Development and reliability of a streetscape observation instrument for international use: MAPS-global

Development, scoring, and reliability for the Microscale Audit of Pedestrian Streetscapes for Safe Routes to School (MAPS-SRTS) instrument

BACKGROUND

Active commuting to school can be a meaningful contributor to overall physical activity in children. To inform better micro-level urban design near schools that can support active commuting to school, there is a need for measures that capture these elements. This paper describes the adaptation of an observational instrument for use in assessing micro-scale environments around urban elementary schools in the United States.

METHODS

The Micro-scale Audit of Pedestrian Streetscapes for Safe Routes to School (MAPS-SRTS) was developed from existing audit instruments not designed for school travel environments and modifications for the MAPS-SRTS instrument include the structure of the audit tool sections, the content, the observation route, and addition of new subscales. Subscales were analyzed for inter-rater reliability in a sample of 36 schools in Austin, TX. To assess reliability for each subscale, one-way random effects single-measure intraclass correlation coefficients (ICC) were used.

RESULTS

Compared to the 30 original subscales, the adapted MAPS-SRTS included 26 (86.6%) subscales with revised scoring algorithms. Most MAPS-SRTS subscales had acceptable inter-rater reliability, with an ICC of 0.97 for the revised audit tool.

CONCLUSIONS

The MAPS-SRTS audit tool is a reliable instrument for measuring the school travel environment for research and evaluation purposes, such as assessing human-scale determinants of active commuting to school behavior and documenting built environment changes from infrastructure interventions.

[Screen time, quality of the adolescent diet, and profile of the school environment]

Adolescents from 30 state schools in Curitiba, State of Paraná, reported total screen time, namely television, video games and laptops. Diet quality was assessed by the frequency of food consumption. The income of the school environment was taken from the Census. The built environment for physical activity was investigated by systematic observation of the school surroundings. Multilevel Poisson Regression was used to estimate associations with the exposure variables. Among 1,200 adolescents, 50.9% being male, and 74.4% were found to be exposed to excessive screen time. Excessive TV screen time (56.5%) was associated with poor diet quality. Excessive video game time (22.0%) was lower among females (PR 0.25; 95%CI 0.18;0.36), associated with poor diet quality, lower school environment income, and the worst classification of the built environment for physical activity. Excessive use of portable screens (53.2%) tended to increase with the income of the school environment. Excessive use of TV and laptops was widespread among adolescents, with different demographic and contextual variables associated according to the type of device used.

Area-level socioeconomic inequalities in overweight and obesity: Systematic review on moderation by built-environment attributes

Residents of lower socioeconomic status (SES) areas are at a higher risk of overweight/obesity than those from higher SES areas. Built environment attributes may mitigate such inequalities. This systematic review synthesised findings of studies examining built environment attributes as potential moderators of the associations between area-level SES and overweight/obesity in adults. From five databases, nine eligible studies were identified. The SES-overweight/obesity relationship was stronger in inner areas and suburbs of large cities, while it was weaker in more rural areas. Two studies examined walkability and reported contrasting findings: no moderation in one and marginally significant moderation (less inequality in higher walkability areas) in the other. No evidence of moderation was found for street connectivity, population density, the food environment, access to physical activity facilities and several perceived environmental attributes. Further research is needed on other built environment attributes (e.g., access to, quantity and quality of green spaces, active transport features), and ideally using prospective study designs and objective makers of adiposity.

