Cost-Effectiveness of Population-Level Physical Activity Interventions: A Systematic Review

Making cities mental health friendly for adolescents and young adults

Urban life shapes the mental health of city dwellers, and although cities provide access to health, education and economic gain, urban environments are often detrimental to mental health1,2. Increasing urbanization over the next three decades will be accompanied by a growing population of children and adolescents living in cities3. Shaping the aspects of urban life that influence youth mental health could have an enormous impact on adolescent well-being and adult trajectories4. We invited a multidisciplinary, global group of researchers, practitioners, advocates and young people to complete sequential surveys to identify and prioritize the characteristics of a mental health-friendly city for young people. Here we show a set of ranked characteristic statements, grouped by personal, interpersonal, community, organizational, policy and environmental domains of intervention. Life skills for personal development, valuing and accepting young people's ideas and choices, providing safe public space for social connection, employment and job security, centring youth input in urban planning and design, and addressing adverse social determinants were priorities by domain. We report the adversities that COVID-19 generated and link relevant actions to these data. Our findings highlight the need for intersectoral, multilevel intervention and for inclusive, equitable, participatory design of cities that support youth mental health.

Economic burden of low cardiorespiratory fitness in Canada

The objective of this study was to estimate health care and health-related productivity costs associated with low cardiorespiratory fitness (CRF) in Canadian adults. We also estimated costs that would be avoided by a 10 percentage point prevalence reduction in low CRF. A prevalence-based approach was used to estimate the economic costs associated with low CRF. Three pieces of information were used: (1) the pooled relative risk estimates of adverse health outcomes consistently associated with low CRF obtained from meta-analyses of prospective cohort studies; (2) the prevalence of low CRF in Canadian men and women obtained from a nationally representative sample; and (3) the direct (health care) and indirect (lost productivity due to premature mortality) costs of the adverse health outcomes based on the Economic Burden of Illness in Canada data. We estimated the total annual economic burden of low CRF in Canadian adults at CAD$3.6 billion, representing 2.7% of the overall Canadian burden of illness costs in 2021. The three most expensive chronic diseases attributable to low CRF were type 2 diabetes (CAD$1.3 billion), heart disease (CAD$701 million), and depression/anxiety (CAD$565 million). Prescription drug expenditures and hospital care expenditures were the main contributors to the total economic burden. An absolute 10% reduction in the prevalence of low CRF (from 45.5% to 35.5%) would save an estimated CAD$644 million per year in costs. In conclusion, low CRF is an important contributor to the economic burden of illness in Canada. Evidence-based and cost-effective strategies that aim to increase CRF at the population level may help alleviate health care costs and improve health.

Cost Analysis of a Culturally Appropriate, Community-Delivered Intervention to Increase Physical Activity

Purpose

Understand the cost of delivering existing community-based, no cost to participant, aerobic dance and yoga classes in an underserved, racial and ethnic minority community in the Midwest.

Design

Pilot 4-month observational, descriptive, cost analysis of community fitness classes.

Setting

Community-wide, group-based, fitness classes online, and in parks and community centers in traditionally Black neighborhoods in Kansas City.

Participants

Participants (N = 1428) were recruited from underserved, racial and ethnic minority areas of Kansas City, Missouri.

Intervention

Aerobic dance and yoga classes were provided free of charge to all residents of Kansas City, Missouri online and in-person. Each class was approximately 1 hour, with a warmup and cooldown. All classes were delivered by African American women.

Methods

Descriptive statistics of the costs for the program are presented. Cost per metabolic equivalents (MET) were calculated. Independent samples t-tests were conducted to examine differences between aerobic dance and yoga cost per MET.

Results

The total program costs were $10,759.88 USD, with 1428 participants attending 82 classes over the 4-month intervention. The cost per MET was $1.67, $1.11, and $0.74/MET-hour/session/attendee for low, moderate, and high-intensity aerobic dance, respectively, and $3.02/MET-hour/session/attendee for yoga. Aerobic dance had a significantly lower cost per MET than yoga ( t = 13.6, P < .001, t = 47.6, P < .001, t = 92.8, P < .001, for low, moderate, and high-intensity, respectively).

Conclusions

Delivering community-based, physical activity interventions in racial and ethnic minority communities is a potential way to increase physical activity. The costs of group-based fitness classes are similar to other physical activity interventions. Further research needs to be conducted on the costs to increase physical activity of traditionally underserved populations who suffer from higher rates of inactivity and comorbidities.

Associations Between Parent's Perceived Neighborhood Environment and Objectively Measured Walkability With Their Children's Physical Activity

BACKGROUND

Neighborhoods are one setting to promote children's physical activity. This study examined associations between neighborhood features and children's physical activity and whether season or socioeconomic status modified these associations.

METHODS

Parents (n = 641) of children aged 6-10 years completed the Neighborhood Environment Walkability Scale-Abbreviated. Walkability was objectively measured at 400, 800, and 1200 m around the centroid of participants' postal codes. Children's physical activity was measured via StepsCount pedometers and parental report. Regression analyses were performed with interaction terms for season and socioeconomic status. Multiple imputation was used primarily to triangulate the results for children with missing steps data (n = 192).

RESULTS

Higher perceived residential density and traffic hazards were significantly associated with lower squareroot transformed parental-reported physical activity and steps per day, respectively. Higher perceived aesthetics was associated with higher squareroot transformed parental-reported physical activity. Socioeconomic status modified 2 associations though they were not significant upon stratification. During winter months, better perceived infrastructure and safety for walking was associated with higher squareroot transformed parental-reported physical activity. No other significant associations emerged.

CONCLUSION

Residential density, traffic hazards, and aesthetics are important for children's physical activity. Few associations were modified by socioeconomic status or season. The need for objective and subjective measures of the neighborhood environment and children's physical activity is apparent.

Economic evaluation of a multi-strategy intervention that improves school-based physical activity policy implementation

BACKGROUND

Internationally, government policies mandating schools to provide students with opportunities to participate in physical activity are poorly implemented. The multi-component Physically Active Children in Education (PACE) intervention effectively assists schools to implement one such policy. We evaluated the value of investment by health service providers tasked with intervention delivery, and explored where adaptations might be targeted to reduce program costs for scale-up.

