A systematic review of the effect of infrastructural interventions to promote cycling: strengthening causal inference from observational data

Methods used to conceptualize dimensions of health equity impacts of public health interventions in systematic reviews

OBJECTIVES

Our aims were to, first, identify and summarize the use of methods, frameworks, and tools as a conceptual basis for investigating dimensions of equity impacts of public health interventions in systematic reviews including an equity focus. These include PROGRESS-Plus, which identifies key sociodemographic characteristics that determine health outcomes. Second, we aimed to document challenges and opportunities encountered in the application of such methods, as reported in systematic reviews.

STUDY DESIGN AND SETTING

We conducted a methodological study, comprising an overview of systematic reviews with a focus on, or that aimed to assess, the equity impacts of public health interventions. We used electronic searches of the Cochrane Database of Systematic Reviews, the Database of Promoting Health Effectiveness Reviews (DoPHER), and the Finding Accessible Inequalities Research in Public Health Database, supplemented with automated searches of the OpenAlex dataset. An active learning algorithm was used to prioritize title-abstract records for manual screening against eligibility criteria. We extracted and analyzed a core dataset from a purposively selected sample of reviews, to summarize key characteristics and approaches to conceptualizing investigations of equity.

RESULTS

We assessed 322 full-text reports for eligibility, from which we included 120 reports of systematic reviews. PROGRESS-Plus was the only formalized framework used to conceptualize dimensions of equity impacts. Most reviews were able to apply their intended methods to at least some degree. Where intended methods were unable to be applied fully, this was usually because primary research studies did not report the necessary information. A general rationale for focusing on equity impacts was often included, but few reviews explicitly justified their focus on (or exclusion of) specific dimensions. In addition to practical challenges such as data not being available, authors highlighted significant measurement and conceptual issues with applying these methods which may impair the ability to investigate and interpret differential impacts within and between studies. These issues included investigating constructs that lack standardized operationalization and measurement, and the complex nature of differential impacts, with dimensions that may interact with one another, as well as with particular temporal, personal, social or geographic contexts.

CONCLUSION

PROGRESS-Plus is the predominant framework used in systematic reviews to conceptualize differential impacts of public health interventions by dimensions of equity. It appears sufficiently broad to encompass dimensions of equity examined in most investigations of this kind. However, PROGRESS-Plus does not necessarily ensure or guide critical thinking about more complex pathways, including interactions between dimensions of equity, and with wider contextual factors, and important practical, measurement and conceptual challenges remain. The findings from investigations of equity impacts in systematic reviews could be made more useful through more explicitly rationalized and considered approaches to the design, conduct and reporting of both primary research and the reviews themselves.

Associations between gentrification, census tract-level socioeconomic status, and cycling infrastructure expansions in Montreal, Canada

Background

Cycling infrastructure investments support active transportation, improve population health, and reduce health inequities. This study examines the relationship between changes in cycling infrastructure (2011-2016) and census tract (CT)-level measures of material deprivation, visible minorities, and gentrification in Montreal.

Methods

Our outcomes are the length of protected bike lanes, cyclist-only paths, multi-use paths, and on-street bike lanes in 2011, and change in total length of bike lanes between 2011 and 2016 at the CT level. Census data provided measures of the level of material deprivation and of the percentage of visible minorities in 2011, and if a CT gentrified between 2011 and 2016. Using a hurdle modeling approach, we explore associations among these CT-level socioeconomic measures, gentrification status, baseline cycling infrastructure (2011), and its changes (2011-2016). We further tested if these associations varied depending on the baseline level of existing infrastructure, to assess if areas with originally less resources benefited less or more.

Results

In 2011, CTs with higher level of material deprivation or greater percentages of visible minorities had less cycling infrastructure. Overall, between 2011 and 2016, cycling infrastructure increased from 7.0% to 10.9% of the road network, but the implementation of new cycling infrastructure in CTs with no pre-existing cycling infrastructure in 2011 was less likely to occur in CTs with a higher percentage of visible minorities. High-income CTs that were ineligible for gentrification between 2011 and 2016 benefited less from new cycling infrastructure implementations compared to low-income CTs that were not gentrified during the same period.