A Classroom-Based Intervention to Promote Physical Literacy in Children: ALPHYL Study Protocol

Physical literacy is crucial for children's appropriate development and physical, social and mental health. In a school setting, class-based physical activity (PA) interventions are considered to be appropriate programs to foster PA participation and cognitive development. The purpose of this project, named the Active Learning in PHYsical Literacy (ALPHYL) study, was to describe a multicomponent classroom-based physically-active learning randomised control trial (RCT) in primary school children. The main purpose was to promote children's physical literacy, academic achievement and cognitive function. The ALPHYL study is mainly based on physical literacy, active school models and the Supportive, Active, Autonomous, Fair and Enjoyable principles. The ALPHYL is an 8-10-week RCT to be conducted in six primary schools (12 classes) in Valencia (Spain) and its metropolitan area. Schools will be randomly assigned to the intervention or waiting-list control group. After a 30 h in-person training course for teachers and weekly meetings in the three months of resource preparation, the ALPHYL intervention will be conducted in physical education (PE) and non-PE lessons by teachers. The intervention consists of at least three daily sessions of physically active learning in addition to model-based PE teaching. Its feasibility will be evaluated weekly according to the Reach, Effectiveness, Adoption, Implementation and Maintenance framework. To assess its effectiveness, a pre-test, post-test and retention (8-10 weeks post-intervention) with primary outcomes (i.e., PA level, motor competence, perceived motor competence and PL, motivation, perceived social support, academic achievement and cognitive function), secondary outcomes and covariates will be collected.

Forschungsprojekt EUBeKo

Hintergrund

Bewegung ist über eine Reihe sozialökologischer Bedingungsfaktoren zu verstehen, an welchen eine erfolgreiche Bewegungsförderung ansetzen muss. Kommunen nehmen dabei eine bedeutende Rolle ein, da sie gesundheitsförderliche Verhältnisse ermöglichen können. Häufig wird die Konzipierung, Umsetzung und Evaluierung sozialökologischer Ansätze jedoch nicht systematisch und theoriegeleitet abgeleitet. Veränderungen in den Verhältnissen werden durch das Verhalten und die Entscheidungen sog. „change agents“ bzw. kommunaler Entscheidungstragender, wie z. B. Bürgermeister:innen, beeinflusst. Daher ist es wichtig, Einflussfaktoren auf Entscheidungsprozesse zu kennen, um Überzeugungsarbeit für Bewegungsförderung in der Kommune zu leisten. Zudem braucht es Multiplikator:innen (z. B. Mitarbeitende in Gesundheitsämtern), die Kompetenzen besitzen, verhältnisorientierte Interventionen in Kommunen systematisch umzusetzen.

Zielstellung und Projektverlauf

Das Forschungsprojekt „Entscheidungs- und Umsetzungsprozesse verhältnisorientierter Bewegungsförderung in der Kommune für mehr Chancengerechtigkeit systematisch planen und implementieren“ (EUBeKo) wurde im Rahmen des Förderschwerpunkts „Bewegung und Bewegungsförderung“ des Bundesministeriums für Gesundheit gefördert. In diesem Beitrag werden das Projekt EUBeKo mit seinen zwei Forschungsfragen zum einen nach der Rolle und den Kompetenzen von Multiplikator:innen und zum anderen nach den Einflussfaktoren auf kommunale Entscheidungsprozesse sowie die Planung und Umsetzung verhältnisorientierter Bewegungsförderung in zwei Modellkommunen als auch die Strategien der Dissemination (z. B. Projekt-Webseite) beschrieben.

Diskussion und Schlussfolgerungen

Zu den Stärken des Projekts zählt die systematische und theoriegeleitete Aufbereitung und Durchführung eines Prozesses verhältnisorientierter Bewegungsförderung in der Kommune mit besonderem Fokus auf Planungs- und Entscheidungsprozesse sowie auf die Zielgruppen der kommunalen Multiplikator:innen und Entscheidungstragenden. Herausforderungen finden sich im Theorie-Praxis-Transfer und in den Auswirkungen der COVID-19-Pandemie („coronavirus disease 2019“) auf die Projektumsetzung.

