% vs 39.2%, p = 0.031). The connected loop nature of the trail and its length was perceived to encourage more and different forms of physical activity.

CONCLUSION

Creating an accessible loop trail away from motorised traffic can lead to increased trail use and potentially total physical activity. The modification to the trail encouraged proportionate and real increases in usage among vulnerable populations such as children and perhaps greater total physical activity especially for people not meeting physical activity recommendations. The findings suggest that the benefits of environmental changes such as these can accrue to those most in need of support for being physically active.

The effects of changes to the built environment on the mental health and well-being of adults: Systematic review

There is increasing interest in the influence of place on health, and the need to distinguish between environmental and individual level factors. For environmental-level factors, current evidence tends to show associations through cross-sectional and uncontrolled longitudinal analyses rather than through more robust study designs that can provide stronger causal evidence. We restricted this systematic review to randomised (or cluster) randomised controlled trials and controlled before-and-after studies of changes to the built environment. Date of search was December 2016. We identified 14 studies. No evidence was found of an effect on mental health from 'urban regeneration' and 'improving green infrastructure' studies. Beneficial effects on quality-of-life outcomes from 'improving green infrastructure' were found in two studies. One 'improving green infrastructure' study reported an improvement in social isolation. Risk-of-bias assessment indicated robust data from only four studies. Overall, evidence for the impact of built environment interventions on mental health and quality-of-life is weak. Future research requires more robust study designs and interdisciplinary research involving public health, planning and urban design experts.

Community wide interventions for increasing physical activity

BACKGROUND

Multi-strategic community wide interventions for physical activity are increasingly popular but their ability to achieve population level improvements is unknown.

OBJECTIVES

To evaluate the effects of community wide, multi-strategic interventions upon population levels of physical activity.

SEARCH METHODS

We searched the Cochrane Public Health Group Segment of the Cochrane Register of Studies,The Cochrane Library, MEDLINE, MEDLINE in Process, EMBASE, CINAHL, LILACS, PsycINFO, ASSIA, the British Nursing Index, Chinese CNKI databases, EPPI Centre (DoPHER, TRoPHI), ERIC, HMIC, Sociological Abstracts, SPORT Discus, Transport Database and Web of Science (Science Citation Index, Social Sciences Citation Index, Conference Proceedings Citation Index). We also scanned websites of the EU Platform on Diet, Physical Activity and Health; Health-Evidence.org; the International Union for Health Promotion and Education; the NIHR Coordinating Centre for Health Technology (NCCHTA); the US Centre for Disease Control and Prevention (CDC) and NICE and SIGN guidelines. Reference lists of all relevant systematic reviews, guidelines and primary studies were searched and we contacted experts in the field. The searches were updated to 16 January 2014, unrestricted by language or publication status.

SELECTION CRITERIA

Cluster randomised controlled trials, randomised controlled trials, quasi-experimental designs which used a control population for comparison, interrupted time-series studies, and prospective controlled cohort studies were included. Only studies with a minimum six-month follow up from the start of the intervention to measurement of outcomes were included. Community wide interventions had to comprise at least two broad strategies aimed at physical activity for the whole population. Studies which randomised individuals from the same community were excluded.

DATA COLLECTION AND ANALYSIS

At least two review authors independently extracted the data and assessed the risk of bias. Each study was assessed for the setting, the number of included components and their intensity. The primary outcome measures were grouped according to whether they were dichotomous (per cent physically active, per cent physically active during leisure time, and per cent physically inactive) or continuous (leisure time physical activity time (time spent)), walking (time spent), energy expenditure (as metabolic equivalents or METS)). For dichotomous measures we calculated the unadjusted and adjusted risk difference, and the unadjusted and adjusted relative risk. For continuous measures we calculated percentage change from baseline, unadjusted and adjusted.

