Predictors of healthier and more sustainable school travel mode profiles among Hong Kong adolescents

Associations between parental perceptions of neighbourhood environments and active travel to school: IPEN Adolescent study

BACKGROUND

Studies of correlates of active transport to and from school (ATS) focus mainly on children, have a limited conceptualisation of ATS trips, lack heterogeneity in built environments, and rarely consider effect modifiers. This study aimed to estimate associations of parent-perceived neighbourhood environment characteristics with self-reported ATS among adolescents from 14 countries, and whether associations differ by sex, city/region, and distance to school.

METHODS

Observational cross-sectional design. Data were from the International Physical activity and Environment Network (IPEN) Adolescent study and included 6302 adolescents (mean age 14.5 ± 1.7 years, 54% girls) and a caretaker from 16 diverse sites. Adolescents self-reported usual travel to and from school by walking and bicycling (days/week) and time it would take to walk. Parents completed the Neighbourhood Environment Walkability Scale for Youth (13 scores computed). Generalised additive mixed models estimated associations of parent neighbourhood perceptions with 1) any active transport to/from school, 2) regular walking (5-10 times/week), 3) regular cycling to/from school, and 4) profiles of ATS generated using latent profile analyses. Interactions were also explored.

RESULTS

Overall, 58.7% reported any ATS, 39.9% regularly walked, 7.7% regularly cycled, and four profiles of ATS were identified: walk to and from school; walk from school; cycle to and from school; no ATS. Distance to school was negatively associated with all outcomes, though evidence was weak for regular cycling to/from school. Land use mix - diversity was positively related to all ATS outcomes except those related to cycling. Accessibility and walking facilities were associated with higher odds of any ATS, regular walking to/from school, and the profile walking to and from school. Residential density was negatively related to regular cycling to/from school. Positive associations were observed between traffic safety and any ATS, and between safety from crime, aesthetics, and odds of regular cycling to/from school. Distance to school, adolescent sex, and city moderated several associations.

CONCLUSIONS

Parent perceptions of compact, mixed-use development, walking facilities, and both traffic and crime-related safety were important supportive correlates of a range of ATS outcomes among adolescents in high- and low-middle-income countries. Policies that achieve these attributes should be prioritised to support more widespread ATS.

Associations of perceived neighbourhood and home environments with sedentary behaviour among adolescents in 14 countries: the IPEN adolescent cross sectional observational study

BACKGROUND

Understanding environmental correlates of sedentary behaviour (SB) among young people is important as such data can identify approaches to limit sedentary time. This paper estimates associations of parent-reported neighbourhood and adolescent-reported home environments with SB among adolescents aged 11-19 years from 14 countries.

METHODS

In the International Physical activity and the Environment Network (IPEN) Adolescent Study (an observational, cross-sectional multi-country study), adolescents wore a triaxial accelerometer for seven days that assessed sedentary time (ST). Adolescents completed survey measures of sedentary behaviour (SB) related to recreational screen time and sitting time in motor vehicles. Parents and adolescents completed surveys assessing neighbourhood and home environments. Accelerometer based ST was available in 3,982 adolescents while survey data were available for 6,302 dyads. We estimated the total and direct effects of each environmental attribute on ST and SB. Sex of the adolescent and city/country were examined as moderators.

RESULTS

The average ST in adolescents from 14 countries ranged from 7.8 to 10.5 h/day. Personal social media was the only significant correlate of total ST across both sexes. With respect to self-reported SB, adolescents accumulated an average of 3.8 h of non-school screen time per day and nearly 40 min of transport-related sitting time. Screen time was associated with all home environment variables, including social media account, as well as land use mix-diversity, traffic safety, and crime safety. Transport-related sitting time was related to land use mix-diversity, recreation facilities, walking facilities, and pedestrian infrastructure, but no home environment variables. City/country and sex were significant moderators of several associations.

CONCLUSIONS

Both home and neighbourhood environment features were related to ST and SB. Having social media accounts emerged as a major contributor towards sedentarism in adolescents.