Conclusion

Montreal's municipal cycling infrastructure programs did not exacerbate socioeconomic disparities in cycling infrastructure from 2011 to 2016 in CTs with pre-existing infrastructure. However, it is crucial to prioritize the implementation of cycling infrastructure in CTs with high populations of visible minorities, particularly in CTs where no cycling infrastructure currently exists.

Does cycle commuting reduce the risk of mental ill-health? An instrumental variable analysis using distance to nearest cycle path

BACKGROUND

Previous studies have linked cycling with improved mental wellbeing but these studies tend to use cross-sectional survey data that have small sample sizes and self-reported health measures, and are potentially susceptible to omitted-variable bias and reverse causation. We use an instrumental variable approach and an objective measure of mental ill-health taken from linked administrative data to ask: 'Does cycle commuting reduce the risk of mental ill-health?'

METHODS

Our study links data on commuting in Edinburgh and Glasgow from the Scottish population census with mental health prescriptions from the National Health Service Prescribing Information System records. We use road distance from home to nearest cycle path as an instrumental variable for cycle commuting.

RESULTS

In total, 378 253 people aged 16-74 years living and working in the City of Edinburgh and Glasgow City council areas at the 2011 census were included in our study; 1.85% of commuters in Glasgow and 4.8% of commuters in Edinburgh cycled to work. Amongst cyclists, 9% had a prescription for mental health compared with 14% amongst non-cyclists. Using a bivariate probit model, we estimate a mean average reduction in prescriptions for antidepressants and/or anxiolytics in the 5 years following the census of -15.1% (95% CI: -15.3% to -15.0%) amongst cycle commuters compared with those who use any other mode to commute.

CONCLUSIONS

This work suggests that cycle commuting is causally related to reduced mental ill-health and provides further evidence in support of the promotion of active travel to encourage commuters travelling shorter distances to shift to cycle commutes.

Does the Installation or the Improvement of Existing Outdoor Parks Increase Physical Activity Levels? A Systematic Review

Investment in outdoor parks is proposed as a promising large-scale strategy to promote physical activity (PA). This study aimed to systematically review the impact of park renovations or installing new ones in increasing PA. Searches were conducted using predefined terms in three databases (PubMed, Scopus, and Web of Science) in March 2022. Studies examining the effectiveness of park renovations or developing new ones in increasing PA and having control or comparison were eligible for inclusion. Study quality was assessed using the Quality Assessment Tool for Quantitative Studies. Data were extracted from the included records using a predefined extraction table. The database search yielded 959 records, and 26 were included. For park renovations (n = 17), 11 (65%) studies presented findings supporting a positive effect on PA. The other six (35%) studies found no PA benefits when compared to control or pre-renovations/improvement levels. Regarding new installations (n = 9), five (56%) studies presented improvements in PA, and four (44%) did not. A promising positive impact of park renovations and new installations on park use and PA was observed. The review findings reflect the need to understand the context, daily routines, and interests of the surrounding population before renovating or installing new outdoor parks.

Integrating Equity Into Bicycle Infrastructure, Planning, and Programming: A Mixed Methods Exploration of Implementation Among Participants in the Bicycle Friendly Community Program

INTRODUCTION

Integrating equity considerations into bicycle infrastructure, planning, and programming is essential to increase bicycling and reduce physical inactivity-related health disparities. However, little is known about communities' experiences with activities that promote equity considerations in bicycle infrastructure, planning, and programming or about barriers and facilitators to such considerations. The objective of this project was to gain in-depth understanding of the experiences, barriers, and facilitators that communities encounter with integrating equity considerations into bicycle infrastructure, planning, and programming.

METHODS

We administered a web-based survey in 2022 to assess communities' experiences with 31 equity-focused activities in 3 areas: 1) community engagement, education, events, and programming (community engagement); 2) data collection, evaluation, and goal setting (data); and 3) infrastructure, facilities, and physical amenities (infrastructure). Respondents were people who represented communities in the US that participated in the League of American Bicyclists' Bicycle Friendly Community (BFC) Program. We then conducted 6 focus groups with a subset of survey respondents to explore barriers and facilitators to implementing equity-focused activities.

