Healthy urban environments for children and young people: A systematic review of intervention studies

Urban density and child health and wellbeing: A scoping review of the literature

This scoping review explores the relationship between urban density and child health and wellbeing, focusing on how urban density has been measured and its association with various child health outcomes. By analysing 53 studies spanning from 1972 to 2023, we identify significant variability in how urban density is defined and measured and mixed evidence regarding its relationship with different child health outcomes. We also highlight context-specific findings, which may be connected to a range of dynamic and interconnected local and socio-cultural factors. While most studies showed mixed or inconclusive results for physical health and mental health and wellbeing, some consistent findings were observed for positive associations between urban density and growth and nutritional status in studies from Asia and Africa, and for negative impacts on child development in studies from Europe and North America. The review highlights the need for improved reporting standards, consistent terminology, and context-specific approaches to better understand and address the complex interplay between urban density and child health. It underscores the importance of considering broader social determinants and the unique experiences of children within urban environments for improved policy, practice and placemaking, advocating for participatory research methods to capture children's perspectives on urban density.

Preventing Religion-Based Hate Crime Victimization Among Youth: A Systematic Review of Personal, Collective, and Policy Responses

Hate crime victimization targeting the victim's religious identity poses a serious problem for individuals, communities, and societies. This systematic review describes countermeasures to such victimization, aiming for broad descriptive inclusion by canvassing personal adaptations, collective programs, and institutional-governmental policies. Targeting peer-reviewed articles published between 2002 and 2022, we found 44 articles describing measures related to religion-based victimization prevention. We classified the studied measures into 12 main types. The most salient personal adaptations included camouflage-type blending in to avoid victimization, using religion as a source of resilience, and changing routines to deflect risk. At the collective level, mobilizing community resilience, stereotype reduction, and place-based solutions were often researched. The relatively few institutional-level studies addressed measures to enhance the connection between victims and authorities by various means. The experimental studies heavily concentrated on experiments supporting the efficacy of changing people's perceptions as a means of prevention. The review concludes with a discussion about research and policy implications.

The role of playgrounds in promoting children's health - a scoping review

BACKGROUND

Active outdoor play is important for children's health and development, and playgrounds provide good places for play. However, the importance of playground use for health and well-being is unclear. Our scoping review aims to create an overview of all research on playground use and health benefits for children.

METHODS

Scopus, Web of Science, SportDiscus, and PsycInfo were searched using two search blocks, focusing on 'playground' and 'children' respectively, for publications from 2000 to November 2023. The primary inclusion criterion was examining the relationship between playground use and positive physical, mental, or social health outcomes. Only papers published in English were reviewed. For each publication, we synthesized and condensed the results, categorizing them by playground setting, reported health outcome, participant age group, study design, methodologies, publication's country, year, and 'stage of evidence'.

RESULTS

Data from 247 studies were extracted and nearly 80% of these publications were descriptive or exploratory studies. Fifty-two were intervention studies. Adding playground markings to schoolyards led to increased physical activity. Greening schoolyards had mainly positive effects on social and mental health. In Early Childhood Education and Care, renewing play structures had a positive effect on physical activity in three publications. All Public Open Space interventions we found were different, with mixed effects on health outcomes.

CONCLUSIONS

The existing evidence provides good arguments for policy makers, city planners and school-leaders to invest in adding playground markings in schoolyards as this will likely result in more physical activity. The evidence for the health benefits of investing in new play structures indicated that tailoring the playground to local needs is important as 'one size does not fit all' and playgrounds need to be designed as engaging and interesting places for children's play if they are to generate health benefits. Investing in 'greening' playgrounds is likely to result in social and mental health benefits for children, but does not always result in more physical activity. The research field needs more efficacy and effectiveness studies, and in particular replication and scale-up studies to demonstrate which type of playground interventions are successful.

PROTOCOL

The review protocol was registered at Open Science Framework ( https://doi.org/10.17605/OSF.IO/UYN2V ).

A Qualitative Exploration of the Built Environment as a Key Mechanism of Safety and Social Cohesion for Youth in High-Violence Communities

The characteristics of a neighborhood's built environment may influence health-promoting behaviors, interactions between neighbors, and perceptions of safety. Although some research has reported on how youth in high-violence communities navigate danger, less work has investigated how these youth perceive the built environment, their desires for these spaces, and how these desires relate to their conceptions of safety and perceptions of other residents. To fill this gap, this study used focus group data from 51 youth ages 13-24 living in New Orleans, Louisiana. Four themes were developed using reflexive thematic analysis: community violence is distressing and disruptive, youth use and want to enjoy their neighborhood, systemic failure contributes to negative outcomes, and resources and cooperation create safety. This analysis indicates that young people desire to interact with the built environment despite the threat of community violence. They further identified built environment assets that facilitate socialization and recreation, such as local parks, and social assets in the form of cooperation and neighbor-led civic engagement initiatives. In addition, the youth participants demonstrated awareness of structural inequities that influence neighborhood health and violence-related outcomes. This study contributes to efforts to understand how youth with high levels of community violence exposure understand and interact with the built and social environments.

Understanding a community's needs for an emergency department-based childhood injury prevention programme: a mixed-methods study

OBJECTIVE

Unintentional injuries are the most common cause of childhood death in the USA and are preventable. We developed a framework for an injury prevention programme using local injury data and understanding stakeholder perspectives.

METHODS

We used a mixed-methods approach. We performed a retrospective cross-sectional analysis of children presenting to an academic hospital system between January 2019 and December 2020 with an injury-related diagnosis. The primary outcome was encounters with an injury-related ICD-10 code. We conducted a thematic analysis by interviewing caregivers and emergency department (ED) providers.

RESULTS

There were 10 193 unique injury-related encounters. Most common injuries were natural/environmental (22.9%), falls (20.0%) and striking an object (5.1%). Highest rates of injury were seen in children who identified as Native Hawaiian or Pacific Islander (154 injuries per 10 000 children per year), followed by Hispanic or Latino (148). Three out of 20 zip code areas represented 43.4% of all injuries and correlated with lower household income. Twenty-five caregivers and eight ED providers participated in interviews that resulted in four major themes: perceptions of injury risk, caregiver receipt of injury prevention information, barriers and provider counselling.

CONCLUSION

Clear differences exist within the injury burden in San Francisco by demographics, geography and type of injury. The findings from the study will guide the first steps in designing a strategic paediatric injury prevention centre. The methods may guide future investigations into the dynamic needs of clinicians and caregivers regarding injury. A strategic programme focused on the community's unique needs and barriers may effectively reduce injury rates.