Physical Activity and Food Environments in and around Schools: A Case Study in Regional North-West Tasmania

A better understanding of the physical activity (PA) infrastructure in schools, the walkability of neighborhoods close to schools, and the food environments around schools, particularly in rural, socioeconomically challenged areas such as the North-West (NW) of Tasmania, could be important in the wider effort to improve the health of school-age children. Accordingly, this research aimed to assess PA resources, walkability, and food environments in and around schools in three socioeconomically disadvantaged, regional/rural Local Government Areas (LGAs) of Tasmania, Australia. A census of schools (including assessment of the PA infrastructure quality within school grounds), a walkability assessment, and a census of food outlets surrounding schools (through geospatial mapping) were executed. Most of the schools in the study region had access to an oval, basketball/volleyball/netball court, and free-standing exercise equipment. In all instances (i.e., regardless of school type), the quality of the available infrastructure was substantially higher than the number of incivilities observed. Most schools also had good (i.e., within the first four deciles) walkability. Numerous food outlets were within the walking zones of all schools in the study region, with an abundance of food outlets that predominantly sold processed unhealthy food.

International evaluation of the Microscale Audit of Pedestrian Streetscapes (MAPS) Global instrument: comparative assessment between local and remote online observers

OBJECTIVES

The use of online imagery by non-local observers to conduct remote, centralized collection of streetscape audit data in international studies has the potential to enhance efficiency of collection and comparability of such data for research on built environments and health. The objectives of the study were to measure (1) the consistency in responses between local in-field observers and non-local remote online observers and (2) the reliability between in-country online observers and non-local remote online observers using the Microscale Audit of Pedestrian Streetscapes Global tool to characterize pedestrian-related features along streets in five countries.

METHODS

Consistency and inter-rater reliability were analyzed between local and non-local observers on a pooled database of 200 routes in five study regions (Melbourne, Australia; Ghent, Belgium; Curitiba, Brazil; Hong Kong, China; and Valencia, Spain) for microscale environmental feature subscales and item-level variables using the intraclass correlation coefficient (ICC).

RESULTS

A local in-field versus remote online comparison had an ICC of 0.75 (95 % CI: 0.68-0.80) for the grand total score. An ICC of 0.91 (95 % CI: 0.88-0.93) was found for the local online versus remote online comparison. Positive subscales yielded stronger results in comparison to negative subscales, except for the similarly poor-performing positive aesthetics/social characteristics.

CONCLUSIONS

This study demonstrated remote audits of microscale built environments using online imagery had good reliability with local in-field audits and excellent reliability with local online audits. Results generally supported remote online environmental audits as comparable to local online audits. This identification of low-cost and efficient data acquisition methods is important for expanding research on microscale built environments and physical activity globally.

Study protocol: health survey of Sao Paulo: ISA-Physical Activity and Environment

Background

Many studies have investigated the association between the built environment and physical activity behavior in urban settings. However, most of the studies conducted in low- and middle-income countries were cross-sectional, which are limited to identify behavioral determinants. We propose a prospective cohort study to verify the relationship between built environment features and leisure-time and transport-related physical activity in adults from Sao Paulo city, Brazil.

Methods

Prospective multilevel cohort, denominated “ISA-Physical Activity and Environment”. It will build on the Health Survey of Sao Paulo in 2015 (“Inquérito de Saúde de São Paulo (ISA)” in Portuguese). The Health Survey of Sao Paulo, originally designed as a cross-sectional survey, had a multi-stage sample, covering 150 census tracts distributed in five health administrative areas. Data collection was performed by face-to-face interviews until December 2015 and the sample comprised 4043 individuals aged 12 years or more. The ISA-Physical Activity and Environment study will reassess people who are aged 18 years or more in 2020, including telephone and household interviews. The primary outcome will be leisure-time and transport-related physical activity, assessed through the International Physical Activity Questionnaire long version. Exposure variables will be built environment features in the areas participants live and work in the follow-up. Data analysis will include multivariate multilevel linear and logistic models. We will also conduct cost-effectiveness analysis and develop agent-based models to help inform decision-makers. The study will be conducted by an interdisciplinary research team specialized in physical activity epidemiology, nutritional epidemiology, georeferencing applied to health, statistics, agent-based modeling, public health policy, and health economics.