RESULTS

Survey respondents (N = 194) had experience with a mean (SD) of 5.9 (5.7) equity-focused activities. Focus group participants (N = 30) identified themes related to community engagement (outreach to and engagement of underrepresented communities, cultural perceptions of bicycling, and funding and support for community rides and programs); data (locally relevant data); and infrastructure (political will, community design, and infrastructure). They described barriers and facilitators for each.

CONCLUSION

Communities are challenged with integrating equity into bicycle infrastructure, planning, and programming. Multicomponent strategies with support from entities such as the BFC program will be required to make progress.

''I felt marvellous e-cycling. If I had long hair I would have flicked it": a qualitative investigation of the factors associated with e-cycling engagement among adults with type 2 diabetes

Background

Physical activity (PA) is a key component in the management of type 2 diabetes. However, this population have low rates of PA engagement. Electrically assisted cycling has been identified as a means through which to increase PA by incorporating activity into daily life, while overcoming some of the barriers to conventional cycling. The determinants of e-cycling among people living with chronic disease are largely unknown. The aim of this research was to explore the determinants of e-cycling among individuals with type 2 diabetes using the Theoretical Domains Framework (TDF) and the Capability, Opportunity and Motivation for Behaviour change model (COM-B). This information is important for determining the suitability of future e-cycling initiatives and, if appropriate, inform future e-cycling interventions.

Method

One-to-one semi structured interviews were conducted with 16 participants from the e-cycling arm of a pilot randomised controlled trial between September 2019 and April 2020. The TDF was used to develop the interview guide. The framework method of analysis was used, incorporating both deductive and inductive reasoning. A conceptual model of the factors that influence e-cycling in this population was created.

Results

The most commonly reported TDF domains were skills, knowledge, belief about capabilities, belief about consequences and environmental context and resources. Specifically, e-bike training facilitated e-cycling engagement by providing participants with the skills, knowledge, and confidence needed to ride the e-bike and ride on the road. In addition, the enjoyment of e-cycling was a key facilitator to engagement. Participants engaged in e-cycling to improve their health rather than for environmental reasons. Most barriers to e-cycling related to the natural or physical environment.

Conclusion

This study provides insight into the personal, social, and environmental factors associated with e-cycling in this population. The findings of this study can be used to develop a more refined e-cycling intervention targeting the factors identified as influencing e-cycling engagement. In addition, this information will help in the selection of mechanistic outcome measures for evaluation.

Effects of major urban redesign on sedentary behavior, physical activity, active transport and health-related quality of life in adults

BACKGROUND

The built environment is increasingly recognized as a determinant for health and health behaviors. Existing evidence regarding the relationship between environment and health (behaviors) is varying in significance and magnitude, and more high-quality longitudinal studies are needed. The aim of this study was to evaluate the effects of a major urban redesign project on physical activity (PA), sedentary behavior (SB), active transport (AT), health-related quality of life (HRQOL), social activities (SA) and meaningfulness, at 29-39 months after opening of the reconstructed area.

METHODS

PA and AT were measured using accelerometers and GPS loggers. HRQOL and sociodemographic characteristics were assessed using questionnaires. In total, 241 participants provided valid data at baseline and follow-up. We distinguished three groups, based on proximity to the intervention area: maximal exposure group, minimal exposure group and no exposure group.

RESULTS

Both the maximal and minimal exposure groups showed significantly different trends regarding transport-based PA levels compared to the no exposure group. In the exposure groups SB decreased, while it increased in the no exposure group. Also, transport-based light intensity PA remained stable in the exposure groups, while it significantly decreased in the no exposure group. No intervention effects were found for total daily PA levels. Scores on SA and meaningfulness increased in the maximal exposure group and decreased in the minimal and no exposure group, but changes were not statistically significant.

CONCLUSION

The results of this study emphasize the potential of the built environment in changing SB and highlights the relevance of longer-term follow-up measurements to explore the full potential of urban redesign projects.

TRIAL REGISTRATION

This research was retrospectively registered at the Netherlands Trial Register (NL8108).

