Causal systems mapping to promote healthy living for pandemic preparedness: a call to action for global public health

Social Vulnerability and Leisure-Time Physical Activity in the United States From 2020 to 2022: An Unaltered Crisis Within a Crisis

BACKGROUND

No leisure time physical activity (NO-LTPA) continues to be a leading behavioral driver of poor health outcomes in the United States. The current investigation explores the relationship between, short term, longitudinal changes in social vulnerability and NO-LTPA within the context of culturally distinct U.S. regions.

METHODS

We merged county-level data on physical inactivity prevalence, the Social Vulnerability Index (SVI), and the American Nations regional cultures schematic.

RESULTS

The prevalence of NO-LTPA was significantly higher: 1) In American Nations Group 1 in both 2020 and 2022; and 2) During 2022 in both American Nation Groups. The overall SVI score was significantly higher in American Nations Group 1 in both 2020 and 2022 but there were no significant differences in either group from 2020 to 2022. There were 1161 U.S. counties (i.e., 37%) that had a decrease in NO-LTPA from 2020 to 2022 (mean reduction = -1.7 ±1.5) compared to 1970 U.S. counties that has no change or an increase in NO-LTPA from 2020 to 2022 (mean increase = 2.0 ±1.6). The difference in 2020 to 2022 change in SVI was statistically significant (-0.8 ±0.50 vs 0.04 ±0.51, P < .001) between counties with a decrease in NO-LTPA compared to those with no change or an increase.

DISCUSSION

These current findings indicate the SVI-NO-LTPA crisis within a crisis continues to be a factor in the U.S. The fact that there was a statistical signal between SVI and NO-LTPA change indicates improving the former may likewise improve the latter.

Profiling the persistent and episodic nature of long COVID symptoms and the impact on quality of life and functional status: a cohort observation study

Background

Post-viral issues following acute infection with coronavirus disease 2019 (COVID-19), referred to widely as long COVID, are associated with episodic, persistent, and disabling symptoms affecting quality of life and functional status. Evidence demonstrates a significant impairment and long disease course, but there remains limited empirical data to profile and determine the fluctuating symptom profile of long COVID.

Methods

We devised a 16-week, multicentre prospective cohort observation study to profile changes in patient-reported outcomes, and biological, physiological, psychological, and cognitive parameters following diagnosis and/or referral to an established long COVID clinic. Following baseline assessments, participants completed four face-to-face visits interspersed with telephone consultations. Face-to-face visits included physiological assessment, patient-reported outcome measures (PROMs), functional status, and respiratory function. Telephone consultations involved PROMs and symptom profiling.

Results

Patient-reported outcomes improved from baseline to week sixteen, but demonstrated between visit fluctuations in frequency and severity. Further findings highlight the severity and frequency of long COVID symptom profiles and the extent of quality of life and functional status impairment.

Conclusions

The data presented here highlight the episodic and relapsing nature and should be used to help characterise long COVID disability. They can inform the development of long COVID-specific guidelines and support services that can adequately respond to the reductions in patient well-being.

The inclusion and consideration of cultural differences and health inequalities in physical activity behaviour in the UK - the impact of guidelines and initiatives

Despite widespread attempts from governments and leading health organisations worldwide to promote equity in healthy living medicine, the evidence suggests that attempts to curb worsening public health have been almost entirely ineffective. Despite significant advancements in knowledge, medicine, and technology, as well as the promotion of guidelines and the implementation of numerous global initiatives aimed at addressing health disparities and mitigating the progression of non-communicable diseases (NCDs) worldwide, substantial work remains to be undertaken particularly in addressing inequalities in physical activity. Achieving equitable access to health resources and parity in health outcomes remains a critical and unresolved challenge. Whilst it is recognized that the public health paradigm is broad and complex, with many intersecting and interacting parts, the actions and considerations required to address the urgent and escalating scale of the problem appear at a crossroads of now or never. Throughout this narrative review, we describe the effectiveness of landmark physical activity-related guidelines, policies and national interventions that have been implemented since the turn of the century to address physical activity behaviour in the context of health inequalities.

DiScO: novel rapid systems mapping to inform digital transformation of health systems

Background

Global health systems are confronting challenges that intersect climate change with evolving communicable and non-communicable public health risks. Addressing these challenges requires systems integration via citizen big data that exist outside health systems. However, systems integration across jurisdictions is a complex challenge that requires stakeholder input. This study's purpose was to conduct rapid systems mapping with international health system stakeholders to inform the development and implementation of a global digital citizen science observatory (DiScO), which aims to catalyze digital transformation of health systems across jurisdictions.