MAIN RESULTS

After the selection process had been completed, 33 studies were included. A total of 267 communities were included in the review (populations between 500 and 1.9 million). Of the included studies, 25 were set in high income countries and eight were in low income countries. The interventions varied by the number of strategies included and their intensity. Almost all of the interventions included a component of building partnerships with local governments or non-governmental organisations (NGOs) (29 studies). None of the studies provided results by socio-economic disadvantage or other markers of equity. However, of those included studies undertaken in high income countries, 14 studies were described as being provided to deprived, disadvantaged or low socio-economic communities. Nineteen studies were identified as having a high risk of bias, 10 studies were unclear, and four studies had a low risk of bias. Selection bias was a major concern with these studies, with only five studies using randomisation to allocate communities. Four studies were judged as being at low risk of selection bias although 19 studies were considered to have an unclear risk of bias. Twelve studies had a high risk of detection bias, 13 an unclear risk and four a low risk of bias. Generally, the better designed studies showed no improvement in the primary outcome measure of physical activity at a population level.All four of the newly included, and judged to be at low risk of bias, studies (conducted in Japan, United Kingdom and USA) used randomisation to allocate the intervention to the communities. Three studies used a cluster randomised design and one study used a stepped wedge design. The approach to measuring the primary outcome of physical activity was better in these four studies than in many of the earlier studies. One study obtained objective population representative measurements of physical activity by accelerometers, while the remaining three low-risk studies used validated self-reported measures. The study using accelerometry, conducted in low income, high crime communities of USA, emphasised social marketing, partnership with police and environmental improvements. No change in the seven-day average daily minutes of moderate to vigorous physical activity was observed during the two years of operation. Some program level effect was observed with more people walking in the intervention community, however this result was not evident in the whole community. Similarly, the two studies conducted in the United Kingdom (one in rural villages and the other in urban London; both using communication, partnership and environmental strategies) found no improvement in the mean levels of energy expenditure per person per week, measured from one to four years from baseline. None of the three low risk studies reporting a dichotomous outcome of physical activity found improvements associated with the intervention.Overall, there was a noticeable absence of reporting of benefit in physical activity for community wide interventions in the included studies. However, as a group, the interventions undertaken in China appeared to have the greatest possibility of success with high participation rates reported. Reporting bias was evident with two studies failing to report physical activity measured at follow up. No adverse events were reported.The data pertaining to cost and sustainability of the interventions were limited and varied.

AUTHORS' CONCLUSIONS

Although numerous studies have been undertaken, there is a noticeable inconsistency of the findings in the available studies and this is confounded by serious methodological issues within the included studies. The body of evidence in this review does not support the hypothesis that the multi-component community wide interventions studied effectively increased physical activity for the population, although some studies with environmental components observed more people walking.

Who uses new walking and cycling infrastructure and how? Longitudinal results from the UK iConnect study

OBJECTIVE

To examine how adults use new local walking and cycling routes, and what characteristics predict use.

METHODS

1849 adults completed questionnaires in 2010 and 2011, before and after the construction of walking and cycling infrastructure in three UK municipalities. 1510 adults completed questionnaires in 2010 and 2012. The 2010 questionnaire measured baseline characteristics; the follow-up questionnaires captured infrastructure use.

RESULTS

32% of participants reported using the new infrastructure in 2011, and 38% in 2012. Walking for recreation was by far the most common use. In both follow-up waves, use was independently predicted by higher baseline walking and cycling (e.g. 2012 adjusted rate ratio 2.09 (95% CI 1.55, 2.81) for >450 min/week vs. none). Moreover, there was strong specificity by mode and purpose, e.g. baseline walking for recreation specifically predicted walking for recreation on the infrastructure. Other independent predictors included living near the infrastructure, better general health and higher education or income.

CONCLUSIONS

The new infrastructure was well-used by local adults, and this was sustained over two years. Thus far, however, the infrastructure may primarily have attracted existing walkers and cyclists, and may have catered more to the socio-economically advantaged. This may limit its impacts on population health and health equity.