Associations between school-level environment and individual-level factors of walking and cycling to school in Canadian youth

Identifying individual-level and school-level correlates of walking and cycling to school remains a public health priority as only one in four Canadian youth actively travels to school. This study aimed to estimate the prevalence of Canadian youth in grades 6 to 10 who walk, cycle, or use motorised transport to go to school, and to examine if school neighbourhood walkability, neighbourhood-level and individual-level correlates are associated with mode of transportation to school. Data come from the 2017/2018 Health Behaviour in School-aged Children study. The walkability of the schools' neighbourhood was measured using the Canadian Active Living Environments (Can-ALE) index. We observed that only 22.4% and 4.2% of youth walked and cycled to school, respectively. Most (73.4%) used motorised transport to school, including 53.2% of youth who lived less than 5 minutes from school. Schools located in neighbourhoods with higher Can-ALE classes (i.e., higher walkability) were positively associated with walking to school. No statistically significant association between school walkability and cycling to school was observed. Individual-level socioeconomic status (SES) was associated with walking, but not cycling, to school. Conversely, neighbourhood-level SES was associated with cycling, but not with walking, to school. Correlates of walking to school differed from those for cycling to school, suggesting that different approaches to promoting active transportation are needed.

Gender-specific social and environmental correlates of active travel to school in four European countries: the HBSC Study

Introduction

Despite the health benefits, a large proportion of girls and boys in Europe do not travel to school actively. A better understanding of the correlates associated with this behavior could guide interventions. This study examines perceived social and environmental correlates of active travel to school (ACTS) from the 2017/18 Health Behavior in School-Aged Children (HBSC) survey in four European countries, with a special emphasis on gender differences (n = 22,023).

Methods

Logistic regression was conducted to analyze associations between the perceived importance of each correlate and ACTS behavior for 11-, 13-, and 15-year-old girls and boys from Germany, Czechia, Poland, and Slovakia. All models were adjusted for age, family affluence, and meeting World Health Organization recommendations for moderate-to-vigorous physical activity.

Results

Rates of ACTS significantly differed between girls and boys. In Czechia, 65% of girls and boys traveled to school actively, followed by Slovakia (61.4% girls and 58.4% boys), Poland (57.7% girls and 60.2% boys), and Germany (42.6% girls and 48.6% boys). Girls were less likely to actively travel to school compared to boys (odds ratio [OR]: 0.92, 95% confidence interval [CI]: 0.87-0.97). Increasing age (OR: 0.95, 95% CI: 0.93-0.97) and a greater distance to school index (OR: 0.89, 95% CI: 0.88-0.90) were both negatively associated with ACTS. The perceived importance of living closer to school and of road and neighborhood safety was positively associated with ACTS, with a stronger association in boys than in girls for neighborhood safety. On the contrary, the perceived importance of having people to walk with was negatively associated with ACTS, with a stronger association in girls (OR: 0.74, 95% CI: 0.65-0.84) than in boys (OR: 0.77, 95% CI: 0.66-0.88).

Discussion

This study provides insights into perceived social and environmental correlates associated with ACTS behavior. Future research should include gender-specific perceptions and more in-depth investigations of correlates encouraging ACTS, especially considering social aspects, safety issues, and the structuring of the environment in different cultural settings.

Modelling count, bounded and skewed continuous outcomes in physical activity research: beyond linear regression models

BACKGROUND

Inference using standard linear regression models (LMs) relies on assumptions that are rarely satisfied in practice. Substantial departures, if not addressed, have serious impacts on any inference and conclusions; potentially rendering them invalid and misleading. Count, bounded and skewed outcomes, common in physical activity research, can substantially violate LM assumptions. A common approach to handle these is to transform the outcome and apply a LM. However, a transformation may not suffice.

METHODS

In this paper, we introduce the generalized linear model (GLM), a generalization of the LM, as an approach for the appropriate modelling of count and non-normally distributed (i.e., bounded and skewed) outcomes. Using data from a study of physical activity among older adults, we demonstrate appropriate methods to analyse count, bounded and skewed outcomes.