METHODS

A prospective trial-based economic evaluation of an implementation intervention in 61 primary schools in New South Wales (NSW), Australia. Schools were randomised to the PACE intervention or a wait-list control. PACE strategies included centralised technical assistance, ongoing consultation, principal's mandated change, identifying and preparing in-school champions, educational outreach visits, and provision of educational materials and equipment. Effectiveness was measured as the mean weekly minutes of physical activity implemented by classroom teachers, recorded in a daily log book at baseline and 12-month follow-up. Delivery costs (reported in $AUD, 2018) were evaluated from a public finance perspective. Cost data were used to calculate: total intervention cost, cost per strategy and incremental cost (overall across all schools and as an average per school). Incremental cost-effectiveness ratios (ICERs) were calculated as the incremental cost of delivering PACE divided by the estimated intervention effect.

RESULTS

PACE cost the health service provider a total of $35,692 (95% uncertainty interval [UI] $32,411, $38,331) to deliver; an average cost per school of $1151 (95%UI $1046, $1236). Training in-school champions was the largest contributor: $19,437 total; $627 ($0 to $648) average per school. Educational outreach was the second largest contributor: $4992 total; $161 ($0 to $528) average per school. The ICER was $29 (95%UI $17, $64) for every additional minute of weekly physical activity implemented per school.

CONCLUSION

PACE is a potentially cost-effective intervention for increasing schools implementation of a policy mandate. The investment required by the health service provider makes use of existing funding and infrastructure; the additional cost to assist schools to implement the policy is likely not that much. PACE strategies may be adapted to substantially improve delivery costs.

TRIAL REGISTRATION

Australia New Zealand Clinical Trials Registry ACTRN12617001265369; Prospectively registered 1st September 2017 https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373520.

Municipal resources to promote adult physical activity - a multilevel follow-up study

Background

In Finland, local authorities (municipalities) provide many services, including sports and physical activity facilities such as pedestrian and bicycle ways and lanes, parks, sports arenas and pools. This study aimed to determine whether local authorities can promote physical activity by allocating resources to physical activity facilities.

Methods

The data on municipality expenditure on physical activity and sports, number of sports associations receiving subsidies from the municipality, kilometers of ways for pedestrians and bicycles and hectares of parks in 1999 and 2010 were gathered from national registers. These data were combined using unique municipal codes with individual survey data on leisure-time physical activity (N = 3193) and commuting physical activity (N = 1394). Panel data on physical activity originated from a national health survey, the Health 2000 study, conducted in 2000–2001 and 2011–2012. We used the data of persons who answered the physical activity questions twice and had the same place of residence in both years. In the data, the individuals are nested within municipalities, and multilevel analyses could therefore be applied. The data comprised a two-wave panel and the individuals were followed over 11 years.

Results

The resources for physical activity varied between municipalities and years. Municipal expenditure for physical activity and total kilometers of pedestrian ways increased significantly during the 11 years, although a clear decrease was observed in individuals’ physical activity. In our models, individual characteristics including higher education level (OR 1.87) and better health status (OR 7.29) increased the odds of increasing physical activity. Female gender was associated with lower (OR 0.83) leisure-time physical activity. Living in rural areas (OR 0.37) decreased commuting physical activity, and age (OR 1.05) increased it. Women (OR 3.16) engaged in commuting physical activity more than men.

Conclusions

Individual-level factors were more important for physical activity than local resources. A large part of the variation in physical activity occurs between individuals, which suggests that some factors not detected in this study explain a large part of the overall variation in physical activity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13617-8.

Associations of park features with park use and park-based physical activity in an urban environment in Asia: A cross-sectional study

Park use is associated with health, yet our understanding of park features related to their use is limited. Singapore's parks were audited for 30 micro-features, then geospatial analysis characterized micro-features scores for parks nearest to participants' homes. Adults (3,435) reported their park use and park-based physical activity. Using linear regression models, we found living near a park with higher micro-features scores was associated with more time in parks and park-based physical activity. Specific micro-features were associated with more park time (wildlife areas, water features, forested areas, unpaved trails (2-2.6 h/month, p < 0.05)) and with physical activity in parks (water features, forested areas, large playground, open green spaces (1.8-2.2 h/month, p < 0.05)). These findings could inform parks planning to support population-health.

Results from Poland’s 2022 Report Card on Physical Activity for Children and Youth

This paper presents the methodology and results of Poland’s 2022 Report Card on physical activity (PA) of children and adolescents, as part of the Global Matrix (GM) 4.0 project. The aim of this paper is to discuss the current state of PA of children and adolescents in Poland. Grades were assigned to ten indicators of behaviors, physical fitness and sources of influence or settings, based on a synthesis of the best available data. In Poland two indicators: Overall Physical Activity (OPA) and Active Play were not assessed. Out of the other indicators, School received the highest score B+, whereas the other indicators had generally moderate to weak scores (between C+ and D). Scores for Organized Sport and Physical Activity, School and Physical Fitness indicators were improved compared with the previous GM, whereas scores for Active Transport and Government were lower. No positive changes regarding OPA or Sedentary Behaviors were observed. One of the limitations of PA promotion in Poland is that government-level PA policies are overly focused on organized PA and sport. Recommendations for improving PA monitoring in Poland, influencing PA behaviors and strengthening PA settings and sources of influence are also discussed.

Proposal of a Comprehensive and Multi-Component Approach to Promote Physical Activity among Japanese Office Workers: A Qualitative Focus Group Interview Study

Office workers spend up to two-thirds of their working hours sitting and are less physically active than other occupational groups. It is necessary to develop an effective approach to promote physical activity among office workers. We conducted a focus group interview with seven Japanese office workers to investigate the current status (topic 1) of, and their opinions on (topic 2), physical activity promotion programs in their workplace. Data were analyzed using qualitative data analysis. We classified the data from topic 1 into individual, socio-cultural, physical, and organizational environments. Most participants indicated that they spent a lot of time sitting and needed programs for a wide range of corresponding employee demands. We classified the data from topic 2 into capability, opportunity, and motivation. Most participants indicated that they wanted evidence-based information, a standing desk, and a conducive workplace environment to enhance physical activity. Thus, we proposed a comprehensive and multi-component approach comprising individual (information delivery), socio-cultural environment (team building, supportive atmosphere), physical environment (standing desk, use of poster), and organizational (incentive, encouraging message from an executive, workplace policy) strategies. Future studies should evaluate the effectiveness of this proposal.