Impactful co-design: Adult decision-makers' perspectives on actualising children's ideas for health-promoting neighbourhoods in Aotearoa New Zealand

Our study sought to understand adult decision-makers' views on what was important for actualising children's ideas using co-design, towards creating health-promoting local environments. Ten adult decision-makers, experienced in co-design with children aged 5-13 years in Aotearoa New Zealand, participated in individual interviews. We generated three themes (Empowering children within co-design; Being intentional about children's influence; Curating who is involved) using reflexive thematic analysis. Our themes informed a novel framework of 'impactful co-design' accompanied by a practical checklist for adult decision-makers (practitioners, policy-makers, and researchers). Study findings affirm co-designing local neighbourhoods as an inherently social and technical endeavour, advocate for greater consideration of inclusivity and cultural context, and highlight the need for co-design with children to include safety, empowerment, and evaluation. We position impactful co-design as one useful process to enact children's meaningful participation.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Exploring young people's views of their local area related to the 20-minute neighbourhood policy: a national cross-sectional study

This study aimed to examine how young people subjectively perceive their local neighbourhoods and compare these perceptions with objective data regarding access to amenities aligned with features of the 20-minute neighbourhood (20MN) policy. Objective data (n:287 aged 12-18 years) were gathered through an online adaptation of the Place Standard Tool for Young People in Scotland. Subjective data concerning access to ten amenities in line with the 20MN concept, along with crime statistics, area-level deprivation and urbanicity were spatially linked. The association between perceptions of localities and factors such as gender, as well as both subjective and objective neighbourhood assessments were examined. Young people were most satisfied with nature and active travel in their local area. Conversely, their satisfaction was lowest for active travel to school. Rural young people were more dissatisfied with their localities. Agreement was observed between satisfaction with their 20 neighbourhoods and objective data indicating the presence of frequent public transportation, recreational spaces, and access to services. In conclusion, our study highlights the importance of amenities in healthy urban planning, showing a positive impact on young people's perceptions. Additionally, we uncover a connection between crime perceptions and area-level crime variables, potentially influencing health outcomes.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Reported barriers to physical activity and the role of built environment among overweight and obese youth attending a Canadian pediatric weight management clinic

Objective

To assess activity levels and role of the built environment among overweight and obese youth referred to a pediatric weight management clinic.

Design

A cross-sectional study using a caregiver-administered survey was completed from October 2017 to February 2018.

Results

The study analyzed 210 surveys. Participants were 52 % male and average age was 11.6 years (3-18 years). Of those surveyed, 73 % of respondents reported ≥ 2 h of average daily screen time in the past 3 months, and 74 % of children partook in < 60 min of daily physical activity of any intensity. The most common location for physical activity was a recreational facility. The least common was nearby green spaces. Moreover, 77 % of caregivers felt that their child did not engage in enough physical activity, and the most common cited barrier was motivation. The built environment, however, was not cited as a barrier to active living as 90 % of caregivers reported their community was safe, and greater than 80 % of caregivers agreed their community was aesthetically beautiful, well connected with good infrastructure. The majority of commonly used spaces were located within 2 km of their home, however, it was uncommon for children to walk or bike to them.

Conclusion

Overweight and obese children referred to our clinic are not meeting national recommendations for physical activity and screen time. The built environment does not appear to be a large contributing factor to decreased physical activity in this population and the most common reason cited for lack of physical activity was motivation.

An Overview of How the Built Environment Relates to Children's Health

PURPOSE OF REVIEW

Explore the varied pathways between the built environment and children's health. The review begins by describing how the built environment and transport infrastructure relate to conditions that lead to health outcomes. The review examines emissions, noise, and traffic dangers in relation to children's physical, mental, and social health.

RECENT FINDINGS

Evidence is increasing for walkable neighborhoods and health-related behavior such as physical activity. However, diverse land uses (often supporting walkability) were also found to increase traffic injuries. Cognitive impacts of motorways on children at schools were found. Finally, the relationships between social activities and built environment are beginning. The built environment's influence on various physical health outcomes is increasingly clear and is often through a transport pathway. However, the links with mental and social health are less developed, though recent findings show significant results. Having accessible child-relevant destinations is an important consideration for children's health.

School-Based Interventions to Support Healthy Indoor and Outdoor Environments for Children: A Systematic Review

Environmental exposures are associated with children's health. Schools are often urban exposure 'hotspots' for pollution, noise, lack of green space and un-walkable built environments. The aim of this systematic review was to explore the impact of school-based interventions on the modification of indoor and outdoor stressors related to the built and natural environment on children's exposure and health. A systematic review of seven databases was performed. We included quantitative studies on children aged 5-12, which reported intervention delivered within school settings aimed at addressing key environmental exposures including air pollution, green spaces, traffic noise or active travel; and reported physical and mental health, physical activity or active travel behavior. The quality of studies was assessed and interventions were described using a standardized framework. A narrative synthesis approach was used to describe the findings. Thirty-nine papers were included on three main intervention types: improve indoor air quality by the increase of ventilation rates in classrooms; increase children's green time or greening schools, and multicomponent interventions to increase active travel to school by changes in pedestrian facilities. No eligible intervention to reduce traffic noise at school was found. Increasing ventilation rates improved short-term indoor air quality in classrooms, but the effect on cognitive performance was inconsistent. Greening schools and increasing children's green time have consistent positive effects on cognition and physical activity, but not in behavior. Multi-component interventions can increase walking and cycling after three years. Overall, the studies were rated as having poor quality owing to weak study designs. We found modest evidence that school-based built and natural environment interventions can improve children's exposure and health.

The impact of interventions in the built environment on physical activity levels: a systematic umbrella review

Physical activity is good for people's health. The relationship between the built environment and physical activity has been well documented. However, evidence is both scarce and scattered on specific urban interventions, i.e., intentional redesigns of the built environment that promote physical activity accompanied by pre- and post-effect measurement. This umbrella review aims to synthesize the findings of systematic reviews focused on these urban interventions. We followed the PRISMA 2020 and JBI umbrella review protocol guidelines and searched seven databases covering the period between Jan 2010 and April 2022 using keywords relating to the built environment, health, physical activity, and interventions. This yielded seven systematic reviews, in which we identified several urban interventions that can promote physical activity. We found positive effects of urban interventions on physical activity regarding park renovations, adding exercise equipment, introducing a (new) pocket park, improving cycling environments, improving walking & cycling environments, as well as multi-component initiatives for active travel and enhancing the availability & accessibility of destinations. The findings suggest that the urban environment can effectively promote physical activity, especially by adding various facilities and destinations and by making the environment better suitable for active use.