RESULTS

We show how fitting an LM when inappropriate, especially for the type of outcomes commonly encountered in physical activity research, substantially impacts the analysis, inference, and conclusions compared to a GLM.

CONCLUSIONS

GLMs which more appropriately model non-normally distributed response variables should be considered as more suitable approaches for managing count, bounded and skewed outcomes rather than simply relying on transformations. We recommend that physical activity researchers add the GLM to their statistical toolboxes and become aware of situations when GLMs are a better method than traditional approaches for modeling count, bounded and skewed outcomes.

Neighborhood Built and Social Environment Influences on Lifestyle Behaviors among College Students in a High-Density City: A Photovoice Study

Based on the social ecological approach, a photovoice study was conducted to explore how neighborhood built and social environments facilitate or hinder college students' lifestyle behaviors, including physical activity, active transportation, and dietary behavior. A total of 37 college students took photos about neighborhood built and social environments that may affect their physical activity, dietary behavior, and active transportation, and shared their perceptions about how neighborhood built and social environments influence their lifestyle behaviors. Our findings demonstrated that the availability and accessibility of services, school facilities, and home facilities affected physical activity and dietary behaviors among college students. Moreover, the well-developed transportation facilities and networks benefit college students' active transportation. Environments-based interventions are recommended in future research to better understand the associations between neighborhood built and social environments and lifestyle behaviors in college students.

Sedentary behavior and cardiovascular disease risk: An evolutionary perspective

A ubiquitous aspect of contemporary societies is sedentary behavior (SB), defined as low intensity activities in a seated, reclined, or supine posture. Leading public health agencies, including the World Health Organization, have recognized the strong association between SB and poor health outcomes, particularly cardiovascular disease. However, while public health agencies have begun to advocate for “reductions” in SB, the current US guidelines are typically vague and non-specific. There is good reasoning behind this non-committal advocacy—there is limited mechanistic and clinical evidence to support policy development. To guide SB policy development, it is important to first consider the origins and evolution of SB, including the following: 1) is SB really a novel/contemporary behavior? i.e., how has this behavior evolved? 2) how did our ancestors sit and in what contexts? 3) how does SB interact with 24-hour activity behaviors, including physical activity and sleep? 4) what other historical and contemporary facets of life interact with SB? and 5) in what context do these behaviors occur and how might they provide different evolutionarily novel stressors? This perspective article will synthesize the available evidence that addresses these questions and stimulate discussion pertaining to the lessons that we can learn from an historical and evolutionary perspective. Last, it will outline the gaps in current SB interruption literature that are hindering development of feasible SB reduction policy.

Descriptive epidemiology of the prevalence of adolescent active travel to school in Asia: a cross-sectional study from 31 countries

OBJECTIVE

This study aimed to examine the prevalence of adolescent active travel to school (ATS) across 31 countries and territories in Asia, overall and by age group, sex and body mass index (BMI) category.

DESIGN

Cross-sectional study.

SETTING

31 Asian countries.

PARTICIPANTS

152 368 adolescents aged 13-17 years with complete data for age, sex, measured weight and height and active travel to school from 31 Asian countries from the Global School-based student Health Survey (GSHS).

PRIMARY OUTCOME

Self-reported active travel to school categorised into passive (0 days) and active (1-7 days).

RESULTS

Overall prevalence of adolescent ATS in Asia based on random-effect meta-analysis was 55%, ranging from 18% (UAE) to 84% (Myanmar). There was limited subregional variation: 47% in the Eastern Mediterranean (EM), 56% in the South East Asia and 64% in the Western Pacific. Summarised by random-effect meta-analysis, being an older adolescent aged 16 years and older (vs younger age below 16 years: OR: 1.08; 95% CI: 1.00 to 1.16) was positively associated with ATS. This association was strongest in EM countries. Summarised by random-effect meta-analysis, females (vs males: OR: 0.79; 95% CI: 0.71 to 0.89) and adolescents with overweight/obesity (vs underweight and normal BMI: OR: 0.92; 95% CI: 0.86 to 0.99) were less likely to use ATS. Association with sex was strongest in EM countries. Heterogeneity was considerable in all meta-analyses.