Impact of structural-level environmental interventions on physical activity: a systematic review

OBJECTIVE

To determine the effectiveness of structural-level environmental interventions on the changes in PA levels in the populations examined.

METHODS

Natural experiments that involve environmental intervention with structural modification were included. The primary outcome PA levels with consideration of both objective and subjective measurements. An electronic search was carried out in Medline/Pubmed, SCIENCE DIRECT, WEB OF SCIENCE, and CINAHL up to January 2022. Two reviewers screened titles and abstracts, selected studies, extracted relevant data, and examined study quality. A qualitative synthesis was performed.

RESULTS

Twenty-six articles were included. The structural-level environmental interventions included 4 fundamental areas: schools, work environments, streets or cities, and neighborhoods or parks. Of the 26 studies, 21 examined outdoor environments like parks, cities, pedestrian walkways, or steps, while 5 examined indoor or closed environments like schools and workplaces revealing that structural-level environmental interventions improve PA levels with the greatest effect in parks and active transportation. A risk of bias is inherent in natural experiments which is a limitation of this study. In schools and work areas, there is evidence of both decrease in sedentary time and an increase in PA related to environmental modifications.

CONCLUSION

Structural-level environmental modifications in parks and active transportation demonstrated greater effects in promoting PA. Environmental modifications can impact physical activity in the population. Given that the economic and cultural setting is a key variable when considering the effectiveness of structural interventions, and since only 1 of the 26 reviewed articles included such data, more studies examining economic factors are needed especially in low- and middle-income countries like in South America.

TRIAL REGISTRATION

PROSPERO CRD42021229718.

Barriers and enablers to local active travel during COVID-19: A case study of Streetspace interventions in two London boroughs

Background: During the coronavirus disease 2019 (COVID-19) pandemic, UK local authorities increased emergency active travel interventions. This study aimed to understand what aspects of temporary Streetspace for London schemes represent barriers or enablers to walking and cycling for short local journeys. Methods: Focusing on two Inner London boroughs, we conducted 21 semi-structured stakeholder interviews and sampled 885 public comments about Streetspace schemes. We triangulated the data in a thematic analysis to identify barriers and enablers, which were categorised using the Capability, Opportunity, Motivation, Behaviour (COM-B) model. Results: Opportunity and motivation factors were reflected in the barriers (accessibility and integration of the schemes; controversy, dissatisfaction, and doubt) and enablers (new routes and spaces; sustainability and health beliefs) and mixed themes (changes to traffic and appeal of the area; feelings of safety). Capability was not reflected in the main themes. Conclusions: Although aspects of Streetspace schemes were seen to enable active travel, our findings suggest that additional processes to address the acceptability, fairness, and unintended consequences of emergency interventions will be important to their long-term success for health and sustainability.

A UWB/INS Trajectory Tracking System Application in a Cycling Safety Study

This paper focuses on the safety issue for cyclists and pedestrians at unsignalized intersections. The cycling speed needs to be calmed when approaching the intersection. This study proposes and deploys an integrated portable ultra-wideband/inertial navigation system (UWB/INS) to extract cycling trajectories for a cycling safety study. The system is based on open-source hardware and delivers an open-source code for an adaptive Kalman filter to enhance positioning precision for data quality assurance at an outdoor experimental site. The results demonstrate that the system can deliver reliable trajectories for low-mobility objects. To mitigate accident risk and severity, varied cycling speed calming measures are tested at an experimental site. Based on the trajectory data, the statistical features of cycling velocities are evaluated and compared. A new proposed geometric design is found to be most effective when compared with conventional traffic signs.