Methods

A rapid qualitative systems mapping study was conducted during the International Society for Behavioral Nutrition and Physical Activity Annual Global Summit in Uppsala, Sweden, in June 2023. The choice of the venue and approach was informed by three key criteria: (1) Established evidence linking physical activity and nutrition with non-communicable diseases; (2) Concrete existing methods of obtaining citizen big data by physical activity and nutrition researchers; (3) Precedence of physical activity and nutrition researchers conducting citizen science as well behavioral/clinical big data collection. The design of this study was an innovative pre-post systems map development, which consisted of (1) real-time rapid systems mapping (pre/initial map) by engaging with international stakeholders and (2) adjustment of the real-time systems map (post/final map) after analyzing stakeholder discussion data.

Results

Rapid systems mapping resulted in a complex network that included key themes to successfully develop and implement DiScO: priorities, opportunities, risks, challenges, partnerships, and resources. Additionally, a new theme emerged organically through stakeholder group discussions - mitigation strategies. The adapted rapid systems map (i.e., after data analyses) depicts 23 key nodes of intervention across the seven key themes.

Conclusion

Rapid systems mapping at international symposia is a novel methodological approach to capture stakeholder input, particularly to understand complexity across international jurisdictions - an approach that can be replicated across disciplines and sectors to inform digital transformation of health systems. The development and implementation of DiScO, a platform for decentralization and democratization of technology, will take into consideration all the key nodes of intervention identified in the rapid systems map to promote digital health for equity across global jurisdictions.

Arthritis in the Regional Cultures of the American Nations: An Overlooked Component of a Larger Unhealthy Lifestyle Syndemic

Introduction: Health indices vary widely within the United States (U.S.), with clear "belts and epicenters" where the prevalence of unhealthy lifestyle behaviors, chronic disease, and disability are all high. Arthritis is a significant, well-established risk factor for developing chronic disease. In this paper, we hypothesize that the prevalence and patterns of arthritis in the U.S. will mirror that of other leading health issues across the country. Methods: We merged county-level data on arthritis, disability, and depression prevalence, the Lifestyle Health Index (LHI), the Social Vulnerability Index (SVI) and the American Nations regional cultures schematic. Results: Data was available from 3073 U.S. counties. We found age-adjusted arthritis prevalence has statistically significant and generally strong Pearson product correlations (r ≈ 0.70, P < 0.001) with (1) LHI sub scores and overall score; (2) Depression prevalence; (3) Disability prevalence; and (4) SVI. The geographic distribution of age-adjusted arthritis prevalence according to the American Nations regional cultures model demonstrated clear heterogeneity across regions. Conclusions: The status of population health in the U.S. is disconcerting and the current model of health care delivery, which is often approached from a siloed (condition-specific vs holistic care), reactionary, secondary prevention model, is inadequate to the challenge.

What determines participation in sport for older adults in England: A multilevel analysis of Active Lives data

Physical inactivity within an ageing population is an ongoing public health concern for policymakers. Engagement in sport forms a foundation of policy designed to encourage physical activity participation and improve health and wellbeing. This study aimed to (i) understand the extent to which older adults participate in sport and the (ii) correlates that predict this involvement within an English population sample of older adults. A further aim was (iii) to examine the extent in which sports participation may vary due to the opportunity provided across Active Partnerships in England. To address this, a multi-level analysis framed through COM-B was conducted of the 2021 English Active Lives dataset (i.e., during the COVID-19 pandemic). The Active Lives survey provides population-level insight into sport, exercise, and physical activity participation across England. It samples upwards of n = 180,000 participants beyond the age of 16 years and asks questions on factors that influence participation. Our findings drawn from a sample of n = 68,808 older adults (i.e., >60-years of age) indicate that when accounting for variation across regions sports participation was significantly predicted by age (β = -.246, p = .040) and multiple deprivation (β  = .706, p = .030). Further, our analysis suggests sports participation across regions is associated with changes in the perceptions of opportunity to participate (β = -28.70, p = .001). As the UK transitions from the COVID-19 pandemic, findings have implications for the promotion of sports participation for older adults, in that local, regional, and national stakeholders must do more to change perceptions of social and physical opportunity within an ageing population. This may be achieved through adaptations to the recreational sporting landscape, raising awareness, and supportive policy changes on a national level.

Qualitative systems mapping in promoting physical activity and cardiorespiratory fitness: Perspectives and recommendations

The purpose of this report is to provide a perspective on the use of qualitative systems mapping, provide examples of physical activity (PA) systems maps, discuss the role of PA systems mapping in the context of iterative learning to derive breakthrough interventions, and provide actionable recommendations for future work. Systems mapping methods and applications for PA are emerging in the scientific literature in the study of complex health issues and can be used as a prelude to mathematical/computational modeling where important factors and relationships can be elucidated, data needs can be prioritized and guided, interventions can be tested and (co)designed, and metrics and evaluations can be developed. Examples are discussed that describe systems mapping based on Group Model Building or literature reviews. Systems maps are highly informative, illustrate multiple components to address PA and physical inactivity issues, and make compelling arguments against single intervention action. No studies were identified in the literature scan that considered cardiorespiratory fitness the focal point of a systems maps. Recommendations for future research and education are presented and it is concluded that systems mapping represents a valuable yet underutilized tool for visualizing the complexity of PA promotion.