Discussion

There are few longitudinal studies on the relationship between the built environment and physical activity behavior in low- and middle-income countries. We believe that the ISA-Physical Activity and Environment study will contribute with important results for the progress of the knowledge in this field and for the implementation of policies that promote leisure-time physical activity and active travel in Sao Paulo and similar cities across the world.

Reliability of streetscape audits comparing on-street and online observations: MAPS-Global in 5 countries

BACKGROUND

Microscale environmental features are usually evaluated using direct on-street observations. This study assessed inter-rater reliability of the Microscale Audit of Pedestrian Streetscapes, Global version (MAPS-Global), in an international context, comparing on-street with more efficient online observation methods in five countries with varying levels of walkability.

METHODS

Data were collected along likely walking routes of study participants, from residential starting points toward commercial clusters in Melbourne (Australia), Ghent (Belgium), Curitiba (Brazil), Hong Kong (China), and Valencia (Spain). In-person on the street and online using Google Street View audits were carried out by two independent trained raters in each city. The final sample included 349 routes, 1228 street segments, 799 crossings, and 16 cul-de-sacs. Inter-rater reliability analyses were performed using Kappa statistics or Intraclass Correlation Coefficients (ICC).

RESULTS

Overall mean assessment times were the same for on-street and online evaluations (22 ± 12 min). Only a few subscales had Kappa or ICC values < 0.70, with aesthetic and social environment variables having the lowest overall reliability values, though still in the "good to excellent" category. Overall scores for each section (route, segment, crossing) showed good to excellent reliability (ICCs: 0.813, 0.929 and 0.885, respectively), and the MAPS-Global grand score had excellent reliability (ICC: 0.861) between the two methods.

CONCLUSIONS

MAPS-Global is a feasible and reliable instrument that can be used both on-street and online to analyze microscale environmental characteristics in diverse international urban settings.

International Physical Activity and Built Environment Study of adolescents: IPEN Adolescent design, protocol and measures

INTRODUCTION

Only international studies can provide the full variability of built environments and accurately estimate effect sizes of relations between contrasting environments and health-related outcomes. The aims of the International Physical Activity and Environment Study of Adolescents (IPEN Adolescent) are to estimate the strength, shape and generalisability of associations of the community environment (geographic information systems (GIS)-based and self-reported) with physical activity and sedentary behaviour (accelerometer-measured and self-reported) and weight status (normal/overweight/obese).

METHODS AND ANALYSIS

The IPEN Adolescent observational, cross-sectional, multicountry study involves recruiting adolescent participants (ages 11-19 years) and one parent/guardian from neighbourhoods selected to ensure wide variations in walkability and socioeconomic status using common protocols and measures. Fifteen geographically, economically and culturally diverse countries, from six continents, participated: Australia, Bangladesh, Belgium, Brazil, Czech Republic, Denmark, Hong Kong SAR, India, Israel, Malaysia, New Zealand, Nigeria, Portugal, Spain and USA. Countries provided survey and accelerometer data (15 countries), GIS data (11), global positioning system data (10), and pedestrian environment audit data (8). A sample of n=6950 (52.6% female; mean age=14.5, SD=1.7) adolescents provided survey data, n=4852 had 4 or more 8+ hours valid days of accelerometer data, and n=5473 had GIS measures. Physical activity and sedentary behaviour were measured by waist-worn ActiGraph accelerometers and self-reports, and body mass index was used to categorise weight status.

ETHICS AND DISSEMINATION

Ethical approval was received from each study site's Institutional Review Board for their in-country studies. Informed assent by adolescents and consent by parents was obtained for all participants. No personally identifiable information was transferred to the IPEN coordinating centre for pooled datasets. Results will be communicated through standard scientific channels and findings used to advance the science of environmental correlates of physical activity, sedentary behaviour and weight status, with the ultimate goal to stimulate and guide actions to create more activity-supportive environments internationally.