Effectiveness of Physical Activity in Primary Prevention of Anxiety: Systematic Review and Meta-Analysis of Randomized Controlled Trials

The aim of this study was to evaluate the effectiveness of physical activity in the primary prevention of anxiety. A systematic review of randomized controlled trials (RCTs) was performed. RCTs were searched in seven electronic databases. We included RCTs that assessed either the incidence of anxiety or the reduction of anxiety symptoms which excluded participants with baseline anxiety. Measurements were required to have been made using validated instruments. Objective or subjective (with validated questionnaires) verification of the performance of physical activity was required. Three reviewers carried out the search, selection, data extraction, and risk assessment of Cochrane Collaboration’s tool simultaneously and independently, reaching an agreement in their discrepancies by consensus. In addition, a meta-analysis of fixed-effects model was carried out. Three RCTs met inclusion criteria, comprising 350 patients from 3 different countries. A meta-analysis was performed using five comparisons extracted from the selected studies, and the pooled standardized mean difference (SMD) was −0.18 (95% CI: −0.44; 0.07), p = 0.158. The heterogeneity was irrelevant, I² = 17.7% (p = 0.30). There is no evidence that anxiety can be prevented through physical activity, although the quality of evidence was very low.

Effects of Large-Scale Municipal Safe Routes to School Infrastructure on Student Active Travel and Physical Activity: Design, Methods, and Baseline Data of the Safe Travel Environment Evaluation in Texas Schools (STREETS) Natural Experiment

Past evaluations of Safe Routes to School (SRTS) programs have been relatively small in scope and have lacked objective measurements of physical activity. A 2016 Mobility Bond in Austin, Texas, USA, allocated USD 27.5 million for infrastructure changes to facilitate active commuting to schools (ACS). The Safe TRavel Environment Evaluation in Texas Schools (STREETS) study aims to determine the health effects of these infrastructure changes. The purpose of this paper is to describe the STREETS study design, methods, and selected baseline results. The STREETS study is comprised of two designs: (1) a serial cross-sectional design to assess changes in ACS prevalence, and (2) a quasi-experimental, prospective cohort to examine changes in physical activity. Differences between study arms (Austin SRTS and comparison) were assessed for school demographics, ACS, and school programs. At baseline, 14.3% of school trips were made by ACS, with non-significant differences between study arms. Only 26% of schools implemented ACS-related programs. Some significant differences across SRTS and comparison schools were identified for several school- and neighborhood-level characteristics. Substantial changes are needed across area schools and neighborhoods to promote optimum ACS. STREETS study longitudinal findings will be critical for informing optimal future implementations of SRTS programs.

Cost-analysis and cost-effectiveness of physical activity interventions in Brazilian primary health care: a randomised feasibility study

Physical exercise programs have been carried out in primary health care in Brazil and have provided good results in terms of effectiveness, their economic contribution has not been investigated yet. The aim of the study is to verify the feasibility of brief counseling physical activity intervention and to compare its economic cost and cost-effectiveness with supervised physical exercise intervention in primary care. A multi-arm parallel feasibility trial, with equal randomization [1:1:1] was conducted in Basic Health Units in Brazil. 61 participants were randomized in Brief Counseling Intervention (BCI), Supervised Physical Exercise Intervention (SPEI) and Control Group (CG). Interventions lasted one year. The BCI is more economical than the SPEI, costing around 50% less in the economic comparisons (session cost, annual cost and cost per participant annually). At leisure time, the cost to move one person to the physically active category at 12 months is estimated in R$369.00 for BCI and R$426.21 for the SPEI. The Incremental Cost-effectiveness Ratio (ICER) is R$310.32. The BCI is feasible and more economic, however, the cost effective is not that different. Thus, it is strongly recommended that the two interventions be offered at primary care in Brazil.

Is it worth it? Cost-effectiveness analysis of a commercial physical activity app

BACKGROUND

Government interest in investing in commercial physical activity apps has increased with little evidence of their cost-effectiveness. This is the first study to our knowledge to examine the cost-effectiveness of a commercial physical activity app (Carrot Rewards) despite there being over 100,000 in the major app stores.

METHODS

A cost-effectiveness analysis was performed to calculate the incremental cost-effectiveness ratio (ICER) of the app compared to a no-intervention reference scenario using a five-year time horizon. Primary data was collected between 2016 and 2017. Data synthesis, model creation, and statistical analyses were conducted between 2019 and 2020. An age-, sex-, and geography-dependent Markov model was developed assuming a public healthcare payer perspective. A closed cohort (n = 38,452) representing the population reached by Carrot Rewards in two Canadian provinces (British Columbia, Newfoundland & Labrador) at the time of a 12-month prospective study was used. Costs and effects were both discounted at 1.5% and expressed in 2015 Canadian dollars. Subgroup analyses were conducted to compare ICERs between provinces, sexes, age groups, and engagement levels.

RESULTS

Carrot Rewards had an ICER of $11,113 CAD per quality adjusted life year (QALY), well below a $50,000 CAD per QALY willingness-to-pay (WTP) threshold. Subgroup analyses revealed that the app had lower ICERs for British Columbians, females, highly engaged users, and adults aged 35-64 yrs., and was dominant for older adults (65 + yrs). Deterministic sensitivity analyses revealed that the ICER was most influenced by the relative risk of diabetes. Probabilistic sensitivity analyses revealed varying parameter estimates predominantly resulted in ICERs below the WTP threshold.

CONCLUSIONS

The Carrot Rewards app was cost-effective, and dominant for older adults. These results provide, for the first time, rigorous health economic evidence for a commercial physical activity app as part of public health programming.