Urban planning for healthy cities. A review of the progress of the European Healthy Cities Programme

The purpose of this paper is to evaluate the progress made by European cities in relation to Healthy Urban Planning (HUP) during Phase IV of the World Health Organization's Healthy Cities programme (2003-2008). The introduction sets out the general principle of HUP, identifying three levels or phases of health and planning integration. This leads on to a more specific analysis of the processes and substance of HUP, which provide criteria for assessment of progress. The assessment itself relies on two sources of data provided by the municipalities: the Annual Review Templates (ARTs) 2008 and the response to the Phase IV General Evaluation Questionnaire. The findings indicate that the evidence from different sources and questions in different sections are encouragingly consistent. The number of cities achieving a good level of understanding and activity in HUP has risen very substantially over the period. In particular, those achieving effective strategic integration of health and planning have increased. A key challenge for the future will be to develop planning frameworks which advance public health concerns in a spatial policy context driven often by market forces. A health in all policies approach could be valuable.

Community wide interventions for increasing physical activity

BACKGROUND

Multi-strategic community wide interventions for physical activity are increasingly popular but their ability to achieve population level improvements is unknown.

OBJECTIVES

To evaluate the effects of community wide, multi-strategic interventions upon population levels of physical activity.

SEARCH STRATEGY

We searched the Cochrane Public Health Group Specialised Register, The Cochrane Library, MEDLINE, MEDLINE in Process, EMBASE, CINAHL, LILACS, PsycINFO, ASSIA, The British Nursing Index, Chinese CNKI databases, EPPI Centre (DoPHER, TRoPHI), ERIC, HMIC, Sociological Abstracts, SPORTDiscus, Transport Database and Web of Science (Science Citation Index, Social Sciences Citation Index, Conference Proceedings Citation Index). We also scanned websites of the EU Platform on Diet, Physical Activity and Health; Health-Evidence.ca; the International Union for Health Promotion and Education; the NIHR Coordinating Centre for Health Technology (NCCHTA) and NICE and SIGN guidelines. Reference lists of all relevant systematic reviews, guidelines and primary studies were followed up. We contacted experts in the field from the National Obesity Observatory Oxford, Oxford University; Queensland Health, Queensland University of Technology, the University of Central Queensland; the University of Tennessee and Washington University; and handsearched six relevant journals. The searches were last updated to the end of November 2009 and were not restricted by language or publication status.

SELECTION CRITERIA

Cluster randomised controlled trials, randomised controlled trials (RCT), quasi-experimental designs which used a control population for comparison, interrupted time-series (ITS) studies, and prospective controlled cohort studies (PCCS) were included. Only studies with a minimum six-month follow up from the start of the intervention to measurement of outcomes were included. Community wide interventions had to comprise at least two broad strategies aimed at physical activity for the whole population. Studies which randomised individuals from the same community were excluded.

DATA COLLECTION AND ANALYSIS

At least two review authors independently extracted the data and assessed the risk of bias of each included study. Non-English language papers were reviewed with the assistance of an epidemiologist interpreter. Each study was assessed for the setting, the number of included components and their intensity. Outcome measures were grouped according to whether they were dichotomous (physically active, physically active during leisure time and sedentary or physically inactive) or continuous (leisure time physical activity, walking, energy expenditure). For dichotomous measures we calculated the unadjusted and adjusted risk difference, and the unadjusted and adjusted relative risk. For continuous measures we calculated net percentage change from baseline, unadjusted and adjusted risk difference, and the unadjusted and adjusted relative risk.

MAIN RESULTS

After the selection process had been completed 25 studies were included in the review. Of the included studies, 19 were set in high income countries, using the World Bank economic classification, and the remaining six were in low income countries. The interventions varied by the number of strategies included and their intensity. Almost all of the interventions included a component of building partnerships with local governments or non-governmental organisations (NGOs) (22 studies). None of the studies provided results by socio-economic disadvantage or other markers of equity consideration. However of those included studies undertaken in high income countries, 11 studies were described by the authors as being provided to deprived, disadvantaged, or low socio-economic communities.Fifteen studies were identified as having a high risk of bias, 10 studies were unclear, and no studies had a low risk of bias. Selection bias was a major concern with these studies, with only one study using randomisation to allocate communities (Simon 2008). No studies were judged as being at low risk of selection bias although 16 studies were considered to have an unclear risk of bias. Eleven studies had a high risk of detection bias, 10 with an unclear risk and four with no risk. Assessment of detection bias included an assessment of the validity of the measurement tools and quality of outcome measures. The effects reported were inconsistent across the studies and the measures. Some of the better designed studies showed no improvement in measures of physical activity. Publication bias was evident.