The role of neighbourhood design in cycling activity during COVID-19: An exploration of the Melbourne experience

COVID-19 restrictions imposed significant changes on human mobility patterns, with some studies finding significant increases or decreases in cycling. However, to date there is little understanding on how the neighbourhood-level built environment influenced cycling behaviour during the COVID-19 restrictions. As different neighbourhood have different built environment characteristics, it is possible that cycling trends varied across different built environment settings. We aimed to answer this question by examining recreational cycling during different stages of lockdown in Melbourne, Australia. We compared self-reported recreational cycling frequency (weekly) data from 1344 respondents between pre-COVID and two different stages in lockdown. We tested whether the built environment of their residential neighbourhood and different sociodemographic characteristics influenced leisure cycling rates and whether the effect of these factors varied between different stages of COVID-19 restriction. We found that cycling declined significantly during the two stages of COVID-19 lockdown. Cycling infrastructure density and connectivity are two built environment factors that had a significant effect on limiting the decline in leisure cycling during the pandemic. Furthermore, men and younger people had higher cycling rates in comparison to other groups, suggesting that restrictions on indoor activities and travel limits were not enough to encourage women or older people to cycle more during the pandemic.

Wave 1 results of the INTerventions, Research, and Action in Cities Team (INTERACT) cohort study: Examining spatio-temporal measures for urban environments and health

Built environment interventions have the potential to improve population health and reduce health inequities. The objective of this paper is to present the first wave of the INTErventions, Research, and Action in Cities Team (INTERACT) cohort studies in Victoria, Vancouver, Saskatoon, and Montreal, Canada. We examine how our cohorts compared to Canadian census data and present summary data for our outcomes of interest (physical activity, well-being, and social connectedness). We also compare location data and activity spaces from survey data, research-grade GPS and accelerometer devices, and a smartphone app, and compile measures of proximity to select built environment interventions.

Changes in physical activity after joining a bikeshare program: a cohort of new bikeshare users

Background

There are hundreds of bikeshare programs worldwide, yet few health-related evaluations have been conducted. We enrolled a cohort of new bikeshare members in Philadelphia (Pennsylvania, USA) to assess whether within-person moderate and vigorous physical activity (MVPA) increased with higher use of the program and whether effects differed for vulnerable sub-groups.

Methods

During 2015–2018, 1031 new members completed baseline and one-year follow-up online surveys regarding their personal characteristics and past 7-day MVPA minutes per week (minutes per week with- and without walking). Participants were linked to their bikeshare trips to objectively assess program use. Negative binomial (for continuous outcomes) and multinomial (for categorical outcomes) regression adjusted for person characteristics (socio-demographics, health), weather, biking-infrastructure, and baseline biking.

Results

Participant median age was 30, 25% were of Black or Latino race/ethnicity, and 30% were socioeconomically disadvantaged. By follow-up, personal bike ownership increased and 75% used bikeshare, although most used it infrequently. Per 10 day change in past year (PY) bikeshare use, non-walking MVPA min/wk increased 3% (roughly 6 min/wk, P < 0.014). More days of bikeshare was also associated with change from inactive to more active (odds ratio for ≥ 15 days in PY vs. no bikeshare use 1.80, CI 1.05–3.09, P < 0.03). Results were consistent across vulnerable sub-groups. In general, impacts on MVPA were similar when exposure was personal bike or bikeshare.

Conclusions

Bikeshare facilitated increases in cycling, slightly increased non-walking MVPA, and showed potential for activating inactive adults; however, for larger program impact, members will need to use it more frequently.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12966-022-01353-6.

InterMob: a 24-month randomised controlled trial comparing the effectiveness of an intervention including behavioural change techniques and free transport versus an intervention including air pollution awareness-raising on car use reduction among regular car users living in Grenoble, France

Background

Frequent car use contributes to health and environmental issues such as air pollution, climate change and obesity. Active and sustainable mobility (bike, walk, public transport, car sharing) may address these issues. Different strategies have been implemented in past research, involving hard levers, aimed at modifying the economical or geographical context (e.g., free public transport), and soft levers, aimed at modifying psychological processes (e.g., personalised transport advice). However, few studies have combined both hard and soft levers. In addition, few have used robust methodologies (e.g., randomised controlled trials), followed behavioural changes in the long-term, and been anchored in behaviour change theories. InterMob aims to address these limits by implementing a 24-month randomised controlled trial including hard and soft levers. The objectives of InterMob are to a) evaluate the effectiveness of an experimental arm versus an active controlled arm, and b) identify the processes of mobility change.