Physical Activity Interventions for Primary Prevention in Adults: A Systematic Review of Randomized Controlled Trial-Based Economic Evaluations

BACKGROUND

Physical inactivity is a worldwide pandemic associated with major chronic diseases. Given limited resources, policy makers are in need of physical activity interventions that provide best value for money.

OBJECTIVE

To summarize evidence from RCT-based economic evaluations of primary prevention physical activity interventions in adult populations outside the workplace setting.

DESIGN

Systematic review of health economic evaluations. Incremental cost-effectiveness ratios (ICERs) in US$ per MET-hour gained were estimated on the basis of mean differences in intervention costs and standardized effects between intervention and control groups.

DATA SOURCES

Identification of relevant studies via systematic searches in electronic databases (MEDLINE, Embase and NHSEED).

ELIGIBILITY CRITERIA

Cost-effectiveness analyses in which all data (except unit costs) came from one RCT investigating physical activity interventions for primary prevention or health promotion in an adult population in high-income countries.

RESULTS

In twelve eligible studies, 22 interventions were investigated. Interventions were based on advice, goal setting and follow-up support, exercise classes, financial incentives or teaching on behavioral change. The ICER varied widely among the interventions and four interventions showed an ICER below the applied benchmark of US$0.44 to US$0.63 per MET-hour gained. These four interventions were based on individualized advice via print or web.

CONCLUSION

We found evidence from RCTs indicating cost-effectiveness of some physical activity interventions for primary prevention in adults. However, the majority of interventions assessed would not be cost-effective according to the benchmark applied. Furthermore, our study showed that trial-based evidence on cost-effectiveness of physical activity interventions is scarce. Therefore, we recommend that future studies investigating the efficacy or effectiveness of such interventions consider costs as an additional outcome and assess cost-effectiveness.

Taking a local government perspective for economic evaluation of a population-level programme to promote exercise

BACKGROUND

In order to tackle the issue of physical inactivity, local governments have implemented population-level programmes to promote exercise. While evidence is accumulating on the cost-effectiveness of these interventions, studies have typically adopted a health sector perspective for economic evaluation. This approach has been challenged as it does not allow for key concerns by local governments, which are primary stakeholders, to be addressed.

OBJECTIVES

To show how taking a local government perspective for economic evaluation can be implemented in practice and this may affect the economic conclusions.

METHODS

Based on data from a case study, the health equity impact of the intervention and its opportunity cost from a service provider viewpoint were assessed. The cost-effectiveness implications of a change in perspective were subsequently estimated by means of scenario analysis.

FINDINGS

The intervention was found to provide adult residents living in the most deprived city areas with greater health benefits compared with the rest of the population. However, a negative net equity impact was found in the short-term. The opportunity cost of the intervention was estimated to be substantially lower than its financial cost (£2.77 per person/year), with significant implications for decision-making.

CONCLUSIONS

Taking a local government perspective can affect the conclusions drawn from the economic evaluation of population-level programmes to promote exercise, and therefore influence decision making.

Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2021 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors related to cardiovascular disease.

RESULTS

Each of the 27 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

A systematic review of economic evaluations of public health interventions targeting alcohol, tobacco, illicit drug use and problematic gambling: Using a case study to assess transferability

AIMS

To identify and assess the cost-effectiveness of public health interventions targeting the use of alcohol, illicit drugs and tobacco, as well as problematic gambling behavior (ANDTS), and consider whether the results from these evaluations are transferable to the Swedish setting.

METHODS

A systematic review of economic evaluations within the area of ANDTS was conducted including studies published between January 2000 and November 2018, identified through Medline, PsychINFO, Web of Science, the National Health Service Economic Evaluation Database and Health Technology Assessment. The quality of relevant studies and the possibilities of transferring results were assessed using criteria set out by the Swedish Agency for Health Technology Assessment.

RESULTS

Out of 54 relevant studies, 39 were of moderate to high quality and included in the review, however none for problematic gambling. Eighty-one out of a total of 91 interventions were cost-effective. The interventions largely focusing on taxed-based policies or screening and brief interventions. Thirteen of these studies were deemed to have high potential for transferability, with effect estimates considered relevant, and with good feasibility for implementation in Sweden.

CONCLUSIONS

Interventions targeting alcohol- and illicit-drug use and tobacco use are cost-effective approaches, and results may be transferred to the Swedish setting. Caution must be taken regarding cost estimates and the quality of the evidence which the studies are based upon.

Moving to policy-amenable options for built environment research: The role of micro-scale neighborhood environment in promoting walking

BACKGROUND

Altering micro-scale features of neighborhoods (e.g., the presence and condition of benches, sidewalks, trees, crossing signals, walking paths) could be a relatively cost-effective method of creating environments that are conducive to physical activity. The Virtual Systematic Tool for Evaluating Pedestrian Streetscapes (Virtual-STEPS) was created to virtually audit the microscale environment of cities using Google Street View (GSV). The objective of this study was to evaluate the collective influence of items from the Virtual-STEPS tool on walking outcomes (utilitarian walking and walking for leisure), while accounting for self-selection of walkers into walking-friendly neighborhoods.

METHODS

Adults (N = 1403) were recruited from Montreal and Toronto from neighborhoods stratified by their level of macro-scale walking-friendliness and walking rates. The micro-scale environment of 5% of street segments from the selected neighborhoods was audited using the Virtual-STEPS tool and a micro-scale environment score was assigned. The scores were then linked to each respondent from the survey. A multilevel logistic regression analysis was used to model the relationship between the micro-scale environment score and odds of both utilitarian walking (i.e., walking for purpose such as to go shopping or go to work or school) and walking for leisure for at least 150 min per week, while accounting for environmental and demographic covariates as well as self-selection.

RESULTS

Micro-scale neighborhood features were associated with elevated odds of walking for leisure (OR: 1.14, CI: 1.04-1.25). The association between micro-scale neighborhood features and walking for utilitarian purposes was, however, inconclusive (OR: 1.01, CI: 0.90-1.13). On the other hand, macro-scale walk-friendliness was associated with elevated odds of walking for utilitarian purposes (OR: 2.01, CI:1.42-2.84) and the association between macro-scale features and leisure walking was inconclusive (OR: 1.02, CI: 0.78-1.34).