CONCLUSION

The prevalence of adolescent ATS in Asia varies substantially. Overall, older and male adolescents, and adolescents with underweight and normal BMI category are more likely to actively travel to school. However, the main contributor to differences in ATS between and within regions remain unknown. Although there is substantial scope for improving ATS rates in Asia, any policy actions and interventions should be cognisant of local built, social and natural environmental contexts that may influence active travel behaviour.

Environmental Issues Are Health Issues

Abstract. Increasing demands on ecosystems, decreasing biodiversity, and climate change are among the most pressing environmental issues of our time. As changing weather conditions are leading to increased vector-borne diseases and heat- and flood-related deaths, it is entering collective consciousness: environmental issues are human health issues. In public health, the field addressing these issues is known as environmental health. This field addresses both the effects people have on their environment as well as the effects of the environment on people. Psychology, as a discipline concerned with explaining, predicting, and changing behavior has much to contribute to these issues because human behavior is key in promoting environmental health. To date, however, an integrative view of environmental health in psychology is lacking, hampering urgently needed progress. In this paper, we review how the environment and human health are intertwined, and that much can be gained through a systemic view of environmental health in psychology. Based on a review of the literature, we suggest that psychologists unite efforts to promote an integrative science and practice of environmental health psychology, and jointly address environmental-health related behavior. The research agenda for this field will include integrating behavior change theory and intervention approaches. Thereby, psychology can potentially make an important contribution to sustained environmental health for generations to come.

Active Transportation to School. Utopia or a Strategy for a Healthy Life in Adolescence

The way adolescents travel to school can be an important contribution to achieving their daily physical activity recommendations. The main objective of this research is to know which variables are associated with the mode of transportation used to and from school by Portuguese adolescents. The 2018 Health Behaviour in School-aged Children questionnaire was applied to 5695 adolescents with an average age of 15.5 (SD ± 1.8), 53.9% of whom were female. The associations were studied by applying χ2 tests and multivariate logistic regression models. In this study, 36.5% of the participants reported walking or cycling to school. Active transportation to school is associated with age (OR = 1.3; p < 0.05), sufficient physical activity (OR = 1.2; p < 0.05), adequate number of hours of sleep (OR = 1.2; p < 0.05), perception of happiness (OR = 1.2; p < 0.05) and living near the school (OR = 2.4; p < 0.05). The results revealed that adolescents' choice to travel to/from school using an active mode of transportation increased with age, physical activity, hours of sleep, perception of happiness, and living near the school.

Are school-based measures of walkability and greenness associated with modes of commuting to school? Findings from a student survey in Ontario, Canada

OBJECTIVES

In Canada, students are increasingly reliant on motorized vehicles to commute to school, and few meet the recommended overall physical activity guidelines. Infrastructure and built environments around schools may promote active commuting to and from school, thereby increasing physical activity. To date, few Canadian studies have examined this research question.

METHODS

This study is a cross-sectional analysis of 11,006 students, aged 11-20, who participated in the 2016/2017 Ontario Student Drug Use and Health Survey. The remote sensing-derived Normalized Difference Vegetation Index (NDVI), at a buffer of 500 m from the schools' locations, was used to characterize greenness, while the 2016 Canadian Active Living Environments (Can-ALE) measure was used for walkability. Students were asked about their mode of regular commuting to school, and to provide information on several socio-demographic variables. Multivariable logistic regression models were used to quantify associations between active commuting and greenness and the Can-ALE. The resulting odds ratios, and their 95% confidence intervals, were adjusted for a series of risk factors that were collected from the survey.