A Realist-Informed Review of Digital Empowerment Strategies for Adolescents to Improve Their Sexual and Reproductive Health and Well-being

The use of digital technologies for health has been rapidly gaining ground in the last decade, including as a strategy to empower adolescents living in urban resource-constrained settings. Nevertheless, unclarity and incoherence remain regarding which programme strategies generate which outcomes, as well as regarding the importance of context. We set out to answer the question "How do digital empowerment strategies work to improve adolescent health and well-being?". We conducted a realist-informed review, the first on this subject matter to our knowledge. The realist methodology is geared towards the understanding of socially complex interventions, such as digital empowerment. We synthesized the data into a programme theory uncovering social mechanisms and context conditions underlying specific programme strategies. We found that digital technologies enlarge the space for adolescents to access information to health services on their own terms and provide anonymity, which leads to a sense of safety if access is not curbed by gatekeepers. If adolescents have access to information adapted to their needs, they will be able to make informed decisions, and this will contribute to improved health outcomes because their better understanding enlarges their sense of individual agency. We identified two main gaps in the literature on digital interventions for adolescents. Both are related to an under-theoretisation of the concepts the programmes rely on in implementation: (1) the urban environment the programme has to operate in and its meaning for the adolescents; (2) the socio-developmental stage of the adolescents the programmes work in.

The Effectiveness of Interventions to Increase Participation and Physical Activities in Parks: A Systematic Review of the Literature

Although a variety of interventions in many countries have been developed to increase park use and to improve public participation in physical activities in parks, knowledge of their overall effectiveness is lacking. A systematic literature review was undertaken to further understand the effectiveness of various interventions that aim to increase the use of parks and physical activity participation in parks. This systematic review utilized the standard Preferred Reporting Items for Systematic Reviews and Meta-Analysis procedure, and of the 3801 studies identified, 60 studies were reviewed in-depth, with 44 studies assessed for quality of evidence and risk of bias. Most of the 44 reviewed studies found that various interventions had positive impacts on park use and physical activity participation in parks. Interventions were classified into both demand and supply, with more studies focusing on the supply side. The strongest evidence on the effectiveness of various interventions was found for park prescriptions; safe access to parks; playgrounds, and park renovation and renewal/design. However, the assessment of quality of evidence and risk of bias showed that most studies suffer from potential biases and evidence weaknesses, suggesting a need to further establish external validity.

Evaluation of a civic engagement approach to catalyze built environment change and promote healthy eating and physical activity among rural residents: a cluster (community) randomized controlled trial

BACKGROUND

Prior studies demonstrate associations between risk factors for obesity and related chronic diseases (e.g., cardiovascular disease) and features of the built environment. This is particularly true for rural populations, who have higher rates of obesity, cancer, and other chronic diseases than urban residents. There is also evidence linking health behaviors and outcomes to social factors such as social support, opposition, and norms. Thus, overlapping social networks that have a high degree of social capital and community cohesion, such as those found in rural communities, may be effective targets for introducing and maintaining healthy behaviors.

METHODS

This study will evaluate the effectiveness of the Change Club (CC) intervention, a civic engagement intervention for built environment change to improve health behaviors and outcomes for residents of rural communities. The CC intervention provides small groups of community residents (approximately 10-14 people) with nutrition and physical activity lessons and stepwise built environment change planning workshops delivered by trained extension educators via in-person, virtual, or hybrid methods. We will conduct process, multilevel outcome, and cost evaluations of implementation of the CC intervention in a cluster randomized controlled trial in 10 communities across two states using a two-arm parallel design. Change in the primary outcome, American Heart Association's Life's Simple 7 composite cardiovascular health score, will be evaluated among CC members, their friends and family members, and other community residents and compared to comparable samples in control communities. We will also evaluate changes at the social/collective level (e.g., social cohesion, social trust) and examine costs as well as barriers and facilitators to implementation.

DISCUSSION

Our central hypothesis is the CC intervention will improve health behaviors and outcomes among engaged citizens and their family and friends within 24 months. Furthermore, we hypothesize that positive changes will catalyze critical steps in the pathway to improving longer-term health among community residents through improved healthy eating and physical activity opportunities. This study also represents a unique opportunity to evaluate process and cost-related data, which will provide key insights into the viability of this approach for widespread dissemination.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT05002660 , Registered 12 August 2021.

Examining the state, quality and strength of the evidence in the research on built environments and physical activity among children and youth: An overview of reviews from high income countries

BACKGROUND

Built environments have shown to be associated with health, with physical activity (PA) considered one of the critical pathways for achieving benefits. Navigating available evidence on the built environment and PA is challenging given the number of reviews.

OBJECTIVE

Examine the current state and quality of research looking at associations between built environments and total PA and domains of PA (i.e., leisure/recreation, transportation, school) among children and youth (1-18 years).

METHODS

We systematically searched the grey literature and six bibliographic databases from January 2000 to May 2020. Review quality was assessed using the AMSTAR2. Results by age group were synthesized using narrative syntheses and harvest plots, and certainty of the evidence was assessed using a modified GRADE approach.

RESULTS

This overview included 65 reviews. Most reviews were of very low-to-low quality. High certainty was found for positive associations between transportation PA and walking/cycling/active transportation (AT) infrastructure. There was high certainty for positive associations between streets/play streets and total PA, alongside lower certainty for transportation and leisure PA. Very low-to-moderate certainty supports schoolyards designed to promote PA were positively associated with total PA, but mixed for school PA (except children). Less consistent positive associations were found for forests/trees, greenspace/open space, recreation facilities, street lighting, traffic safety, population/residential density, proximity/access to destinations, neighbourhood characteristics, and home environments. There is very low-to-moderate certainty for negative associations between greater distance to school and traffic volume and domains of PA. Generally, null or mixed associations were observed for aesthetics, parks, AT comfort infrastructure, land-use mix, street connectivity, urban/rural status, and public transit.

DISCUSSION

There remains a need for high quality systematic reviews and studies to evaluate the effects of environmental changes across the pediatric age spectrum and using a PA domain approach. Given the global physical inactivity crisis the built environment remains and important means to promote PA among children/youth.

Shaping Pathways to Child Health: A Systematic Review of Street-Scale Interventions in City Streets

Street-level built environment factors, for example, walking infrastructure, building density, availability of public transport, and proliferation of fast-food outlets can impact on health by influencing our ability to engage in healthy behaviour. Unhealthy environments are often clustered in deprived areas, thus interventions to improve the built environments may improve health and reduce inequalities. The aim of this review was to identify whether street-level built environment interventions can improve children's health in high income countries. A secondary aim was to describe key built environment elements targeted in interventions and research gaps. A systematic review of published literature was conducted by a multi-disciplinary team. Ten intervention papers were included. Physical activity or play was the only health outcome assessed. Most interventions described temporary changes including closure of streets to traffic (N = 6), which were mainly located in deprived neighbourhoods, or the addition of technology to 'gamify' active travel to school (N = 2). Two studies reported permanent changes to street design. There was limited evidence that closing streets to traffic was associated with increases in activity or play and inconclusive evidence with changes to street design and using technology to gamify active travel. Our ability to draw conclusions was hampered by inadequate study designs. Description of interventions was poor. Rigorous evaluation of built environment interventions remains challenging. We recommend a multi-disciplinary approach to evaluation, explicit reporting of built environment indicators targeted in interventions and offer solutions to others working in this area.