CONCLUSIONS

Our results imply that micro-scale features of neighborhoods collectively promote leisure walking but not necessarily utilitarian walking, even after accounting for self-selection. In contrast, macro-scale features may collectively promote utilitarian walking, but not leisure walking. Micro scale features of neighborhoods fall within the budget of local jurisdictions and our results suggest that jurisdictions that improve micro-scale features may expect increased leisure walking in populations.

The Role of the Teacher in the Implementation of a School-Based Intervention on the Physical Activity Practice of Children

Medium- or long-term intervention strategies for physical activity practice (PAP) need to be more effective in terms of their implementation by practitioners. The aim of this study was to evaluate the role of a teacher to implement the Team Pentathlon (TP) in order to improve the PAP in primary children. TP is a health education program made to improve PAP of children through individual and collective achievements. In this study, 203 children (age: 10–13 years) in grades 5 and 6 (intervention group (IG) N = 104, control group (CG) N = 99) were guided to increase their PAP during an eight-week period by five elementary school teachers (physical education or classroom) who had received four training sessions. Levels of PAP (self-reported) were compared between groups (IG/CG), sex, socioeconomic status of the schools and between teachers: baseline and during TP. Several teachers noted significant increases in PAP in the IG for both boys and girls (p ≤ 0.05 or p < 0.01), whereas others found only small improvements in PAP. One teacher even observed higher PAP in the CG. Training session records revealed that the teacher himself, how the TP is implemented, and proper resources were the three elements that explained the successful implementation of the TP program. The implementation of the TP significantly increased the PAP in primary children. Training sessions helped teachers to implement the TP program but personal engagement, motivation, respecting protocol, and an adequate environment are also necessary in improving the PAP of children.

Active travel and social justice: Addressing disparities and promoting health equity through a novel approach to Regional Transportation Planning

Public health impacts of transportation policies and infrastructure investment are becoming better understood, particularly for those associated with physical activity. Yet health impacts are not routinely evaluated within the context of the development of a Regional Transportation Plan (RTP) and subsequent programming and investment processes. This is particularly concerning because the spatial distribution of planned transportation infrastructure potentially has significant health equity implications for vulnerable populations at greater risk of chronic disease. This study discusses the application of the National Public Health Assessment Model (NPHAM) - a new approach that expands several scenario planning tools to include health - for the San Joaquin Council of Governments 2018 RTP. It demonstrates how quantifying health impacts at a finer spatial scale (census block groups) helps assess the extent to which RTP strategies are likely to benefit or harm health. It further enables a spatial form of health equity analysis that can help planners understand where infrastructure is most needed to meet social equity goals. To the knowledge of the authors, this is the first example of a quantified, health equity analysis of transport physical activity and a health outcome - body mass index - associated with an RTP; it demonstrates significant advancement in transportation planning practice and policy.

Cost-effectiveness of a proportionate universal offer of free exercise: Leeds Let’s Get Active

Background

The purpose of this paper is to assess the cost-effectiveness of a proportionate universal programme to reduce physical inactivity (Leeds Let us Get Active (LLGA)) in adults.

Methods

A continuous-time Markov chain model was developed to assess the cost implications and QALY gains associated with increases in physical activity levels across the adult population. A parametric survival analysis approach was applied to estimate the decay of intervention effect over time. Baseline model data were obtained from previous economic models, population-based surveys and other published literature. A cost-utility analysis was conducted from a health care sector perspective over the programme duration (39 months). Scenario and probabilistic sensitivity analyses were performed to test the robustness of cost-effectiveness results.

Results

In total, 51 874 adult residents registered to the programme and provided baseline data,19.5% of which were living in deprived areas. Under base case assumptions, LLGA was found to be likely to be cost-effective. However, variations in key structural assumptions showed sensitivity of the results.

Conclusions

Results from this study suggest a non-negligible level of uncertainty regarding the effectiveness, and therefore, cost-effectiveness of a universal offer of free leisure centre-based exercise that targets hard to reach groups. Further data collection and a shift towards prospective evaluations are needed.

A Comparative Study of Participation in Physical Education Classes among 170,347 Adolescents from 54 Low-, Middle-, and High-Income Countries

Given the need for comparative research on the participation of adolescents in physical education (PE) classes as a privileged space for physical activity (PA) promotion, this study sought to estimate, analyse and compare the prevalence of participation in PE classes among adolescents from 54 countries and to examine sex, age, country income and world regions disparities. Data from the Global Students Health Survey (2010–2015) were used, comprising 170,347 adolescents (90,305 girls, aged 13–17 years) from nationally representative samples of 54 countries—of which 7 are low-income, 23 lower-middle-income, 14 upper-middle-income and 10 high-income—and six world regions. The weighted percentages of adolescents participating in PE classes (never, 1–2 days/week, 3–4 days/week, 5 or more days/week) were estimated along 95% confidence intervals and compared across sex, age, country income, region, and country. Most adolescents reported to participate in PE on 1–2 days/week (55.2%), but almost 20% of adolescents reported never participating in PE. Girls, compared to boys, presented a lower prevalence for participating ≥5 days/week (girls 16.8%, boys 20.0%). The prevalence of participating in PE on ≥3 days/week was higher among adolescents aged 13–14 years when compared to adolescents aged 15–17 years (boys: 30.9% vs. 24.6%; girls: 26.1% vs. 18.2%). Concerning the countries’ income, the prevalence of never participating in PE was higher in high-income countries, and participating on ≥3 days/week was higher in low-income countries, but further research is recommended. The findings suggest that national, regional and worldwide data highlight the importance of improving participation in PE, particularly for girls and older adolescents. An improved and continued monitoring of PE policies and their actual implementation is needed worldwide.