AUTHORS' CONCLUSIONS

Although numerous studies have been undertaken, there is a noticeable inconsistency of the findings of the available studies and this is confounded by serious methodological issues within the included studies. The body of evidence in this review does not support the hypothesis that multi-component community wide interventions effectively increase population levels of physical activity. There is a clear need for well-designed intervention studies and such studies should focus on the quality of the measurement of physical activity, the frequency of measurement and the allocation to intervention and control communities.

Physical activity by stealth? The potential health benefits of a workplace transport plan

OBJECTIVES

There are few published evaluations of the effects of travel policy on health-enhancing physical activity. The purpose of this study was to investigate the effect of a workplace travel plan, which mainly focused on restricting parking opportunities, on levels of active commuting and its potential to contribute to public health.

STUDY DESIGN

Analysis of a repeated bi-annual travel survey in a workplace setting.

METHODS

Usual mode of commuting, gender, age, worksite location and distance commuted to and from work were obtained from the University of Bristol Staff Travel Surveys conducted in 1998 (n = 2292), 2001 (n = 2332), 2003 (n = 1950), 2005 (n = 2647) and 2007 (n = 2829). Z-tests were used to examine the significance of trends in active commuting between 1998 and 2007. The largest and most recent survey (2007) was used to calculate the effects of gender, age and salary band on mode of transport, length of commuter journey, and the extent to which active commuting contributed to meeting national recommendations for physical activity.

RESULTS

Results showed that between 1998 and 2007, in contrast to national trends, the percentage of respondents who reported that they usually walked to work increased from 19.0% to 30.0% (Z = 4.24, P < 0.001). The percentage of regular cyclists increased from 7.0% to 11.8%, but this was not statistically significant. In 2007, regular walkers were more likely to be female, under 35 years of age and earning a middle-band salary. Regular cyclists were more likely to be male, aged 36-45 years and earning a higher-band salary. Approximately 70% of respondents who usually walked or cycled to work achieved greater than 80% of the recommended guidelines for physical activity through their active commuting.

CONCLUSIONS

This study suggests that transport plans aimed at reducing car usage should be considered as a feasible and effective strategy for increasing health-enhancing physical activity among the workforce.

Impact of academic exposure on health status of university students

OBJECTIVE: To assess the impact of academic life on health status of university students. METHODS: Longitudinal study including 154 undergraduate students from the Universidade de Aveiro, Portugal, with at least two years of follow-up observations. Sociodemographic and behavioral characteristics were collected using questionnaires. Students' weight, height, blood pressure, serum glucose, serum lipids and serum homocysteine levels were measured. Regression analysis was performed using linear mixed-effect models, allowing for random effects at the participant level. RESULTS: A higher rate of dyslipidemia (44.0% vs. 28.6%), overweight (16.3% vs. 12.5%) and smoking (19.3% vs. 0.0%) was found among students exposed to the academic life when compared to freshmen. Physical inactivity was about 80%. Total cholesterol, high density lipoprotein-cholesterol (HDL-C), triglycerides, systolic blood pressure, and physical activity levels were significantly associated with gender (p<0.001). Academic exposure was associated with increased low density lipoprotein-cholesterol (LDL-C) levels (about 1.12 times), and marginally with total cholesterol levels (p=0.041). CONCLUSIONS: High education level does not seem to have a protective effect favoring a healthier lifestyle and being enrolled in health-related areas does not seem either to positively affect students' behaviors. Increased risk factors for non-transmissible diseases in university students raise concerns about their well-being. These results should support the implementation of health promotion and prevention programs at universities.