Examining the effectiveness of place-based interventions to improve public health and reduce health inequalities: an umbrella review

BACKGROUND

Locally delivered, place-based public health interventions are receiving increasing attention as a way of improving health and reducing inequalities. However, there is limited evidence on their effectiveness. This umbrella review synthesises systematic review evidence of the health and health inequalities impacts of locally delivered place-based interventions across three elements of place and health: the physical, social, and economic environments.

METHODS

Systematic review methodology was used to identify recent published systematic reviews of the effectiveness of place-based interventions on health and health inequalities (PROGRESS+) in high-income countries. Nine databases were searched from 1st January 2008 to 1st March 2020. The quality of the included articles was determined using the Revised Assessment of Multiple Systematic Reviews tool (R-AMSTAR).

RESULTS

Thirteen systematic reviews were identified - reporting 51 unique primary studies. Fifty of these studies reported on interventions that changed the physical environment and one reported on changes to the economic environment. Only one primary study reported cost-effectiveness data. No reviews were identified that assessed the impact of social interventions. Given heterogeneity and quality issues, we found tentative evidence that the provision of housing/home modifications, improving the public realm, parks and playgrounds, supermarkets, transport, cycle lanes, walking routes, and outdoor gyms - can all have positive impacts on health outcomes - particularly physical activity. However, as no studies reported an assessment of variation in PROGRESS+ factors, the effect of these interventions on health inequalities remains unclear.

CONCLUSIONS

Place-based interventions can be effective at improving physical health, health behaviours and social determinants of health outcomes. High agentic interventions indicate greater improvements for those living in greater proximity to the intervention, which may suggest that in order for interventions to reduce inequalities, they should be implemented at a scale commensurate with the level of disadvantage. Future research needs to ensure equity data is collected, as this is severely lacking and impeding progress on identifying interventions that are effective in reducing health inequalities.

TRIAL REGISTRATION

PROSPERO CRD42019158309.

Measuring the Built Environment in Studies of Child Health-A Meta-Narrative Review of Associations

Although the built environment (BE) is important for children’s health, there is little consensus about which features are most important due to differences in measurement and outcomes across disciplines. This meta-narrative review was undertaken by a multi-disciplinary team of researchers to summarise ways in which the BE is measured, and how this links to children’s health. A structured search of four databases across the relevant disciplines retrieved 108 relevant references. The most commonly addressed health-related outcomes were active travel, physical activity and play, and obesity. Many studies used objective (GIS and street audits) or standardised subjective (perceived) measurements of the BE. However, there was a wide variety, and sometimes inconsistency, in their definition and use. There were clear associations between the BE and children’s health. Objective physical activity and self-reported active travel, or obesity, were positively associated with higher street connectivity or walkability measures, while self-reported physical activity and play had the strongest association with reduced street connectivity, indicated by quieter, one-way streets. Despite the high heterogeneity found in BE measures and health outcomes, the meta-narrative approach enabled us to identify ten BE categories that are likely to support children’s health and be protective against some non-communicable disease risk factors. Future research should implement consistent BE measures to ensure key features are explored. A systems approach will be particularly relevant for addressing place-based health inequalities, given potential unintended health consequences of making changes to the BE.

A multi-scalar perspective on health and urban housing: an umbrella review

With more than half the world's population living in cities, understanding how the built environment impacts human health at different urban scales is crucial. To be able to shape cities for health, an understanding is needed of planetary health impacts, which encompass the human health impacts of human-caused disruptions on the Earth's natural ecosystems. This umbrella review maps health evidence across the spatial scales of the built environment (building; neighbourhood; and wider system, including city, regional and planetary levels), with a specific focus on urban housing. Systematic reviews published in English between January 2011 and December 2020 were searched across 20 databases, with 1176 articles identified and 124 articles screened for inclusion. Findings suggests that most evidence reports on health determinants at the neighbourhood level, such as greenspace, physical and socio-economic conditions, transport infrastructure and access to local services. Physical health outcomes are also primarily reported, with an emerging interest in mental health outcomes. There is little evidence on planetary health outcomes and significant gaps in the research literature are identified. Based on these findings, three potential directions are identified for future research.

Australia in 2030: what is our path to health for all?