Healthy Behaviors through Behavioral Design-Obesity Prevention

Evidence for behavior modification for improved health outcomes was evaluated for nutrition, physical activity (PA), and indoor environmental quality (IEQ). The databases searched included LISTA, PubMed, and Web of Science, with articles rated using an a priori baseline score of 70/100 to establish inclusion. The initial search produced 52,847 articles, 63 of which were included in the qualitative synthesis. Thirteen articles met inclusion for nutrition: cafeteria interventions, single interventions, and vending interventions. Seventeen articles on physical activity were included: stair use, walking, and adjustable desks. For IEQ, 33 articles met inclusion: circadian disruption, view and natural light, and artificial light. A narrative synthesis was used to find meaningful connections across interventions with evidence contributing to health improvements. Commonalities throughout the nutrition studies included choice architecture, increasing the availability of healthy food items, and point-of-purchase food labeling. Interventions that promoted PA included stair use, sit/stand furniture, workplace exercise facilities and walking. Exposure to natural light and views of natural elements were found to increase PA and improve sleep quality. Overexposure to artificial light may cause circadian disruption, suppressing melatonin and increasing risks of cancers. Overall, design that encourages healthy behaviors may lower risks associated with chronic disease.

"It takes time to build trust": a survey Ontario's school-based HPV immunization program ten years post-implementation

OBJECTIVES

Describe Ontario's school-based human papillomavirus (HPV) vaccination program from the perspective of local public health units (PHUs).

METHODS

In 2018, Vaccine Preventable Diseases (VPD) managers at each of Ontario's 35 PHUs were invited to participate in an online survey regarding the organization and delivery of their HPV vaccination program. Questions were asked on the school-based program, training and support of vaccine providers, communication and promotion, assessing coverage rates and perceptions of the program's strengths and challenges. Descriptive statistics were generated for close-ended items. A thematic content analysis was performed for open-ended items.

RESULTS

Eighteen PHUs (54%, n = 19/35) responded. All responding PHUs provided the HPV vaccine in publicly funded schools but only 6 reported being permitted to provide HPV vaccine in private schools. Fact sheets, Q&As or other written information locally developed by the PHUs were the main tools used to communicate with parents (n = 17), students (n = 13), school personnel (n = 13) and school board officials (n = 9). The most frequently reported barriers were: limited program resources, negative perceptions held by parents and/or school staff regarding the HPV vaccine, logistical issues (e.g., getting the consents forms returned, collaboration with schools for vaccine delivery) and the fact that HPV vaccination is not mandatory under Ontario legislation.

CONCLUSION

Local public health units that implement HPV vaccine programs in schools identified logistical barriers, public perceptions about the HPV vaccine and the voluntary nature of the program as the main barriers.

Economic evaluations of public health interventions for physical activity and healthy diet: A systematic review

Physical inactivity and unhealthy dietary habits are associated with an increased disease and economic burden. The aim of this systematic review was to identify economic evaluations of public health interventions targeting physical activity and healthy diet, and assess the quality and transferability of the findings to the Swedish context. A search of published economic evaluations was conducted through electronic databases including PubMed, Web of Science, PsycINFO, National Health Service Economic Evaluation Databases (NHS EED) and the Health Technology Assessment Database (HTA). An additional search was done using references of relevant systematic reviews and websites of relevant organizations were checked to find grey literature. Quality and transferability of the economic evaluations were appraised using a quality assessment tool developed by the Swedish Agency for Health Technology Assessment. Thirty-two economic evaluations, rated as moderate or high quality, of 178 interventions were included; thirteen studies targeting physical activity, thirteen targeting healthy diet and six targeting both. The interventions varied in terms of their content, setting, mode of delivery and target populations. A majority of the economic evaluations reported that the interventions were likely to be cost-effective; however, considerable variations in the methodological and reporting qualities were observed. Only half of the economic evaluations were rated to have a high probability of transferring to the Swedish context. Public health interventions targeting physical activity and dietary habits have a high potential to be cost-effective. However, decision makers should consider the variation in quality and transferability of the available evidence.

Pedometers, the frustrating motivators: a qualitative investigation of users' experiences of the Yamax SW-200 among people with multiple sclerosis

Purpose: Self-monitoring may represent a mechanism to enhance physical activity among people with multiple sclerosis. To optimise activity monitoring as a behavioural tool to increase physical activity, user experience must be understood. This study evaluated user experience of the Yamax SW-200 Digi-walker pedometer in a group of people with MS.Methods: Semi-structured interviews were conducted with 15 adults who participated in a 12-week pedometer-supported behavioural change intervention, the iStep-MS trial. Interviews were audio-recorded and transcribed verbatim. Data were analysed using the Framework Method.Results: An overarching theme Pedometers, the frustrating motivators captures the complex and often contradictory experience of the pedometer. Sub-themes include: Increasing activity awareness, which describes the pedometer's utility in raising activity consciousness; Numeric motivation provides insight into dual motivating and demotivating experiences of using an objective feedback device; (Un) usability focuses on practical concerns encountered in the day-to-day use of the monitor.Conclusion: The Yamax SW-200 Digi-walker raised awareness and enhanced participant motivation to engage in physical activity. Accuracy and usability concerns highlighted warrant consideration in the selection of this pedometer within a population with multiple sclerosis. Trial registration: Changing physical activity behaviour in people with MS: the iStep-MS trial; ISRCTN15343862; https://doi.org/10.1186/ISRCTN15343862Implications for rehabilitationUse of self-monitoring tools such as pedometers can enhance physical activity awareness.Objective, numeric step count feedback is an effective motivational tool for physical activity.Accuracy and usability concerns may limit the value of the Yamax SW-200 Digiwalker for people with MS.Identification of individualised, reliable, usable and acceptable tools is important to ensure engagement with self-monitoring.

Sit–stand desks to reduce sedentary behaviour in 9- to 10-year-olds: the Stand Out in Class pilot cluster RCT

Background

Sedentary behaviour (sitting) is a highly prevalent negative health behaviour, with individuals of all ages exposed to environments that promote prolonged sitting. The school classroom represents an ideal setting for environmental change through the provision of sit–stand desks.