Transit environments for physical activity: Relationship between micro-scale built environment features surrounding light rail stations and ridership in Houston, Texas

INTRODUCTION

Health professionals promote transport-related physical activity because travelers oftentimes walk or bike to and from transit stops or stations. Although previous studies have examined the associations between macro-scale built environment features surrounding light rail transit (LRT) stations (e.g., density) and LRT ridership, this study examined the associations between numerous micro-scale features (e.g., street-level noise pollution) and ridership.

METHODS

This analysis originated from the Houston Travel-Related Activity in Neighborhoods (TRAIN) Study, a project evaluating how an LRT extension impacted adult physical activity in Houston, Texas. In 2014, researchers used the Analytic Audit Tool to quantify 58 micro-scale built environment features within six categories: Land Use Environment, Transportation Environment, Facilities, Aesthetics, Signage, and Social Environment. Feature data were obtained from 590 street segments within 0.25 miles of 22 LRT stations. For each station, separate composite indices were created per category by averaging the computed feature scores (1-7) within each category, with higher scores signifying more physical activity-promoting features. Station-level LRT ridership data were obtained from monthly ridership reports for the 12 months following station opening. Linear mixed models were constructed to examine the associations of the six built environment categories with ridership, adjusting for season, weekday vs. weekend day, and station as a random intercept.

RESULTS

Holding all other variables constant, every one-unit increase in composite index scores for Transportation Environment and Social Environment was associated with an increase in daily ridership by 425 and 488 riders, respectively (p < 0.05). Every one-unit increase in composite index score for Signage was associated with a decrease of 722 riders daily (p < 0.05). The relations of Land Use Environment, Facilities, and Aesthetics with ridership were statistically null (p > 0.05).

CONCLUSIONS

Enhancements to the Transportation Environment and Social Environment may slightly increase overall LRT ridership, and consequently, utilitarian physical activity.

Different neighborhood walkability indexes for active commuting to school are necessary for urban and rural children and adolescents

BACKGROUND

Literature focusing on youth has reported limited evidence and non-conclusive associations between neighborhood walkability measures and active commuting to and from school (ACS). Moreover, there is a lack of studies evaluating both macro- and micro-scale environmental factors of the neighborhood when ACS is analyzed. Likewise, most studies on built environment attributes and ACS focus on urban areas, whereas there is a lack of studies analyzing rural residential locations. Moreover, the relationship between built environment attributes and ACS may differ in children and adolescents. Hence, this study aimed to develop walkability indexes in relation to ACS for urban and rural children and adolescents, including both macro- and micro-scale school-neighborhood factors.

METHODS

A cross-sectional study of 4593 participants from Spain with a mean age of 12.2 (SD 3.6) years was carried out. Macro-scale environmental factors were evaluated using geographic information system data, and micro-scale factors were measured using observational procedures. Socio-demographic characteristics and ACS were assessed with a questionnaire. Several linear regression models were conducted, including all the possible combinations of six or less built environment factors in order to find the best walkability index.

RESULTS

Analyses showed that intersection density, number of four-way intersections, and residential density were positively related to ACS in urban participants, but negatively in rural participants. In rural children, positive streetscape characteristics, number of regulated crossings, traffic calming features, traffic lanes, and parking street buffers were also negatively related to ACS. In urban participants, other different factors were positively related to ACS: number of regulated crossings, positive streetscape characteristics, or crossing quality. Land use mix acted as a positive predictor only in urban adolescents. Distance to the school was a negative predictor on all the walkability indexes. However, aesthetic and social characteristics were not included in any of the indexes.

CONCLUSIONS

Interventions focusing on improving built environments to increase ACS behavior need to have a better understanding of the walkability components that are specifically relevant to urban or rural samples.