CHAPTER 1: HOW AUSTRALIA IMPROVED HEALTH EQUITY THROUGH ACTION ON THE SOCIAL DETERMINANTS OF HEALTH: Do not think that the social determinants of health equity are old hat. In reality, Australia is very far away from addressing the societal level drivers of health inequity. There is little progressive policy that touches on the conditions of daily life that matter for health, and action to redress inequities in power, money and resources is almost non-existent. In this chapter we ask you to pause this reality and come on a fantastic journey where we envisage how COVID-19 was a great disruptor and accelerator of positive progressive action. We offer glimmers of what life could be like if there was committed and real policy action on the social determinants of health equity. It is vital that the health sector assists in convening the multisectoral stakeholders necessary to turn this fantasy into reality. CHAPTER 2: ABORIGINAL AND TORRES STRAIT ISLANDER CONNECTION TO CULTURE: BUILDING STRONGER INDIVIDUAL AND COLLECTIVE WELLBEING: Aboriginal and Torres Strait Islander peoples have long maintained that culture (ie, practising, maintaining and reclaiming it) is vital to good health and wellbeing. However, this knowledge and understanding has been dismissed or described as anecdotal or intangible by Western research methods and science. As a result, Aboriginal and Torres Strait Islander culture is a poorly acknowledged determinant of health and wellbeing, despite its significant role in shaping individuals, communities and societies. By extension, the cultural determinants of health have been poorly defined until recently. However, an increasing amount of scientific evidence supports what Aboriginal and Torres Strait Islander people have always said - that strong culture plays a significant and positive role in improved health and wellbeing. Owing to known gaps in knowledge, we aim to define the cultural determinants of health and describe their relationship with the social determinants of health, to provide a full understanding of Aboriginal and Torres Strait Islander wellbeing. We provide examples of evidence on cultural determinants of health and links to improved Aboriginal and Torres Strait Islander health and wellbeing. We also discuss future research directions that will enable a deeper understanding of the cultural determinants of health for Aboriginal and Torres Strait Islander people. CHAPTER 3: PHYSICAL DETERMINANTS OF HEALTH: HEALTHY, LIVEABLE AND SUSTAINABLE COMMUNITIES: Good city planning is essential for protecting and improving human and planetary health. Until recently, however, collaboration between city planners and the public health sector has languished. We review the evidence on the health benefits of good city planning and propose an agenda for public health advocacy relating to health-promoting city planning for all by 2030. Over the next 10 years, there is an urgent need for public health leaders to collaborate with city planners - to advocate for evidence-informed policy, and to evaluate the health effects of city planning efforts. Importantly, we need integrated planning across and between all levels of government and sectors, to create healthy, liveable and sustainable cities for all. CHAPTER 4: HEALTH PROMOTION IN THE ANTHROPOCENE: THE ECOLOGICAL DETERMINANTS OF HEALTH: Human health is inextricably linked to the health of the natural environment. In this chapter, we focus on ecological determinants of health, including the urgent and critical threats to the natural environment, and opportunities for health promotion arising from the human health co-benefits of actions to protect the health of the planet. We characterise ecological determinants in the Anthropocene and provide a sobering snapshot of planetary health science, particularly the momentous climate change health impacts in Australia. We highlight Australia's position as a major fossil fuel producer and exporter, and a country lacking cohesive and timely emissions reduction policy. We offer a roadmap for action, with four priority directions, and point to a scaffold of guiding approaches - planetary health, Indigenous people's knowledge systems, ecological economics, health co-benefits and climate-resilient development. Our situation requires a paradigm shift, and this demands a recalibration of health promotion education, research and practice in Australia over the coming decade. CHAPTER 5: DISRUPTING THE COMMERCIAL DETERMINANTS OF HEALTH: Our vision for 2030 is an Australian economy that promotes optimal human and planetary health for current and future generations. To achieve this, current patterns of corporate practice and consumption of harmful commodities and services need to change. In this chapter, we suggest ways forward for Australia, focusing on pragmatic actions that can be taken now to redress the power imbalances between corporations and Australian governments and citizens. We begin by exploring how the terms of health policy making must change to protect it from conflicted commercial interests. We also examine how marketing unhealthy products and services can be more effectively regulated, and how healthier business practices can be incentivised. Finally, we make recommendations on how various public health stakeholders can hold corporations to account, to ensure that people come before profits in a healthy and prosperous future Australia. CHAPTER 6: DIGITAL DETERMINANTS OF HEALTH: THE DIGITAL TRANSFORMATION: We live in an age of rapid and exponential technological change. Extraordinary digital advancements and the fusion of technologies, such as artificial intelligence, robotics, the Internet of Things and quantum computing constitute what is often referred to as the digital revolution or the Fourth Industrial Revolution (Industry 4.0). Reflections on the future of public health and health promotion require thorough consideration of the role of digital technologies and the systems they influence. Just how the digital revolution will unfold is unknown, but it is clear that advancements and integrations of technologies will fundamentally influence our health and wellbeing in the future. The public health response must be proactive, involving many stakeholders, and thoughtfully considered to ensure equitable and ethical applications and use. CHAPTER 7: GOVERNANCE FOR HEALTH AND EQUITY: A VISION FOR OUR FUTURE: Coronavirus disease 2019 has caused many people and communities to take stock on Australia's direction in relation to health, community, jobs, environmental sustainability, income and wealth. A desire for change is in the air. This chapter imagines how changes in the way we govern our lives and what we value as a society could solve many of the issues Australia is facing - most pressingly, the climate crisis and growing economic and health inequities. We present an imagined future for 2030 where governance structures are designed to ensure transparent and fair behaviour from those in power and to increase the involvement of citizens in these decisions, including a constitutional voice for Indigenous peoples. We imagine that these changes were made by measuring social progress in new ways, ensuring taxation for public good, enshrining human rights (including to health) in legislation, and protecting and encouraging an independent media. Measures to overcome the climate crisis were adopted and democratic processes introduced in the provision of housing, education and community development.

The Relationship of Urban Form on Children and Adolescent Health Outcomes: A Scoping Review of Canadian Evidence

Urban form can have an impact on health outcomes in children, and the synthesis of findings can identify gaps in the literature and regional reviews may help guide policymakers. This study aims to complete a scoping review of the research relating urban form to health outcomes in children and adolescents from urban Canadian settings. Thirteen online databases were searched to identify studies that had objective measures of urban form and health outcomes. Two research assistants independently reviewed 27,444 titles and abstracts, and 176 full-text articles, returning 32 unique studies with youth-specific data. The majority of the included studies were cross-sectional or ecological (n = 26). Six studies used Canada-wide data and the rest were from Ontario (n = 11), Alberta (n = 6), and Quebec (n = 6). Urban form characteristics included neighbourhood food environment (n = 11), parks/natural space/greenness (n = 10), road or intersection characteristics (n = 7), and aggregated urban form measures (n = 7). Studies examined a variety of health outcomes: the majority considered weight status (n = 16) and injury (n = 10). Although there is over-reliance on mainly cross-sectional study designs, there is evidence suggesting that urban form is associated with health outcomes in Canadian youth, with parks/greenspace, road connectivity, and road characteristics most consistently associated with health outcomes in youth.

Determining Factors in the Use of Urban Parks That Influence the Practice of Physical Activity in Children: A Systematic Review

The design and/or remodelling of urban parks is a good health strategy to alleviate the lack of physical activity (PA) in children and, consequently, the different health problems derived from this. The main objective of the present study was to obtain a systematic review of the design features and characteristics that influence users' visits to urban parks and the PA engagement in them. A literature search was carried out in the Web of Science (WOS) and Scopus databases during the months of June and July 2020. After considering and applying inclusion criteria, the final review sample was formed of 31 scientific papers published between 2010-2020. The results obtained in the review lead us to conclude that the needs of the population (children and family members who care for them) and socio-economic context of the area in which they are built must be considered when constructing and/or remodelling parks. Involving community members in playground renovations can have a positive effect on park use and PA engagement in children.

Recruitment and Retention Strategies for Community-Based Longitudinal Studies in Diverse Urban Neighborhoods

Longitudinal, natural experiments provide an ideal evaluation approach to better understand the impact of built environment interventions on community health outcomes, particularly health disparities. As there are many participant engagement challenges inherent in the design of large-scale community-based studies, adaptive and iterative participant engagement strategies are critical. This paper shares practical lessons learned from the Physical Activity and Redesigned Community Spaces (PARCS) study, which is an evaluation of the impact of a citywide park renovation initiative on physical activity, psychosocial health, and community well-being. The PARCS study, although ongoing, has developed several approaches to improve participant engagement: building trust with communities, adapting the study protocol to meet participants' needs and to reflect their capacity for participation, operational flexibility, and developing tracking systems. These strategies may help researchers anticipate and respond to participant engagement challenges in community-based studies, particularly in low-income communities of color.

Sustainability-Sport-Physical Activity

The present study is a synthesizing analysis of international literature on correlations between sustainability, sport, and physical activity. The study of sustainability is considered essential in modern research; its multidisciplinary approach relies on sports science and sports economics as well. There are several aspects of sustainability that are closely associated with health and health preservation; the beneficial effect of exercise on health is also widely known. For the analysis of this complex matter, our current study relied on secondary sources, and besides exploring specialist literature, it also illustrates and analyzes related statistical data. Our results highlight the correlations between living environment and physical activity, the importance of increasing individual commitment towards sustainability and using green spaces for exercising, as well as questions on social and environmental development in relation to physical activity. The study revealed the existence of highly complex links between physical environment, physical activities, and sustainability. The results section of our study provides a brief summary on the possible ways of making people physically active. Increasing physical activity is of paramount importance for achieving the objectives formulated in relation to sustainability.