Using cardiorespiratory fitness assessment to identify pathophysiology in long COVID - Best practice approaches

Cardio-respiratory fitness (CRF) is well-established in the clinical domains as an integrative measure of the body's physiological capability and capacity to transport and utilise oxygen during controlled bouts of physical exertion. Long COVID is associated with >200 different symptoms and is estimated to affect ∼150 million people worldwide. The most widely reported impact is reduced quality of life and functional status due to highly sensitive and cyclical symptoms that manifest and are augmented following exposure to physical, emotional, orthostatic, and cognitive stimuli, more commonly known as post-exertional symptom exacerbation (PESE) which prevents millions from engaging in routine daily activities. The use of cardiopulmonary exercise testing (CPET) is commonplace in the assessment of integrated physiology; CPET will undoubtedly play an integral role in furthering the pathophysiology and mechanistic knowledge that will inform bespoke Long COVID treatment and management strategies. An inherent risk of previous attempts to utilise CPET protocols in patients with chronic disease is that these are compounded by PESE and have induced a worsening of symptoms for patients that can last for days or weeks. To do this effectively and to meet the global need, the complex multi-system pathophysiology of Long COVID must be considered to ensure the design and implementation of research that is both safe for participants and capable of advancing mechanistic understanding.

Physical Inactivity and Obesity in the United States: At the Intersection of Politics, Socioeconomics, Race, and Culture

Efforts to reverse the physical inactivity (PI) and obesity pandemics in the United States (U.S.) have been unsuccessful. This commentary provides a view of PI and obesity in the U.S. from the intersection of politics, socioeconomics, race, and culture. On a national level, counties where the Democratic presidential candidate received more votes in 2020 than the Republican candidate had a lower PI and obesity prevalence. The percentage completing some college and Black individuals as well as median household income were higher in counties where the Democratic candidate received more votes. Regionally, unique, region-specific cultural identities and partisan coalition demographics were apparent and serve as potential explanations for inconsistencies in PI and obesity prevalence across the U.S. Identifying the driving forces of PI and obesity within specific U.S. regions and crafting messaging that has optimal efficacy on a local level is essential to reducing the burden of cardiovascular disease and other chronic conditions.

Improving Fundamental Movement Skills during Early Childhood: An Intervention Mapping Approach

The earlier in life that a child can begin mastering fundamental movement skills (FMS), the more positive their physical activity (PA) trajectories and health outcomes are. To achieve sufficient development in FMS, children must be guided with tuition and practice opportunities. Schools and educators provide an opportunity for interventions that improve health behaviours and outcomes for children. The aim of this study was to use intervention mapping (IM) to design a programme of school-based intervention to improve FMS for children aged 4-5 years old. Following the six steps of IM, with each step comprising three to five tasks that require the input of a planning group formed by key stakeholders, a programme of intervention was planned. Prior knowledge and primary and secondary evidence was used to support the development of the programme. A logic model of the problem as well as logic models of change, programme design, production, implementation, and evaluation were proposed or completed within the study. The results can be used to begin to implement an FMS-focussed intervention within school settings within England and propose a sustainable and realistic approach for helping children to develop FMS with the support of well-informed educators who are confident to deliver better FMS practice and PA opportunities.

The Impact of COVID-19 on the Social Determinants of Cardiovascular Health

Cardiovascular disease is the leading noncommunicable disease and cause of premature mortality globally. Despite well established evidence of a cause-effect relationship between modifiable lifestyle behaviours and the onset of risk of chronic disease, preventive approaches to curtail increasing prevalence have been ineffective. This has undoubtedly been exacerbated by the response to COVID-19, which saw widespread national lockdowns implemented to reduce transmission and alleviate pressure on strained health care systems. A consequence of these approaches was a well documented negative impact on population health in the context of both physical and mental well-being. Although the true extent of the impact of the COVID-19 response on global health has yet to be fully realised or understood, it seems prudent to review effective preventative and management strategies that have yielded positive outcomes across the spectrum (ie, from individual to society). There is also a clear need to heed lessons learned from the COVID-19 experience in the power of collaboration and how this can be used in the design, development, and implementation of future approaches to address the longstanding burden of cardiovascular disease.