Objectives

The aim of this study was to undertake a pilot cluster randomised controlled trial of the introduction of sit–stand desks in primary school classrooms, to inform a definitive trial. Objectives included providing information on school and participant recruitment and retention, acceptability of the intervention, and outcome measures. A preliminary estimate of the intervention’s effectiveness on the proposed primary outcome (change in weekday sitting time) for inclusion in a definitive trial was calculated, along with a preliminary assessment of potential cost-effectiveness. A full process evaluation was also undertaken.

Design

A two-armed pilot cluster randomised controlled trial with economic and qualitative evaluations. Schools were randomised on a 1 : 1 basis to the intervention (n = 4) or control (n = 4) trial arms.

Setting

Primary schools in Bradford, West Yorkshire, UK.

Participants

Children in Year 5 (i.e. aged 9–10 years).

Intervention

Six sit–stand desks replaced three standard desks (sitting six children) in the intervention classrooms for 4.5 months. Teachers were encouraged to ensure that all pupils were exposed to the sit–stand desks for at least 1 hour per day, on average, using a rotation system. Schools assigned to the control arm continued with their usual practice.

Main outcome measures

Trial feasibility outcomes included school and participant recruitment and attrition, acceptability of the intervention, and acceptability of and compliance with the proposed outcome measures [including weekday sitting measured using activPAL™ (PAL Technologies Ltd, Glasgow, UK) accelerometers, physical activity, adiposity, blood pressure, cognitive function, musculoskeletal comfort, academic progress, engagement and behaviour].

Results

Thirty-three per cent of schools approached and 75% (n = 176) of eligible children took part. At the 7-month follow-up, retention rates were 100% for schools and 97% for children. Outcome measure completion rates ranged from 63% to 97%. A preliminary estimate of intervention effectiveness, from a weighted linear regression model (adjusting for baseline sitting time and wear time) revealed a mean difference in change in sitting of –30.6 minutes per day (95% confidence interval –56.42 to –4.84 minutes per day) between the intervention and control trial arms. The process evaluation revealed that the intervention, recruitment and evaluation procedures were acceptable to teachers and children, with the exception of minor issues around activPAL attachment. A preliminary within-trial economic analysis revealed no difference between intervention and control trial arms in health and education resource use or outcomes. Long-term modelling estimated an unadjusted incremental cost-effectiveness ratio of Stand Out in Class of £78,986 per quality-adjusted life-year gained.

Conclusion

This study has provided evidence of the acceptability and feasibility of the Stand Out in Class intervention and evaluation methods. Preliminary evidence suggests that the intervention may have a positive direction of effect on weekday sitting time, which warrants testing in a full cluster randomised controlled trial. Lessons learnt from this trial will inform the planning of a definitive trial.

Trial registration

Current Controlled Trials ISRCTN12915848.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 8, No. 8. See the NIHR Journals Library website for further project information.

Increasing translation of research evidence for optimal park design: a qualitative study with stakeholders

Background

The design of parks is critical to ensure they are appealing, meet the needs of the community and optimise opportunities for physical activity, relaxation, exposure to nature and social interaction. There is currently a lack of understanding on how research evidence is informing park design and how to reduce the many challenges associated with research-practice-policy translation. Understanding how organisations use evidence for decision-making regarding park design is critical for reducing the research-practice-policy gap and ensuring evidence based strategies inform park design to support healthy active living. This study explored stakeholder perceptions regarding factors that influence the use of research evidence to inform park planning and design, and potential strategies to enhance effective translation of research evidence for optimal park design into policy and practice.

Methods

One-on-one in-depth interviews were conducted with 23 stakeholders within the park design, planning and management sector. Participants shared experiences regarding: influences on park development and design; current park development policies; ways to facilitate use of evidence; and priorities for future research. Interviews were recorded and transcribed verbatim and content analysis performed using NVivo 12.

Results

Research evidence is used and considered important for park planning; however, several barriers were highlighted: time and cost constraints; difficulties accessing research; and limited research relevant to specific needs. Developing partnerships between researchers and park developers and providing evidence in a more accessible format such as short summaries/reports, infographics, presentations, research updates and dedicated research databases emerged as key enablers. The main research gaps identified included research into park features to encourage visitation and cost-benefit analyses studies.

Conclusions

This research is a first step to better understand strategies to promote more effective uptake and use of evidence to inform park planning. Researchers must develop multi-sectoral collaborations and generate policy-relevant research in a readily accessible, timely and user-friendly format to ensure evidence is used to enhance park design and ultimately public health.

Health literacy promotion among young adults: a web-based intervention in German vocational schools

Against the background of an ageing population, the target group of young adults holds strong societal relevance as the future workforce. At the same time, young adults find themselves in a critical phase of life regarding the manifestation of a healthy lifestyle. In this context, young adults' health literacy gains importance. Web-based interventions implemented in educational settings offer the potential for promoting health literacy, although longitudinal studies remain scarce. Within a pre-post cluster randomized controlled trial with 6-month follow-up, this study investigated whether an 8-week web-based intervention in vocational schools (with or without an additional initial face-to-face measure) improves individual competencies within a structural model of health literacy ('self-perception', 'proactive approach to health', 'dealing with health information', 'self-control', 'self-regulation' and 'communication and cooperation'). The control condition was regular school lessons following the curriculum only. A multi-level regression analysis was performed using the control group as reference. None of the interventions showed a significant improvement in any of the dimensions. Significant differences between the intervention and control were obtained for some dimensions, albeit showing reductions. Future research must examine how to build impactful health literacy promotion in educational settings. Investigations into linking digital and face-to-face measures should continue.

Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports on the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2020 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, metrics to assess and monitor healthy diets, an enhanced focus on social determinants of health, a focus on the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors, implementation strategies, and implications of the American Heart Association's 2020 Impact Goals.

RESULTS

Each of the 26 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, healthcare administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

A systematic review of economic evaluations of local authority commissioned preventative public health interventions in overweight and obesity, physical inactivity, alcohol and illicit drugs use and smoking cessation in the United Kingdom

Background

Since 2013, local authorities in England have been responsible for commissioning preventative public health interventions. The aim of this systematic review was to support commissioning by collating published data on economic evaluations and modelling of local authority commissioned public health preventative interventions in the UK.