Primary prevention of overweight and obesity in adolescents: An overview of systematic reviews

The aim of this overview of systematic reviews was to summarize evidence from up-to-date reviews of the effectiveness of interventions aimed at preventing overweight and obesity in adolescents aged 10 to 19 years. We searched nine databases for systematic reviews published between January 2008 and November 2019. We used A Measurement Tool to Assess Systematic Reviews (AMSTAR) 2 to assess the quality of reviews, excluding those of critically low quality, and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) tool to grade the certainty of included evidence. We included 13 reviews. Three reviews focused on dietary behaviour, six on physical activity, and four on both types of behaviours. Individual-oriented and school-based interventions dominated. Results across reviews showed little or no effect on body mass index, or physical activity levels of adolescents, whereas results from a couple of reviews suggest possibly beneficial effects of public health interventions on dietary behaviours (i.e., consumption of sugar-sweetened beverages). The certainty of evidence was low to very low for all outcomes. Overall, the evidence base for the effect of primary interventions to prevent overweight and obesity in adolescents is weak. In particular, there is a lack of reviews assessing the impact of environmental interventions targeting adolescents, and reviews addressing social inequality are virtually absent from this body of literature.

Impact of Perception of Green Space for Health Promotion on Willingness to Use Parks and Actual Use among Young Urban Residents

Promoting the use of green space is a fundamental way to improve physical and mental health and to enhance the quality of life of urban residents. In response to increasing demand for green space in cities, the impact of perception of green space for health promotion on willingness to use parks and actual use among young urban residents was investigated in this study. A total of 1135 young residents (ages 18–35) in three cities in China were surveyed by online questionnaire. A group of multiple regression models was constructed to investigate the influencing perception factors of participants’ willingness to use parks and actual use. The results revealed that the young residents’ perception of green space components for health promotion (green space access, types, sizes, plants, water, sensory features, microclimate environments and amenity facilities) had a greater effect on their willingness to use parks and to promote health, while it was less influential with respect to their actual park use behavior (frequency and duration). Among these variables, green space access is a critical concern for willingness to use toward parks. The disparities of perception of green space for health promotion effect on willingness to use a park and actual use provide a better understanding of the psychological factors affecting park use among young residents. The findings also provided some implications for public health policymakers, urban planners and landscape architects in designing parks to encourage visitation by young people.

The impact of hot food takeaways near schools in the UK on childhood obesity: a systematic review of the evidence

BACKGROUND

Obesity is the greatest health issue for this generation; schools have improved food offered within their grounds. The built environment surrounding schools and pupils' journeys home have not received the same level of attention. This review identified papers on impacts of hot food takeaways surrounding schools in the UK.

METHODS

Methods were informed by the PRISMA (QUORUM) guidelines for systematic reviews. Searches were completed in 12 databases.

RESULTS

A total of 14 papers were included and quality assured before data extraction. Three descriptive themes were found; descriptions of hot food takeaway's geography and impacts concerning schools, strategic food policy and pupils reported food behaviour.

CONCLUSIONS

Most included studies compared anthropometric measures with geographical location of hot food takeaways to find correlations between environment and childhood obesity. There was good evidence of more hot food takeaways in deprived areas and children who spend time in deprived neighbourhoods tend to eat more fast food and have higher BMIs. Few studies were able to quantify the correlation between school's environment and obesity amongst pupils. This lack of evidence is likely a factor of the studies' ability to identify the correlation rather than lack of a correlation between the two variables.

Placement of Outdoor Exercise Equipment and Physical Activity: A Quasi-Experimental Study in Two Parks in Southern California

To reduce the burden of chronic disease, the Centers for Disease Control and Prevention (CDC) funded the Orange County Partnerships to Improve Health (OC-PICH) project in Orange County, California. One of the strategies included adding outdoor exercise equipment (OEE) in two parks in Garden Grove and Anaheim. Using a quasi-experimental pre-post design, we evaluated park users’ physical activity levels before and after OEE installation using the System for Observing Play and Recreation in Communities (SOPARC). The OEE was installed along a walking path in Edison Park (Anaheim) and grouped within a single area (a “fitness zone”) in Garden Grove Park. In both parks, there were significantly greater odds of high-intensity physical activity overall after the installation—19% higher odds in Anaheim, and 23% higher odds in Garden Grove. However, the fitness zone area in Garden Grove had substantially higher odds of increased physical activity post-intervention (OR = 5.29, CI: 3.76–7.44, p < 0.001). While the increases in physical activity levels are consistent with past studies that link OEE to higher levels of physical activity among park users, our findings also suggest that the location and placement of equipment within a park may be an important factor to consider when improving park amenities for physical activity.

Socioeconomic inequalities and the equity impact of population-level interventions for adolescent health: an overview of systematic reviews

OBJECTIVES

Despite robust evidence on health inequalities in adulthood, less attention has been paid to inequalities in adolescence. The aim of this overview was to examine systematic review (SR) evidence on the equity impact of population-level interventions intended to improve health, happiness and wellbeing for adolescents.

STUDY DESIGN

An overview (review of systematic reviews).

METHODS

Eleven electronic databases were systematically searched to identify SRs of population-level interventions for adolescent health. A secondary data analysis of socioeconomic inequality was conducted to identify whether SRs reported on primary studies in terms of disadvantage, by measures of socioeconomic status (SES) and by differential effects.

RESULTS

35,310 review titles were screened; 566 full texts were retrieved and 140 SRs met the predefined selection criteria. Differential intervention effects were considered in 42/140 (30%) SRs, 18/140 (13%) reported primary studies using an SES measure and 16/140 (11%) explicitly reported differential effects. 15/140 SRs (11%) explicitly focused on socioeconomic inequalities; of these 4/15 reported differential intervention effects in more detail, 7/15 concluded there was insufficient primary evidence to identify the impact of interventions on socioeconomic inequalities and 4/15 planned to examine differential effects by SES, but this was not reported further.

CONCLUSIONS

Our overview identifies that there is limited SR evidence on the equity impact of population-level interventions for adolescent health. Strengthening the evidence on whether interventions narrow or widen inequalities for adolescents must be a priority for public health research.