Residents' diverse perspectives of the impact of neighbourhood renewal on quality of life and physical activity engagement: improvements but unresolved issues

Few studies have been published on the reactions of residents to modifications of their residential landscape. We explored residents' experiences of home zone remodelling and construction of a new cycle-walkway in a deprived neighbourhood with a particular focus on aspects of quality of life and physical activity participation. Focus groups (n=5 groups, 21 individuals) were used to investigate residents' perceptions of the effects of neighbourhood change on their lives. Consultation by planners was received positively. Several aspects of the neighbourhood were perceived to have improved, including spatial aesthetics, lighting and streetscape planting. However, influence on physical activity was minimal. Car-focused behaviour and ownership remained dominant, and safety related concerns limited behavioural choices. Residents highlighted many socio-environmental challenges that remained such as sense of neighbourhood safety, poor public transport provision, people's parking behaviour locally, and problem neighbours, and these tended to dominate conversations. Infrastructural intervention may be one important part of multi-layered solutions to improved neighbourhood life.

Healthy urban planning in European cities

This article describes the WHO 'healthy urban planning' (HUP) initiative as it has developed through the laboratory of the Healthy Cities movement and evaluates the degree to which applicant cities successfully developed plans for HUP. The paper provides a brief historical perspective on the relationship of health and planning and an overview of the ways in which urban spatial development affects health. It then turns to the WHO European Healthy Cities Network (WHO-EHCN) and explains the evolution of the HUP programme through Phase III (1998-2002) of the Healthy Cities Project, showing how the programme has grown from experimental beginnings to being 'mainstreamed' in Phase IV (2003-2008). Each city wishing to join the WHO-EHCN in this latter phase produced a programme for further development of HUP, and these were assessed by the Bristol Collaborating Centre. The paper presents the overall results, concluding that a significant progress has been made and the most advanced cities have much to offer municipalities everywhere in the best practice for integrating health into urban planning.

Short-term results of community-based interventions for improving physical activity: Isfahan Healthy Heart Programme

INTRODUCTION

To assess the effect of a comprehensive community-based programme for increasing physical activity (PA) after 2 years of interventions.

MATERIAL AND METHODS

A 6-year, action-oriented, comprehensive, and integrated community-based study, entitled the Isfahan Healthy Heart Programme, was conducted in Iran from the year 2000. The interventions targeted the whole population of nearly 2,180,000 living in two cities, and were compared with another city considered as a reference. Educational, environmental and legislative interventions were conducted at the community level. Annual evaluations were performed among 6,000 representative individuals. This paper presents the changes in PA habits after 2 years of interventions for increasing PA. The PA habits were assessed by using the Baecke questionnaire, and an energy expenditure of 150 kcal for daily leisure time physical activity was adopted as a cut-off for defining active and inactive lifestyle.

RESULTS

In the intervention and reference areas, respectively 85 and 83% of the population were physically inactive. From 2000 to 2002, the daily PA among both genders decreased in both intervention and reference communities. Meanwhile, the leisure-time PA increased significantly in the intervention area, but decreased in the reference area. The transportation PA did not significantly change in the intervention area, but showed a remarkable decline in the reference area.

CONCLUSIONS

We suggest that the synergism resulting from community collaborations has been effective in improving some aspects of PA in our community. The ongoing changes in environmental factors and policies can help in increasing the worksite and transportation PA in later stages of this community-based programme.

Municipal policies and plans of action aiming to promote physical activity and healthy eating habits among schoolchildren in Stockholm, Sweden: a cross-sectional study

Background

Promoting physical activity and healthy eating habits by structural measures that reach most children in a society is presumably the most sustainable way of preventing development of overweight and obesity in childhood. The main purpose of the present study was to analyse whether policies and plans of action at the central level in municipalities increased the number of measures that aim to promote physical activity and healthy eating habits among schoolchildren aged six to 16. Another purpose was to analyse whether demographic and socio-economic characteristics were associated with the level of such measures.