RESULTS

Overall, 21% of students reported active commuting (biking or walking) to school, and this prevalence decreased with increasing age. Students whose schools had higher Can-ALE scores were more likely to be active commuters. Specifically, the adjusted odds ratio (OR) of being an active commuter for schools in the highest quartile of the Can-ALE was 2.11 (95% CI = 1.64, 2.72) when compared with those in the lowest. For children, aged 11-14 years, who attended schools in high dwelling density areas, a higher odds of active commuting was observed among those in the upper quartile of greenness relative to the lowest (OR = 1.41; 95% CI = 0.92, 2.15). In contrast, for lower dwelling density areas, greenness was inversely associated with active commuting across all ages.

CONCLUSION

Our findings suggest that students attending schools with higher Can-ALE scores are more likely to actively commute to school, and that positive impacts of greenness on active commuting are evident only in younger children in more densely populated areas. Future studies should collect more detailed data on residential measures of the built environment, safety, distance between home and school, and mixed modes of commuting behaviours.

Family, school and individual characteristics associated with adolescents' physical activity at school in Hong Kong: the iHealt(H) study

BACKGROUND

Adolescents (11-18-year-olds) are at risk of physical inactivity. There is limited knowledge of physical activity (PA) levels among adolescents in the school setting in Hong Kong. We developed and tested a novel theoretical model of how household/family characteristics, school-level social and physical environmental factors and individual adolescent's characteristics impact on their school-based PA during and after school hours.

METHODS

Cross-sectional study participants were Hong Kong adolescents attending secondary school, paired with their parent/caregiver (n = 1299 dyads). Parents survey-reported on household/family characteristics, parental PA and rules related to PA. Adolescents survey-reported on school PA-friendly policy, PA equipment at school (combined to create PA-friendly index), social support for PA from peers, athletic ability, attitude to and enjoyment of PA. Adolescents self-reported their school-based PA during school hours (physical education; recess) and after school (sports teams/classes). Objectively-measured moderate-to-vigorous PA (MVPA) was measured using accelerometers for a sub-sample of adolescents (n = 588). Generalized additive mixed models were used to estimate how household/family-level and school-level factors, and adolescents' individual characteristics were related to adolescents' school-based PA in Hong Kong, and to identify potential mediators of these associations.

RESULTS

A complex network of potential pathways of influence on adolescents' school-based PA was identified. Overall, most of the significant effects were indirect ones. However, there were far fewer significant pathways between household/family characteristics and objectively-measured MVPA at school than there were for self-reported PA at school. In fact, there were no indirect pathways between these variables and MVPA at school. Gender disparities among pathways were identified. For example, school PA-friendly index was significantly associated with MVPA after school only among girls (eb = 1.06, 95%CI (1.02,1.12)).

CONCLUSIONS

Key points of intervention identified by our study may be in the re-design of PE classes so that adolescents spend more time being physically active during these classes, and promotion of active play during recess. Further research measuring amount, intensity and location of adolescents' PA using accelerometer and Global Positioning Systems is required in Hong Kong, as well as observational studies of PA during PE classes and in the schoolyard during recess, to guide the design of PA interventions.

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.

Profiles of bystanders' motivation to defend school bully victims from a self-determination perspective

This study was aimed at exploring which latent profiles emerge based on ratings of self‐determined motivation to defend victims of bullying, and to explore if they are related to bystander roles and victimization in bullying, as well as student–teacher relations. Data were collected from 1,800 Swedish and Italian students, with an age range between 10 and 18 years (M = 12.6, standard deviation = 1.74). The students completed a survey in their classrooms. Latent profile analysis was used to explore the possible clusters of individuals with similar ratings on the motivational variables. Multivariate analysis of variances were conducted to explore differences between the profiles in relation to their roles when witnessing bullying and to student–teacher relationships. Four latent profiles emerged. The profiles represented respondents (a) high in prosocial motivation, (b) high in externally extrinsic motivation, (c) intermediate in externally extrinsic motivation, and (d) with identified/introjected motivation. Multivariate analyses showed that reports of bystander roles when witnessing bullying, teacher–student relationships, and bullying victimization, significantly differed over the motivational profiles. The bystanders were unevenly distributed across the four groups and most individuals were categorized in the prosocial motivation group. Female and male bystanders were evenly distributed across clusters. The prosocial motivation group experienced victimization to a lesser extent than the other profile groups. Students in the intermediate externally extrinsic group were more likely to take the pro‐bully and outsider role during bullying. Concerning student–teacher relationships, the prosocial motivation group reported the closest relationships with their teachers, while the intermediate externally extrinsic group reported the most conflictual relationships.