A Scoping Review of Bikeability Assessment Methods

Bicycling holds promise as a healthy and sustainable means of transportation and physical activity. Despite the growing interest in community-based environmental approaches to promoting physical activity, bikeability has received relatively little attention. This paper provides a scoping review of the instruments developed to measure bikeability along with practice-based analyses of the tools related to user expertise, estimated cost, and required time to implement. The review summarizes the literature, identifies research gaps, and informs stakeholders with articles from EBSCO and transportation databases published after 2003 when the previous bikeability instrument review paper was published. Data extraction included the tool name, data collection method, study location, data collection scale, type of measure, and description. Two reviewers independently reviewed articles included in the full text review, and the inter-rater agreement exceeded 90%. The database search yielded 388 unique articles, and 17 met the inclusion/exclusion criteria. Most of the studies, 11 of 17, were applied to settings outside of the U.S. Five studies employed a self-report survey, and five studies examined bikeability using geospatial data, like GIS. Seven studies used a direct observation audit tool-one specifically using a mobile app and another using virtual observation techniques with Google Street View. Bikeability tools are useful for assessing communities and their supports for bicycling. Our primary finding is that advances in technology over the past two decades have driven innovative and useful methodologies, in a variety of disciplines, for assessing the environment, but more consensus is needed to provide a universal definition of bikeability.

A Conceptual Framework for Modelling Safe Walking and Cycling Routes to High Schools

Active transport to or from school presents an opportunity for adolescents to engage in daily physical activity. Multiple factors influence whether adolescents actively travel to/from school. Creating safe walking and cycling routes to school is a promising strategy to increase rates of active transport. This article presents a comprehensive conceptual framework for modelling safe walking and cycling routes to high schools. The framework has been developed based on several existing relevant frameworks including (a) ecological models, (b) the “Five Es” (engineering, education, enforcement, encouragement, and evaluation) framework of transport planning, and (c) a travel mode choice framework for school travel. The framework identifies built environment features (land use mix, pedestrian/cycling infrastructure, neighbourhood aesthetics, and accessibility to local facilities) and traffic safety factors (traffic volume and speed, safe road crossings, and quality of path surface) to be considered when modelling safe walking/cycling routes to high schools. Future research should test this framework using real-world data in different geographical settings and with a combination of tools for the assessment of both macro-scale and micro-scale built environment features. To be effective, the modelling and creation of safe routes to high schools should be complemented by other interventions, including education, enforcement, and encouragement in order to minimise safety concerns and promote active transport.

Built Environment, Physical Activity, and Obesity: Findings from the International Physical Activity and Environment Network (IPEN) Adult Study

Creating more physical activity-supportive built environments is recommended by the World Health Organization for controlling noncommunicable diseases. The IPEN (International Physical Activity and Environment Network) Adult Study was undertaken to provide international evidence on associations of built environments with physical activity and weight status in 12 countries on 5 continents (n > 14,000). This article presents reanalyzed data from eight primary papers to identify patterns of findings across studies. Neighborhood environment attributes, whether measured objectively or by self-report, were strongly related to all physical activity outcomes (accelerometer-assessed total physical activity, reported walking for transport and leisure) and meaningfully related to overweight/obesity. Multivariable indexes of built environment variables were more strongly related to most outcomes than were single-environment variables. Designing activity-supportive built environments should be a higher international health priority. Results provide evidence in support of global initiatives to increase physical activity and control noncommunicable diseases while achieving sustainable development goals.