Methods

Questionnaires were used to collect data from 25 municipalities and 18 town districts in Stockholm County, Sweden. The questions were developed to capture municipal structural work and factors facilitating physical activity and the development of healthy eating habits for children. Local policy documents and plans of action were gathered. Information regarding municipal demographic and socio-economic characteristics was collected from public statistics.

Results

Policy documents and plans of action in municipalities and town districts did not seem to influence the number of measures aiming to promote physical activity and healthy eating habits among schoolchildren in Stockholm County. Municipal demographic and socio-economic characteristics were, however, shown to influence the number of measures. In town districts with a high total population size, and in municipalities and town districts with a high proportion of adults with more than 12 years of education, a higher level of health-promoting measures was found. In municipalities with a high annual population growth, the number of measures was lower than in municipalities with a lower annual population growth. Another key finding was the lack of agreement between what was reported in the questionnaires regarding existence and contents of local policies and plans of action and what was actually found when these documents were scrutinized.

Conclusion

Policy documents and plans of action aiming to promote physical activity and healthy eating habits among schoolchildren aged six to 16 in municipalities and town districts in Stockholm County did not seem to have an impact on the local level of measures. Demographic and socio-economic characteristics of the municipalities and town districts were on the other hand associated with local health-promoting measures.

Multidisciplinary research in public health: a case study of research on access to green space

OBJECTIVES

Quantitative analysis of the physical and demographic parameters of access to Thames Chase Community Forest (TCCF), and how these have changed between 1990 and 2003; and qualitative exploration of our understanding of the links between health and the natural environment (TCCF), with a focus on the issue of 'access' to green space.

STUDY DESIGN

Multimethod design involving both quantitative (analysis of physical access to green space) and qualitative (ethnography) components.

METHODS

Quantitative analysis, using geographical information systems, of physical access to the community forest; and ethnographic research including participant observation, non-participant observation, in-depth interviews and attendance at meetings and conferences.

RESULTS

The quantitative analysis showed that public access to green space improved between 1990 and 2003 as a result of the regeneration and acquisition of new areas, and the average reduction in distance to green space was 162 m. However, such improvements were distributed differentially between population groups. In both 1990 and 2003, people from deprived areas and in poorer health had better access to green space than people from less deprived areas, but the greatest improvement in access to green space over this interval occurred in areas of below average deprivation (i.e. in the more affluent areas). The ethnographic research showed different interpretations of the notion of access. Use of TCCF was determined by a variety of factors including whether a person could 'imagine themselves' using such a space, different perceptions of what is actually being accessed (e.g. a place to exercise or a place to socialise), and ideas about using the countryside 'properly'.

CONCLUSIONS

The health benefits of using a green space, such as TCCF, for walking or exercising are well recognized. However, whether people choose to use local green space may be determined by a variety of factors. These are likely to include physical distance to access of green space, as well as perceptions and understandings of what is being accessed and how it should be used. This study has also illustrated the ways in which multiple methods can be integrated in public health research, and the merits of different approaches to undertaking multidisciplinary work of this type.

Variation in biological status among Polish males and underlying socio-economic factors

The main purpose of this study was to evaluate the socio-economic and lifestyle factors associated with biological status of Polish men. Data were collected during a cross-sectional survey carried out in Poznań and several localities in Western Poland, between 2000 and 2002. The sample consisted of 2509 men ranging from 30 to 90 years of age. Biological status was expressed in terms of functional-biological age (BA) computed as a composite z-score of 11 biomarkers according to the method proposed by Borkan and Norris [1980a], and physiological reserve index (PR) developed by Goffauxet al.[2005]. The average biological age profiles (BAP) were compared in several subgroups of participants. The subgroups were categorized based on demographic, socio-economic and lifestyle characteristics. It was found that values of systolic and diastolic blood pressure, BMI, physical and emotional aging indicators and perceived satisfaction with life were significantly associated with most of the study factors, except for smoking habit and education level. The multivariate logistic regression models revealed that two factors, financial situation and physical activity, were significantly associated with the physiological reserve index estimation. The study confirmed the role of the socio-economic and lifestyle factors likely to play in men's biological status and aging rates.