Methods

Regular car users living in Grenoble (N = 300) will be recruited and randomised to one of the two arms. The experimental arm consists in a six-month intervention combining hard levers (free access to transport/bikes), and soft levers (e.g., personalised transport advice). The control arm consists in a six-month intervention aimed at raising awareness on air pollution and its health effects. Both arms will include eight evaluation weeks (spread out over 24 months) based on a GPS, an accelerometer, and a pollution sensor. Moreover, participants will complete mobility logbooks and surveys measuring psychological constructs, socio-economical, and socio-spatial characteristics.

Discussion

InterMob will assess the effectiveness of two interventions aimed at reducing car use within regular car users in the short-, mid- and long-term. Moreover, InterMob will allow to better understand the psychological processes of behaviour change, and the socio-economical and geographical conditions under which the intervention is efficient in reducing car use. Finally, the benefits of mobility change in terms of physical activity, quality of life, and exposure to pollution will be quantified.

Trial registration

ClinicalTrials.gov: NCT05096000 on 27/10/2021 (retrospectively registered).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-14099-4.

Causal assessment in evidence synthesis: A methodological review of reviews

In fields (such as population health) where randomised trials are often lacking, systematic reviews (SRs) can harness diversity in study design, settings and populations to assess the evidence for a putative causal relationship. SRs may incorporate causal assessment approaches (CAAs), sometimes called 'causal reviews', but there is currently no consensus on how these should be conducted. We conducted a methodological review of self-identifying 'causal reviews' within the field of population health to establish: (1) which CAAs are used; (2) differences in how CAAs are implemented; (3) how methods were modified to incorporate causal assessment in SRs. Three databases were searched and two independent reviewers selected reviews for inclusion. Data were extracted using a standardised form and summarised using tabulation and narratively. Fifty-three reviews incorporated CAAs: 46/53 applied Bradford Hill (BH) viewpoints/criteria, with the remainder taking alternative approaches: Medical Research Council guidance on natural experiments (2/53, 3.8%); realist reviews (2/53, 3.8%); horizontal SRs (1/53, 1.9%); 'sign test' of causal mechanisms (1/53, 1.9%); and a causal cascade model (1/53, 1.9%). Though most SRs incorporated BH, there was variation in application and transparency. There was considerable overlap across the CAAs, with a trade-off between breadth (BH viewpoints considered a greater range of causal characteristics) and depth (many alternative CAAs focused on one viewpoint). Improved transparency in the implementation of CAA in SRs in needed to ensure their validity and allow robust assessments of causality within evidence synthesis.

Visualizing changes in physical activity behavioral patterns after redesigning urban infrastructure

The aim of this study was to explore effects of a major urban reconstruction on physical activity (PA) behavior by comparing PA intensity hotspots before and after the tunneling of a highway with a new infrastructure prioritized for walking and cycling. In total, 126 individuals participated before and after the tunneling. GPS loggers and accelerometers were used to assess location and PA levels. A geographic information system (GIS) was used to perform optimized hotspot analyses on PA data, both on transport and stationary data points. The results showed several changes in PA hotspots on trip data, even if total PA levels did not change. At follow-up, PA intensity hotspots were more connected, with the new infrastructure as a central connection. This was true for higher and lower educated individuals. Therefore, if changes in the built environment do not result in changes on population-level outcomes, this does not imply that they have no impact on behavior.

Preliminary Results of a Bicycle Training Course on Adults' Environmental Perceptions and Their Mode of Commuting

This study was designed to analyze the effects of a bicycle training course on both adults’ environmental perceptions and their mode of commuting. Four bicycle training courses for adults were conducted in Granada, Spain in April 2015 and May 2016. The course program was focused on developing practical skills and attitudes on road. From the initial 65 adults who started the course, only 35 adults met the inclusion criteria and were included in the study. Participants completed twice (i.e., before and after the course) a questionnaire about their perceptions of the environment, usual mode of commuting to daily destinations, and sociodemographic characteristics. After finishing the initial questionnaire, the participants completed a bicycle training course based on the methodology “Bikeability” with a duration of 6 h. The results suggest that participants improved their safety perception in relation to the level of crime in the participants’ neighborhood after the bicycle training course. Cycling training courses should last longer in order to produce changes in the mode of commuting and in the environmental perceptions.