A united approach to promoting healthy living behaviours and associated health outcomes: a global call for policymakers and decisionmakers

Chronic disease pandemics have challenged societies and public health throughout history and remain ever-present. Despite increased knowledge, awareness and advancements in medicine, technology, and global initiatives the state of global health is declining. The coronavirus disease 2019 (COVID-19) pandemic has compounded the current perilous state of global health, and the long-term impact is yet to be realised. A coordinated global infrastructure could add substantial benefits to public health and yield prominent and consistent policy resulting in impactful change. To achieve global impact, research priorities that address multi-disciplinary social, environmental, and clinical must be supported by unified approaches that maximise public health. We present a call to action for established public health organisations and governments globally to consider the lessons from the COVID-19 pandemic and unite with true collaborative efforts to address current, longstanding, and growing challenges to public health.

Systems science approaches to cardiovascular disease prevention and management in the era of COVID-19: A Humpty-Dumpty dilemma?

The coronavirus disease 2019 (COVID-19) pandemic necessitated the implementation and prioritizing of strict public health strategies to mitigate COVID-19 transmission and infection over all else. As we enter a 'recovery' phase in which the impact of the virus recedes (but does not relent), we ask, "How do we develop a game plan that considers prevention over management of public health threats of a more chronic nature, including cardiovascular disease?" We frame this choice point as a "Humpty-Dumpty" moment for public health with enduring and potentially irreversible consequences. Citing clear examples of other public health successes and failures, we outline in detail how sustaining cardiovascular population health under complex post-pandemic conditions will necessitate decision-making to be informed with a systems science approach, in which interventions, goals, outcomes and features of complex systems are carefully aligned.

Public policy for healthy living: How COVID-19 has changed the landscape

The coronavirus disease 2019 (COVID-19) pandemic had a transformational impact on public policy as governments played a leading role, working alongside and coordinating with business/industry, healthcare, public health, education, transportation, researchers, non-governmental organizations, philanthropy, and media/communications. This paper summarizes the impact of the pandemic on different areas of public policy affecting healthy living and cardiovascular health including prevention (i.e., nutrition, physical activity, air quality, tobacco use), risk factors for chronic disease (hypertension, diabetes, obesity, substance abuse), access to health care, care delivery and payment reform, telehealth and digital health, research, and employment policy. The paper underscores where public policy is evolving and where there are needs for future evidence base to inform policy development, and the intersections between the public and private sectors across the policy continuum. There is a continued need for global multi-sector coordination to optimize population health.

Mapping One Million COVID-19 Deaths and Unhealthy Lifestyle Behaviors in the United States: Recognizing the Syndemic Pattern and Taking Action

Tragically, the United States (US) surpassed one million documented deaths due to the coronavirus disease 2019 (COVID-19) pandemic. A convincing association between unhealthy lifestyle behaviors and poorer outcomes associated with COVID-19 infection has already been demonstrated and communicated by the Centers for Disease Control and Prevention in public health messaging. The US is experiencing not a pandemic, but a syndemic, specifically an unhealthy lifestyle behaviors-chronic diseases-COVID-19 syndemic. This syndemic has almost certainly significantly contributed to the more than one million deaths the United States has experienced during the pandemic. Decades of a high prevalence of unhealthy lifestyle behaviors laid the foundation for our current unfortunate situation by increasing vulnerability to a novel virus, especially among subgroups who have been historically marginalized. As such, a major pathway to defeating this syndemic is through the promotion of healthy living behaviors for all. Now is the time for action appropriate to meet the demands of a syndemic and a new path forward to a healthier and more equitable future.

Workplace physical activity practices in real life: a scoping review of grey literature for small- and medium-sized enterprises

BACKGROUND

There is a need to scale-up effective physical activity (PA) programmes for small- and medium-sized enterprises (SMEs), where the uptake of PA interventions is low. Identifying real-life workplace practices in PA could contribute to a better understanding of what PA programmes might be most grounded in the 'real world'. However, there is a scarcity of evidence showing what gets done. This study aimed to identify, describe and comprehensively summarize the real-life implementations of workplace PA initiatives, particularly in Europe, as a prior step to disseminating future feasible PA practices for SMEs.

METHODS

A scoping review of grey literature included a systematic search in the Google advanced search platform that permuted a combination of key concepts (PA, workplace, interventions/programmes), internet domains, and search operators in six different languages (Catalan, Finnish, French, Dutch, English and Spanish) between 2015 and November 2020. The analysis process was iterative, and multiple methods were used to sort, group and categorize the initiatives.

RESULTS

There were a total of 713 real-life workplace PA initiatives from different-sized organizations identified. These were categorized into five themes: active work and living, exercise and fitness programs, management and leadership, communication and dissemination, and facilities. Finally, feature trees showing a menu for real-life workplace PA practices were implemented.

CONCLUSIONS

Identifying real-life practice providing a state-of-the-art snapshot of current PA practices in workplaces, which is a starting point to better understand feasible practices in the context of small- and medium-sized workplaces.