Sociodemographic and Built Environment Associates of Travel to School by Car among New Zealand Adolescents: Meta-Analysis

Travelling to school by car diminishes opportunities for physical activity and contributes to traffic congestion and associated noise and air pollution. This meta-analysis examined sociodemographic characteristics and built environment associates of travelling to school by car compared to using active transport among New Zealand (NZ) adolescents. Four NZ studies (2163 adolescents) provided data on participants' mode of travel to school, individual and school sociodemographic characteristics, distance to school and home-neighbourhood built-environment features. A one-step meta-analysis using individual participant data was performed in SAS. A final multivariable model was developed using stepwise logistic regression. Overall, 60.6% of participants travelled to school by car. When compared with active transport, travelling to school by car was positively associated with distance to school. Participants residing in neighbourhoods with high intersection density and attending medium deprivation schools were less likely to travel to school by car compared with their counterparts. Distance to school, school level deprivation and low home neighbourhood intersection density are associated with higher likelihood of car travel to school compared with active transport among NZ adolescents. Comprehensive interventions focusing on both social and built environment factors are needed to reduce car travel to school.

Development and validation of the neighborhood environment walkability scale for youth across six continents

BACKGROUND

The IPEN International Physical Activity and Environment Network Adolescent project was conducted using common study protocols to document the strength, shape, and generalizability of associations of perceived neighborhood environment attributes with adolescents' physical activity and overweight/obesity using data from 15 countries. Countries did not use identical versions of the Neighborhood Environment Walkability Scale for Youth (NEWS-Y) to measure perceived neighborhood environment attributes. Therefore, this study derived a measurement model for NEWS-Y items common to all IPEN Adolescent countries and developed a scoring protocol for the IPEN Adolescent version of the NEWS-Y (NEWS-Y-IPEN) that maximizes between-country comparability of responses. Additionally, this study examined between- and within-country variability, and construct validity of the NEWS-Y-IPEN subscales in relation to neighborhood-level socio-economic status and walkability.

METHODS

Adolescents and one of their parents (N = 5714 dyads) were recruited from neighborhoods varying in walkability and socio-economic status. To measure perceived neighborhood environment, 14 countries administered the NEWS-Y to parents and one country to adolescents. Confirmatory factor analysis was used to derive comparable country-specific measurement models of the NEWS-Y-IPEN. Country-specific standard deviations quantified within-country variability in the NEWS-Y-IPEN subscales, while linear mixed models determined the percentage of subscale variance due to between-country differences. To examine the construct validity of NEWS-Y-IPEN subscales, we estimated their associations with the categorical measures of area-level walkability and socio-economic status.

RESULTS

Final country-specific measurement models of the factor-analyzable NEWS-Y-IPEN items provided acceptable levels of fit to the data and shared the same factorial structure with five latent factors (Accessibility and walking facilities; Traffic safety; Pedestrian infrastructure and safety; Safety from crime; and Aesthetics). All subscales showed sufficient levels of within-country variability. Residential density had the highest level of between-country variability. Associations between NEWS-Y-IPEN subscales and area-level walkability and socio-economic status provided strong evidence of construct validity.

CONCLUSIONS

A robust measurement model and common scoring protocol of NEWS-Y for the IPEN Adolescent project (NEWS-Y-IPEN) were derived. The NEWS-Y-IPEN possesses good factorial and construct validity, and is able to capture between-country variability in perceived neighborhood environments. Future studies employing NEWS-Y-IPEN should use the proposed scoring protocol to facilitate cross-study comparisons and interpretation of findings.