Efficacy of population-wide diabetes and obesity prevention programs: An overview of systematic reviews on proximal, intermediate, and distal outcomes and a meta-analysis of impact on BMI

We conducted an overview of systematic reviews and a meta-analysis of the impact on body mass index (BMI) of primary studies of population-wide obesity and diabetes prevention programs, in order to evaluate their efficacy. We searched eight databases for reviews of population-level programs reporting effect on diet, physical activity, BMI, or prevalence of obesity/overweight or type 2 diabetes mellitus (T2DM). Meta-analysis of primary studies within reviews reporting effect on BMI. Interventions were categorized using ANGELO framework and quality assessment using AMSTAR. Fifty-three systematic reviews were included. Primary studies were largely natural experiments or cross-sectional studies of national data. Increased price of sugar-sweetened beverages (SSBs) and fast food, decreased price of fruit and vegetables, food labelling, and grocery store interventions were associated with positive effects on diet. Park and playground renovations and point-of-choice prompts to increase stair use were associated with positive effects on physical activity. Increased price of SSBs, menu labelling, grocery store interventions, and multicomponent interventions were associated with small reductions in BMI. There was insufficient evidence of impact of any interventions on the prevalence of overweight, obesity, or T2DM. We have identified a promising suite of population-wide actions to improve diet, increase physical activity, and reduce BMI. Impact on subsequent incidence of T2DM remains speculative.

Strong Hearts for New York: A multilevel community-based randomized cardiovascular disease risk reduction intervention for rural women

BACKGROUND

Rural midlife and older women have high rates of cardiovascular disease (CVD) risk factors and lower access to healthy living resources. The Strong Hearts, Healthy Communities (SHHC) intervention, tailored to the needs of rural women, demonstrated effectiveness on many outcomes. The purpose of the Strong Hearts for New York (SHNY) study is to evaluate the efficacy of an enhanced version of the curriculum (SHHC-2.0).

METHODS

SHNY is a randomized controlled efficacy intervention, comparing participants receiving the SHHC-2.0 curriculum with a delayed intervention control group. SHHC, informed by formative research, includes core elements from three evidence-based programs. Changes based on extensive outcome and process evaluation data were made to create SHHC-2.0. Classes will meet twice weekly for 24 weeks and include individual, social, and environmental components. Overweight women age 40 and over will be recruited from 11 rural, medically underserved communities in New York; data will be collected at baseline and 12, 24, 36, and 48 weeks across individual, social, and environmental levels. Primary outcome is body weight. Secondary outcomes include Simple 7 (composite CVD risk score), anthropometric, physiologic, biochemical, physical activity, and dietary intake measures; healthy eating and exercise self-efficacy and attitudes; and self-efficacy of the social network of participants.

DISCUSSION

The aims of this study are to evaluate the efficacy of the enhanced SHHC-2.0 program for participants, changes among participants' social networks, and the difference in outcomes when participants are and are not provided with technological tools (Fitbit and body composition scale).

Association Between the Activity Space Exposure to Parks in Childhood and Adolescence and Cognitive Aging in Later Life

The exposure to green space in early life may support better cognitive aging in later life. However, this exposure is usually measured using the residential location alone. This disregards the exposure to green spaces in places frequented during daily activities (i.e., the ‘activity space’). Overlooking the multiple locations visited by an individual over the course of a day is likely to result in poor estimation of the environmental exposure and therefore exacerbates the contextual uncertainty. A child’s activity space is influenced by factors including age, sex, and the parental perception of the neighborhood. This paper develops indices of park availability based on individuals’ activity spaces (home, school, and the optimal route to school). These measures are used to examine whether park availability in childhood is related to cognitive change much later in life. Multi-level linear models, including random effects for schools, were used to test the association between park availability during childhood and adolescence and cognitive aging (age 70 to 76) in the Lothian Birth Cohort 1936 participants (N = 281). To test for the effect modification, these models were stratified by sex and road traffic accident (RTA) density. Park availability during adolescence was associated with better cognitive aging at a concurrently low RTA density (β = 0.98, 95% CI: 0.36 to 1.60), but not when the RTA density was higher (β = 0.22, 95% CI: −0.07 to 0.51). Green space exposure during early life may be important for optimal cognitive aging; this should be evidenced using activity space-based measures within a life-course perspective.

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.

Mental health benefits of interactions with nature in children and teenagers: a systematic review

Background

It is commonly believed that nature has positive impacts on children’s health, including physical, mental and social dimensions. This review focuses on how accessibility to, exposure to and engagement with nature affects the mental health of children and teenagers.

Methods

Ten academic databases were used to systematically search and identify primary research papers in English or French from 1990 to 1 March 2017. Papers were included for review based on their incorporation of nature, children and teenagers (0–18 years), quantitative results and focus on mental health.

Results

Of the 35 papers included in the review, the majority focused on emotional well-being and attention deficit disorder/hyperactivity disorder. Other outcome measures included overall mental health, self-esteem, stress, resilience, depression and health-related quality of life. About half of all reported findings revealed statistically significant positive relationships between nature and mental health outcomes and almost half reported no statistical significance.

Conclusions

Findings support the contention that nature positively influences mental health; however, in most cases, additional research with more rigorous study designs and objective measures of both nature and mental health outcomes are needed to confirm statistically significant relationships. Existing evidence is limited by the cross-sectional nature of most papers.

Parental perceptions of barriers to active commuting to school in Spanish children and adolescents

Background

: Understanding parental barriers is crucial to promote active commuting to school since the parental perceptions influence how young people commute. This study examined parental barriers to active commuting to school among Spanish children and adolescents, and their association with their gender and the usual mode of commuting. Parents of children ( n = 628) and parents of adolescents ( n = 151) from Granada (Spain) completed a paper-based questionnaire about perceived parental barriers to active commuting to school and mode of commuting. Data were analyzed using the Chi-square test. Among Spanish parents, the most common barriers reported by parents of children were traffic volume and dangerous intersections, whereas the most frequent barriers reported by parents of adolescents were distance to school and dangerous intersections. Compared to parents of children, a greater proportion of parents of adolescents reported distance to school and crime and smaller proportion reported traffic volume as barriers to active commuting to school. Among parents of children, crime was a more commonly reported as a barrier by parents of girls. Although some barriers reported by parents of passive commuters were similar for children and adolescents (such as distance to school and absence of a policeman at crosswalks), other barriers were specific to parents of children. The main parental barriers to active commuting in children were traffic volume and dangerous intersections whereas for adolescents were distance and dangerous intersections. Among Spanish parents, parental barriers to active commuting are influenced by children's age, gender and mode of commuting to school.

A Civic Engagement Approach to Encourage Healthy Eating and Active Living in Rural Towns: The HEART Club Pilot Project

PURPOSE

To assess the feasibility and effectiveness of a civic engagement curriculum (encouraging Healthy Eating and Activity in Rural Towns [HEART] Club) designed to engage rural residents in improving their local food or physical activity environment.

DESIGN

Pre-post surveys and focus groups.

SETTING

Three rural Northeastern towns in the United States.

PARTICIPANTS

Twenty-six rural residents (7-12 per town) recruited by local extension educators.

MEASURES

Online surveys were used to assess outcomes related to feasibility (satisfaction) and effectiveness (knowledge, awareness, motivation, self-efficacy, and group efficacy for community change). Feasibility was also assessed through attendance logs, benchmark achievement records, and post-implementation focus groups.