Tunneling a crosstown highway: a natural experiment testing the longitudinal effect on physical activity and active transport

Background

In the city of Maastricht in the Netherlands, a highway crossing several deprived neighborhoods was tunneled in 2016. The vacant space on top of this tunnel was redesigned and prioritized for pedestrians and cyclists. The aim of this study was to evaluate the effect of this major infrastructural change, named the Green Carpet, on total and transport-based physical activity (PA) levels.

Methods

Participants (≥18 years) were part of one of three area-based exposure groups. The maximal exposure group lived in neighborhoods directly bordering the Green Carpet. The minimal exposure group consisted of individuals living at the other side of the city, and the no exposure group consisted of individuals living in a nearby city. Actual use of the new infrastructure was incorporated as a second measure of exposure. Data were collected before and 3-15 months after the opening of the Green Carpet. Device-based measurements were conducted to obtain PA levels and collect location data. Changes in PA over time and intervention effects were determined using linear mixed models.

Results

PA levels in the Green Carpet area increased for the maximal and minimal exposure groups, but did not lead to an increase in total or transport-based PA. For the no exposure group, transport-based MVPA decreased and transport-based SB increased. The significant interaction (time x exposure) for transport-based SB, indicated differences in trends between the no exposure and maximal exposure group (B=-3.59, 95% CI - 7.15; -0.02) and minimal exposure group (B= -4.02, 95% CI -7.85, -0.19). Trends in the results based on analyses focusing on actual use and non-use of the new infrastructure were similar to those of the area-based analyses.

Conclusions

Results suggest that the Green Carpet led to more PA in this specific area, but did not increase the total volume of PA. The area-based differences might reflect the differences between users and non-users, but we should be careful when interpreting these results, due to possible interference of selective mobility bias. This paper reflects that the relationship between infrastructure and PA is not unambiguous.

Trial registration

This research was retrospectively registered at the Netherlands Trial Register (NL8108).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12966-021-01180-1.

Developing System-Oriented Interventions and Policies to Reduce Car Dependency for Improved Population Health in Belfast: Study Protocol

Reducing car dependency requires orchestrated multi-sectoral, multi-policy action in a complex landscape. Thus, development of proposed interventions to reduce car dependency should be informed by systems thinking, complexity science, and socio-technical transition theory. We aim to co-design sustainable systems-oriented intervention approaches to reduce car dependency in Belfast. The study includes seven integrated tasks—1: Map stakeholders and partnerships influencing car dependency using stakeholder network analysis; 2: A review of systematic reviews regarding interventions to reduce car dependency; 3: Map-related policies via analysis of policy documents and semi-structured interviews; 4: A participatory group model building workshop to co-produce a shared understanding of the complex system perpetuating car dependency and a transition vision; 5: Using Discrete Choice Experiments, survey road users to evaluate the importance of transport infrastructure attributes on car dependency and on alternative modes of travel; 6: Citizen juries will ‘sense-check’ possible actions; and, 7: Stakeholders will interpret the findings, plan orchestrated multi-sectoral action, and agree on ways to sustain collaborations towards the common vision of reducing car dependency. We expect to attain a systemic view of the car dependency issue, potential intervention approaches to reduce it, and a framework for their integration through the co-ordination of stakeholder actions.

Evaluation of a New Urban Cycling Infrastructure in Caceres (Spain)

The purpose of the research is the evaluation of the impact of a new bike lane network built in Cáceres (Spain) in October 2019, a city with a weak tradition in the use of bicycles. Prior to the new project, the percentage of displacement by bicycle was under 0.2% (by contrast, private cars was 56%). The project has introduced a real network in 33 new streets and avenues, and 250 new parking places for bicycles. The impact has been evaluated by two online surveys, one conducted in November–December 2019 just after the inauguration, and the other conducted in January–February 2020. For that, the impact evolution after the first 3 months has also been evaluated. The result allows to analyze the citizens’ response to the new infrastructure; the main conclusion is that the effect of the built infrastructure is clearly positive in terms of new users, new potential users, and bike general image for the citizens. Moreover, this positive effect has grown after the first 3 months.