A GIS-Based Method for Analysing the Association Between School-Built Environment and Home-School Route Measures with Active Commuting to School in Urban Children and Adolescents

In the current call for a greater human health and well-being as a sustainable development goal, to encourage active commuting to and from school (ACS) seems to be a key factor. Research focusing on the analysis of the association between environmental factors and ACS in children and adolescents has reported limited and inconclusive evidence, so more knowledge is needed about it. The main aim of this study is to examine the association between different built environmental factors of both school neighbourhood and home-school route with ACS of children and adolescents belonging to urban areas. The ACS level was evaluated using a self-reported questionnaire. Built environment variables (i.e., density of residents, street connectivity and mixed land use) within a school catchment area and home-school route characteristics (i.e., distance and pedestrian route directness—PRD) were measured using a geographic information system (GIS) and examined together with ACS levels. Subsequently, the association between environmental factors and ACS was analysed by binary logistic regression. Several cut-off points of the route measures were explored using receiver operating characteristic (ROC) curves. In addition, the PRD was further studied regarding different thresholds. The results showed that 70.5% of the participants were active and there were significant associations between most environmental factors and ACS. Most participants walked to school when routes were short (distance variable in children: OR = 0.980; p = 0.038; and adolescents: OR = 0.866; p < 0.001) and partially direct (PRD variable in children: OR = 11.334; p < 0.001; and adolescents: OR = 3.513; p < 0.001), the latter specially for children. Mixed land uses (OR = 2.037; p < 0.001) and a high density of street intersections (OR = 1.640; p < 0.001) clearly encouraged adolescents walking and slightly discouraged children walking (OR = 0.657, p = 0.010; and OR = 0.692, p = 0.025, respectively). The assessment of ACS together with the environmental factors using GIS separately for children and adolescents can inform future friendly and sustainable communities.

School Neighbourhood Built Environment Assessment for Adolescents' Active Transport to School: Modification of an Environmental Audit Tool and Protocol (MAPS Global-SN)

School neighbourhood built environments (SN-BE) can influence adolescents' active transport to school habits. Typically, SN-BE assessment has involved micro-scale (i.e., environmental audits) or macro-scale (Geographic Information Systems (GIS)) assessment tools. However, existing environmental audits are time/resource-intensive and not specific to school neighbourhoods, while GIS databases are not generally purposed to include micro-scale data. This study evaluated the inter-rater reliability and feasibility of using a modified audit tool and protocol (Microscale Audit of Pedestrian Streetscapes Global-School Neighbourhood (MAPS Global-SN)) to assess the SN-BE of twelve secondary schools in Dunedin, New Zealand. Correlations between MAPS Global-SN and GIS measures of the SN-BE were also examined. Specifically, MAPS Global-SN audit and GIS spatial analysis (intersection density, residential density, land use mix, walkability) was conducted within a 0.5 km street-network buffer-zone around all twelve schools. Based on investigator and expert consultation, MAPS Global-SN included eight modifications to both auditing processes and items. Inter-rater reliability data was collected from two independent auditors across two schools. The feasibility of a condensed audit protocol (auditing one side of each street segment in the neighbourhood, compared to both sides) was also assessed. Results indicated the modified MAPS Global-SN tool had good to excellent inter-rater reliability and the condensed MAPS Global-SN audit protocol appeared to sufficiently represent the micro-scale SN-BE. Results also highlighted the complementary nature of micro- and macro-scale assessments. Further recommendations for SN-BE assessment are discussed.

International Mind, Activities and Urban Places (iMAP) study: methods of a cohort study on environmental and lifestyle influences on brain and cognitive health

INTRODUCTION

Numerous studies have found associations between characteristics of urban environments and risk factors for dementia and cognitive decline, such as physical inactivity and obesity. However, the contribution of urban environments to brain and cognitive health has been seldom examined directly. This cohort study investigates the extent to which and how a wide range of characteristics of urban environments influence brain and cognitive health via lifestyle behaviours in mid-aged and older adults in three cities across three continents.

METHODS AND ANALYSIS

Participants aged 50-79 years and living in preselected areas stratified by walkability, air pollution and socioeconomic status are being recruited in Melbourne (Australia), Barcelona (Spain) and Hong Kong (China) (n=1800 total; 600 per site). Two assessments taken 24 months apart will capture changes in brain and cognitive health. Cognitive function is gauged with a battery of eight standardised tests. Brain health is assessed using MRI scans in a subset of participants. Information on participants' visited locations is collected via an interactive web-based mapping application and smartphone geolocation data. Environmental characteristics of visited locations, including the built and natural environments and their by-products (e.g., air pollution), are assessed using geographical information systems, online environmental audits and self-reports. Data on travel and lifestyle behaviours (e.g., physical and social activities) and participants' characteristics (e.g., sociodemographics) are collected using objective and/or self-report measures.