The population effect of crime and neighbourhood on physical activity: an analysis of 15,461 adults

Area-based interventions offer the potential to increase physical activity for many sedentary people in countries such as the UK. Evidence on the effect of individual and area/neighbourhood influences on physical activity is in its infancy, and despite its value to policy makers a population focus is rarely used. Data from a population-based health and lifestyle survey of adults in northwest England were used to analyse associations between individual and neighbourhood perceptions and physical activity. The population effect of eliminating a risk factor was expressed as a likely effect on population levels of physical activity. Of the 15,461 responders, 21,923 (27.1%) were physically active. Neighbourhood perceptions of leisure facilities were associated with physical activity, but no association was found for sense of belonging, public transport or shopping facilities. People who felt safe in their neighbourhood were more likely to be physically active, but no associations were found for vandalism, assaults, muggings or experience of crime. The number of physically active people would increase by 3290 if feelings of "unsafe" during the day were removed, and by 11,237 if feelings of "unsafe" during the night were removed. An additional 8342 people would be physically active if everyone believed that they were "very well placed for leisure facilities". Feeling safe had the potential largest effect on population levels of physical activity. Strategies to increase physical activity in the population need to consider the wider determinants of health-related behaviour, including fear of crime and safety.

An assessment of cardiovascular risk among the people of a Nigerian university community

BACKGROUND

The purpose of this study was to assess the level of cardiovascular disorder risk among the staff and students of Obafemi Awolowo University, Ile-Ife, Nigeria.

METHODS

Six hundred apparently healthy subjects voluntarily participated in this study. They consisted of 200 students, 200 junior workers and 200 senior staff. Subjects' weight, height and blood pressures were taken. Subsequently, the questionnaire used for the Framingham Heart Study was given for completion. The questionnaire sought information on cardiovascular risk factors including smoking habits, sedentary lifestyle, diet, personality trait, age and sex.

RESULTS

Students had a mean risk score of 10.24, junior staff 11.38, and senior staff 12.42. Significant differences were found between the level of risk for the students and that of the senior staff. However, no significant difference existed between the junior and senior staff and no significant difference existed between the level of risk for the students and the junior staff. Further, there was no significant difference in the level of risk for males compared to females.

CONCLUSION

We concluded that the level of cardiovascular risk was low among the subjects selected for this study.

[Material well-being of the province of residence and leisure-time physical inactivity]

OBJECTIVE

To estimate the association between material wellbeing of the province of residence and leisure-time physical inactivity in the Spanish population aged 16 years and older.

METHODS

We used data from the Survey on Disabilities, Impairments and Health Status carried out by the Statistical National Institute in 1999. We analyse 24,561 women and 21,133 men. Respondents were classified as inactive if they reported no leisure-time physical activity. The measure of material wellbeing was the per capita income of the province of residence grouped in quartiles. The measure of the association between per capita income and physical inactivity was the odds ratio (OR) estimated from logit multilevel models.

RESULTS

Association between per capita income and physical inactivity was observed in people aged 45 years and older. The lower prevalence of physical inactivity was observed in provinces with the higher per capita income. However the higher OR was found in quartile 2 of per capita income, because no significant difference was observed between quartile 4 (richest) and quartile 1 (poorest). After adjusting for socioeconomic characteristics and other individual variables, association remained significant in women and disappeared in men. In women, association between per capita income and physical inactivity was higher in the population group with lower personal income.

CONCLUSIONS

Results suggest that physical inactivity in women aged 45 years and older could be related not only with individual characteristics but with the socioeconomic context of the area of residence.