Implementation strategies used to implement nursing guidelines in daily practice: A systematic review

OBJECTIVES

Research specifically addressing implementation strategies regarding nursing guidelines is limited. The objective of this review was to provide an overview of strategies used to implement nursing guidelines in all nursing fields, as well as the effects of these strategies on patient-related nursing outcomes and guideline adherence. Ideally, the findings would help guideline developers, healthcare professionals and organizations to implement nursing guidelines in practice.

DESIGN

Systematic review. PROSPERO registration number: CRD42018104615.

DATA SOURCES

We searched the Embase, Medline, PsycINFO, Web of Science, Cochrane, CINAHL and Google Scholar databases until August 2019 as well as the reference lists of relevant articles.

REVIEW METHODS

Studies were included that described quantitative data on the effect of implementation strategies and implementation outcomes of any type of a nursing guideline in any setting. No language or date of publication restriction was used. The Cochrane Effective Practice and Organisation of Care taxonomy was used to categorize the implementation strategies. Studies were classified as effective if a significant change in either patient-related nursing outcomes or guideline adherence was described. Strength of the evidence was evaluated using the 'Cochrane risk of bias tool' for controlled studies, and the 'Newcastle-Ottawa Quality Assessment form' for cohort studies.

RESULTS

A total of 54 articles regarding 53 different guideline implementation studies were included. Fifteen were (cluster) Randomized Controlled Trials or controlled before-after studies and 38 studies had a before-after design. The topics of the implemented guidelines were diverse, mostly concerning skin care (n = 9) and infection prevention (n = 7). Studies were predominantly performed in hospitals (n = 34) and nursing homes (n = 11). Thirty studies showed a positive significant effect in either patient-related nursing outcomes or guideline adherence (68%, n = 36). The median number of implementation strategies used was 6 (IQR 4-8) per study. Educational strategies were used in nearly all studies (98.1%, n = 52), followed by deployment of local opinion leaders (54.7%, n = 29) and audit and feedback (41.5%, n = 22). Twenty-three (43.4%) studies performed a barrier assessment, nineteen used tailored strategies.

CONCLUSIONS

A wide variety of implementation strategies are used to implement nursing guidelines. Not one single strategy, or combination of strategies, can be linked directly to successful implementation of nursing guidelines. Overall, thirty-six studies (68%) reported a positive significant effect of the implementation of guidelines on patient-related nursing outcomes or guideline adherence. Future studies should use a standardized reporting checklist to ensure a detailed description of the used implementation strategies to increase reproducibility and understanding of outcomes.

Evaluating Cyclists’ Route Preferences with Respect to Infrastructure

Providing a sufficiently appropriate route environment is crucial to ensuring fair and safe biking, thus encouraging cycling as a sustainable mode of transport. At the same time, better understanding of cyclists’ preferences regarding the features of their routes and their infrastructure requirements is fundamental to evaluating improvement of the current infrastructure or the development of new infrastructure. The present study has two objectives. The first is to investigate cyclists’ route preferences by means of a choice experiment based on a stated preference survey. Subsequently, the second objective is to compare cyclist preferences in two countries with different cycling characteristics (both in infrastructure as well as cyclists’ behavior). For this purpose, a graphical online stated preferences survey was conducted in Greece and Germany. Within the framework of statistical analyses, multinomial mixed logit discrete choice models were developed that allow us to quantify the trade-offs of interest, while distinguishing between the preferences of different user groups. In addition, user requirements in Greece, as a country with a low cycling share and very little dedicated bike infrastructure, were compared to the requirements in Germany, where cycling is popular and the infrastructure is well developed. The results over the whole sample indicate that subgroups value infrastructure differently according to their specific needs. When looking at country specifics, users from Greece are significantly more willing to accept longer travel times in return for higher-quality facilities. The utility of low speed limits in mixed traffic is also different. In Germany, low speed limits offset the disturbance caused by motorized traffic, but in Greece they do not. Consequently, the results help to asses which types of infrastructure are most sustainable from a user perspective and help to set priorities when the aim is to adapt the road infrastructure efficiently in a stable strategy.