ETHICS AND DISSEMINATION

The study has been approved by the Human Research Ethics Committee of the Australian Catholic University, the Institutional Review Board of the University of Hong Kong and the Parc de Salut Mar Clinical Research Ethics Committee of the Government of Catalonia. Results will be communicated through standard scientific channels. Methods will be made freely available via a study-dedicated website.

TRIAL REGISTRATION NUMBER

ACTRN12619000817145.

Neighborhood Walkability in Relation to Knee and Low Back Pain in Older People: A Multilevel Cross-Sectional Study from the JAGES

Few studies have focused on a relationship between the built environment and musculoskeletal pain. This study aimed to investigate an association between neighborhood walkability and knee and low back pain in older people. Data were derived from the Japan Gerontological Evaluation Study (JAGES) 2013, a population-based study of independently living people ≥65 years old. A cross-sectional multilevel analysis was performed, of 22,892 participants in 792 neighborhoods. Neighborhood walkability was assessed by residents' perceptions and population density. Dependent variables were knee and low back pain restricting daily activities within the past year. The prevalence of knee pain was 26.2% and of low back pain 29.3%. After adjusting for sociodemographic covariates, the prevalence ratio (PR) of knee and low back pain was significantly lower in neighborhoods with better access to parks and sidewalks, good access to fresh food stores, and higher population densities. After additionally adjusting for population density, easier walking in neighborhoods without slopes or stairs was significantly inversely correlated with knee pain (PR 0.91, 95% confidence interval 0.85-0.99). Neighborhoods with walkability enhanced by good access to parks and sidewalks and fresh food stores, easy walking without slopes or stairs, and high population densities, had lower prevalences of knee and low back pain among older people. Further studies should examine environmental determinants of pain.

The Health and economic effects of light rail lines: design, methods, and protocol for a natural experiment

BACKGROUND

The health impacts of community design have been studied extensively over the past two decades. In particular, public transportation use is associated with more walking between transit stops and shops, work, home and other destinations. Change in transit access has been linked with physical activity and obesity but seldom to health outcomes and associated costs, especially within a causal framework. Health related fiscal impacts of transit investment should be a key consideration in major transit investment decisions.

METHODS

The Rails & Health study is a natural experiment evaluating changes in clinical measures, health care utilization and health care costs among Kaiser Permanente Northwest (KPNW) members following the opening of a new light rail transit (LRT) line in Portland, Oregon. The study is prospectively following 3036 adults exposed to the new LRT line and a similar cohort of 4386 adults who do not live close to the new line. Individual-level outcomes and covariates are extracted from the electronic medical record at KPNW, including member demographics and comorbidities, blood pressure, body mass index, lipids, glycosylated hemoglobin, and health care utilization and costs. In addition, participants are surveyed about additional demographics, travel patterns, physical activity (PA), and perceived neighborhood walkability. In a subsample of the study population, we are collecting direct measures of travel-related behavior-physical activity (accelerometry), global positioning system (GPS) tracking, and travel diaries-to document mechanisms responsible for observed changes in health outcomes and cost. Comprehensive measures of the built environment at baseline and after rail construction are also collected. Statistical analyses will (1) examine the effects of opening a new LRT line on chronic disease indicators, health care utilization, and health care costs and (2) evaluate the degree to which observed effects of the LRT line on health measures and costs are mediated by changes in total and transportation-associated PA.

DISCUSSION

The results of the Rails & Health study will provide urban planners, transportation engineers, health practitioners, developers, and decision makers with critical information needed to document how transit investments impact population health and related costs.