ANALYSIS

Participant characteristics and feasibility measures were summarized using descriptive statistics. Pre-post changes in effectiveness outcomes were assessed using Wilcoxon signed rank tests. Focus group data were thematically examined to identify barriers to and facilitators of HEART Club progress.

RESULTS

Meeting attendance and program satisfaction were high (88% and 91%). Participants reported improvements in awareness; however, no other significant changes were observed. All HEART Clubs accomplished 3 or more project benchmarks after 6 months of implementation. Despite competing priorities and limited finances, groups effectively leveraged existing resources to achieve their goals. Important facilitators of success included stakeholder support, effective leadership, and positive group dynamics.

CONCLUSION

These findings suggest that resident-driven initiatives that build upon local resources and establish feasible goals can successfully foster environmental change in rural communities.

Pediatric Obesity-Assessment, Treatment, and Prevention: An Endocrine Society Clinical Practice Guideline

COSPONSORING ASSOCIATIONS

The European Society of Endocrinology and the Pediatric Endocrine Society. This guideline was funded by the Endocrine Society.

OBJECTIVE

To formulate clinical practice guidelines for the assessment, treatment, and prevention of pediatric obesity.

PARTICIPANTS

The participants include an Endocrine Society-appointed Task Force of 6 experts, a methodologist, and a medical writer.

EVIDENCE

This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation approach to describe the strength of recommendations and the quality of evidence. The Task Force commissioned 2 systematic reviews and used the best available evidence from other published systematic reviews and individual studies.

CONSENSUS PROCESS

One group meeting, several conference calls, and e-mail communications enabled consensus. Endocrine Society committees and members and co-sponsoring organizations reviewed and commented on preliminary drafts of this guideline.

CONCLUSION

Pediatric obesity remains an ongoing serious international health concern affecting ∼17% of US children and adolescents, threatening their adult health and longevity. Pediatric obesity has its basis in genetic susceptibilities influenced by a permissive environment starting in utero and extending through childhood and adolescence. Endocrine etiologies for obesity are rare and usually are accompanied by attenuated growth patterns. Pediatric comorbidities are common and long-term health complications often result; screening for comorbidities of obesity should be applied in a hierarchal, logical manner for early identification before more serious complications result. Genetic screening for rare syndromes is indicated only in the presence of specific historical or physical features. The psychological toll of pediatric obesity on the individual and family necessitates screening for mental health issues and counseling as indicated. The prevention of pediatric obesity by promoting healthful diet, activity, and environment should be a primary goal, as achieving effective, long-lasting results with lifestyle modification once obesity occurs is difficult. Although some behavioral and pharmacotherapy studies report modest success, additional research into accessible and effective methods for preventing and treating pediatric obesity is needed. The use of weight loss medications during childhood and adolescence should be restricted to clinical trials. Increasing evidence demonstrates the effectiveness of bariatric surgery in the most seriously affected mature teenagers who have failed lifestyle modification, but the use of surgery requires experienced teams with resources for long-term follow-up. Adolescents undergoing lifestyle therapy, medication regimens, or bariatric surgery for obesity will need cohesive planning to help them effectively transition to adult care, with continued necessary monitoring, support, and intervention. Transition programs for obesity are an uncharted area requiring further research for efficacy. Despite a significant increase in research on pediatric obesity since the initial publication of these guidelines 8 years ago, further study is needed of the genetic and biological factors that increase the risk of weight gain and influence the response to therapeutic interventions. Also needed are more studies to better understand the genetic and biological factors that cause an obese individual to manifest one comorbidity vs another or to be free of comorbidities. Furthermore, continued investigation into the most effective methods of preventing and treating obesity and into methods for changing environmental and economic factors that will lead to worldwide cultural changes in diet and activity should be priorities. Particular attention to determining ways to effect systemic changes in food environments and total daily mobility, as well as methods for sustaining healthy body mass index changes, is of importance.

Study protocol for a natural experiment in a lower socioeconomic area to examine the health-related effects of refurbishment to parks including built-shade (ShadePlus)

INTRODUCTION

Parks in disadvantaged suburbs often have low quality and few amenities, which is likely to result in them being underutilised for recreation and physical activity. Refurbishment of parks, including shade, walking paths and other amenities, may have broad health-related benefits.

METHODS AND ANALYSIS

The study design, methods and planned analyses for a natural experiment examining the effects of refurbishments including built-shade added to parks in disadvantaged outer suburbs of Melbourne are described. Three intervention parks and three comparison parks matched for equivalence of park and neighbourhood characteristics were selected. Using mixed methods, the outcomes will be assessed during three consecutive spring-summer periods (T1: 2013-2014; T2: 2014-2015: T3: 2015-2016). Primary outcomes included: observed park use, physical activity and shade use. Self-reported social connectedness, community engagement and psychological well-being were assessed as secondary outcomes.

ETHICS AND DISSEMINATION

This study was approved by Cancer Council Victoria's Human Research Ethics Committee. Studies such as ShadePlus can improve understanding of the broader effects of park refurbishments (including physical activity levels and sun protection behaviours, as well as social connectedness and psychological well-being). The study findings will be disseminated through established urban planning and parks and recreation networks, peer review publications and conference presentations.

The effect of changing the built environment on physical activity: a quantitative review of the risk of bias in natural experiments

BACKGROUND

Evidence regarding the association of the built environment with physical activity is influencing policy recommendations that advocate changing the built environment to increase population-level physical activity. However, to date there has been no rigorous appraisal of the quality of the evidence on the effects of changing the built environment. The aim of this review was to conduct a thorough quantitative appraisal of the risk of bias present in those natural experiments with the strongest experimental designs for assessing the causal effects of the built environment on physical activity.

METHODS

Eligible studies had to evaluate the effects of changing the built environment on physical activity, include at least one measurement before and one measurement of physical activity after changes in the environment, and have at least one intervention site and non-intervention comparison site. Given the large number of systematic reviews in this area, studies were identified from three exemplar systematic reviews; these were published in the past five years and were selected to provide a range of different built environment interventions. The risk of bias in these studies was analysed using the Cochrane Risk of Bias Assessment Tool: for Non-Randomized Studies of Interventions (ACROBAT-NRSI).

RESULTS

Twelve eligible natural experiments were identified. Risk of bias assessments were conducted for each physical activity outcome from all studies, resulting in a total of fifteen outcomes being analysed. Intervention sites included parks, urban greenways/trails, bicycle lanes, paths, vacant lots, and a senior citizen's centre. All outcomes had an overall critical (n = 12) or serious (n = 3) risk of bias. Domains with the highest risk of bias were confounding (due to inadequate control sites and poor control of confounding variables), measurement of outcomes, and selection of the reported result.

CONCLUSIONS

The present review focused on the strongest natural experiments conducted to date. Given this, the failure of existing studies to adequately control for potential sources of bias highlights the need for more rigorous research to underpin policy recommendations for changing the built environment to increase physical activity. Suggestions are proposed for how future natural experiments in this area can be improved.