Disability and physical activity in late life—research models and approaches

Prevention of disability in late life has become a major public health concern, a key area of ageing research, and also an important target for the development of effective interventions. The increase in life expectancy and the resulting growth of the elderly population are also thought to be driving up the number of elderly people with disabilities. Despite the message that regular moderate physical activity has substantial health benefits even in very old age, older people remain largely sedentary. The most popular theoretical model for researching the development of disability is the disablement process, which is widely used, in the gerontological literature. The main pathway according to this model leads from diseases and injuries to impairments, functional limitations, and disability. This approach has been challenged most particularly by models, which emphasize the social construction and determinants of disability. Numerous physical exercise interventions have aimed at preventing impairments, functional limitations and disability, and at promoting independent living in late life. A review of the results of these interventions shows that exercise can indeed be effective in preventing impairments and functional limitations, but the evidence regarding the prevention of disability and dependency is inconclusive. The inconsistency of the results is related to differences in research models and approaches, cultural and other differences between the populations studied, and variability in research designs and methods, including definitions of key variables. In the future, research-addressing disability in late life needs to focus on the dynamic interactions between individuals and their social, physical, and cultural environment. Furthermore, randomized trials that are larger and longer than most existing studies of physical activity need to be conducted. Additional evidence can also be obtained by well-conducted observational studies focusing on the prevention of progressive disability related to chronic conditions. One of the key areas of development is in improving the definition of both independent (physical activity and exercise) and outcome (functional limitations, disability) variables. A further challenge is presented by the investigation of dose–response relationships, including both beneficial and possible adverse effects of exercise.

Evidence for public health policy on inequalities: 1: the reality according to policymakers

OBJECTIVE

To explore with UK and international policy advisors how research evidence influences public health policy making, and how its relevance and utility could be improved, with specific reference to the evidence on the production and reduction of health inequalities.

DESIGN, SETTING, AND PARTICIPANTS

Qualitative residential workshop involving senior policy advisors with a substantive role in policy development across a range of sectors (mainly public health, but also including education, social welfare, and health services). In four in depth sessions, facilitated by the authors, focused questions were presented to participants. Their responses were then analysed thematically to identify key themes, relating to the availability and utility of existing evidence on health inequalities.

MAIN RESULTS

The lack of an equity dimension in much aetiological and evaluative research was highlighted by participants. Much public health research was also felt to have weak underlying theoretical underpinnings. As well as evaluations of the effectiveness and cost-effectiveness of policy and other interventions, they identified a need for predictive research, and for methodological research to further develop methods for assessing the impact on health of clusters of interventions.

CONCLUSIONS

This study reinforces the view that there is a lack of information on the effectiveness and cost-effectiveness of policies, and it uncovered additional gaps in the health inequalities evidence base. A companion paper discusses researchers' views of how the production of more relevant public health evidence can be stimulated.

International physical activity policy development: a commentary

Scientific evidence demonstrates, in different degrees for developing and developed countries, that physical activity is associated with substantial health, economic, and societal benefits. However, for varying environmental, social, and individual reasons, people do not tend to engage in the levels of physical activity that would be beneficial to them. Environmental and policy interventions hold particular promise for promoting physical activity because both are designed to influence large groups. Recent multisectoral actions have increased the visibility of physical activity promotion and its synergism with other important community and national issues. Together, these efforts have created an unprecedented opportunity to advance the development of international physical activity policy.

Caring for the health of the public: cross sectional study of the activities of UK public health departments

The relative time spent in different areas of work in public health departments in the UK was assessed by means of a postal questionnaire. Departments spend one third of their time on population health work, this being similar to the amount of time spent on planning health services. Having a planning department in the health authority did not affect the amount of time spent in any area of work. Having a greater number of consultants in the department was associated with a tendency to spend more time on population health and being involved in training was associated with spending less time on planning. Public health departments in the UK are the only part of the health service with responsibility for the broader aspects of public health. Whilst the tensions between medical care and the wider influences upon population health may represent a false dichotomy, public health professionals must maintain a central focus of their work on the wider influences upon population health if balance is to be maintained within the National Health Service.