Methods

Following the PRISMA protocol, we searched for economic evaluations of preventative intervention studies in four different areas: overweight and obesity, physical inactivity, alcohol and illicit drugs use and smoking cessation. The systematic review identified studies between January 1994 and February 2015, using five databases. We synthesized the studies to identify the key methods and examined results of the economic evaluations.

Results

The majority of the evaluations related to cost-effectiveness, rather than cost-benefit analyses or cost-utility analyses. These analyses found preventative interventions to be cost effective, though the context of the interventions differed between the studies.

Conclusions

Preventative public health interventions in general are cost-effective. There is a need for further studies to support justification of continued and/or increased funding for public health interventions. There is much variation between the types of economically evaluated preventative interventions in our review. Broader studies incorporating different contexts may help support funding for local authority-sponsored public health initiatives.

Perceptions of the Built Environment and Support for Policies That Promote Physical Activity

BACKGROUND

To assess how perceptions of the community built environment influence support for community policies that promote physical activity (PA).

METHODS

A national cross-sectional survey assessed perceptions of the local built environment and support of community policies, including school and workplace policies, promoting PA. A random digit-dialed telephone survey was conducted in US counties selected on Behavioral Risk Factor Surveillance System data for high or low prevalence of obesity and inactivity. A total of 1208 subjects were interviewed, 642 from high-prevalence counties and 566 from low-prevalence counties. Analyses were stratified by county prevalence of obesity and inactivity (high or low). Linear models adjusted for covariates were constructed to assess the influence of built environment perceptions on policy support.

RESULTS

Perception of more destinations near the residence was associated with increased support for community policies that promote PA, including tax increases in low-prevalence (obesity and inactivity) counties (P < .01). Positive perception of the workplace environment was associated (P < .001) with increased support for workplace policies among those in high-, but not low-, prevalence counties.

CONCLUSIONS

Support for community policies promoting PA varies by perception of the built environment, which has implications for policy change.

Metabolic Equivalent and its Associated Factors in a Rural Community of Karnataka, India

Background Health benefits of physical activity measured in terms of metabolic equivalent minutes (MET-minutes per week) have been established. However, factors affecting physical activity, like age, gender, body mass index, waist-hip ratio, particularly in rural communities have not been documented on a large sample. Methods Baseline physical activity data of more than 4000 subjects over 30 years of age, who were enrolled in a randomised community-based study on non-communicable diseases, were analysed. Global Physical Activity Questionnaire was used and anthropometric measurements were classified according to the MONICA study manual. Three domains of physical activity were measured as MET-minutes per week - activity at work, travel to and from places and recreational activities. Association of MET-minutes with sociodemographic variables and risk factors for cardiovascular diseases was studied. Results Mean MET-minutes per week of females were found to be significantly lower than that of males and decreased with advancing age and higher BMI in both genders. Married persons, normal BMI, normal waist-hip ratio, lower leisure time activity had demonstrated higher MET values (P = 0.000). In our study, the prevalence of inactivity (<600 MET-minutes) was 3.2% which was similar in both males and females. As high as 96.2% of the subjects had MET-minutes of > 1200. Nearly 50% of the subjects had leisure time ranging from 121 to 240 minutes per day. Conclusion A large majority of adults over 30 years of age in a rural community in Karnataka (96.2%) had very high MET-minutes per week of >1200 per day. Abnormal BMI, higher waist-hip ratio and more leisure time were associated with lower MET-minutes which are modifiable. About 50% had more than 2 hours of leisure time per day. It is recommended that health promotion for active lifestyle should be encouraged.

Cost-Effectiveness of Improvements to the Built Environment Intended to Increase Physical Activity

Background: Improving sidewalks may encourage physical activity by providing safe, defined, and connected walking spaces. However, it is unknown if reduced health care expenditures assumed by increased physical activity offset the investment for sidewalk improvements. Methods: This cost-effectiveness analysis of sidewalk improvements in Houston, TX, was among adults enrolled in the Houston Travel-Related Activity in Neighborhoods Study, 2013-2017 . The 1-year change in physical activity was measured using self-report (n = 430) and accelerometry (n = 228) and expressed in metabolic equivalent (MET) hours per year (MET·h·y^-1). Cost-effectiveness ratios were calculated by comparing annualized sidewalk improvement costs (per person) with 1-year changes in physical activity. Results: The estimated cost-effectiveness ratio were $0.01 and -$0.46 per MET·h·y^-1 for self-reported and accelerometer-derived physical activity, respectively. The cost-effectiveness benchmark was $0.18 (95% confidence interval, $0.06-$0.43) per MET·h·y^-1 gained based on the volume of physical activity necessary to avoid health care costs. Conclusions: Improving sidewalks was cost-effective based on self-reported physical activity, but not cost-effective based on accelerometry. Study findings suggest that improving sidewalks may not be a sufficient catalyst for changing total physical activity; however, other benefits of making sidewalks more walkable should be considered when deciding to invest in sidewalk improvements.

A pedometer-based walking intervention in 45- to 75-year-olds, with and without practice nurse support: the PACE-UP three-arm cluster RCT

BACKGROUND

Guidelines recommend walking to increase moderate to vigorous physical activity (MVPA) for health benefits.

OBJECTIVES

To assess the effectiveness, cost-effectiveness and acceptability of a pedometer-based walking intervention in inactive adults, delivered postally or through dedicated practice nurse physical activity (PA) consultations.

DESIGN

Parallel three-arm trial, cluster randomised by household.

SETTING

Seven London-based general practices.

PARTICIPANTS

A total of 11,015 people without PA contraindications, aged 45-75 years, randomly selected from practices, were invited. A total of 6399 people were non-responders, and 548 people self-reporting achieving PA guidelines were excluded. A total of 1023 people from 922 households were randomised to usual care (n = 338), postal intervention (n = 339) or nurse support (n = 346). The recruitment rate was 10% (1023/10,467). A total of 956 participants (93%) provided outcome data.

INTERVENTIONS

Intervention groups received pedometers, 12-week walking programmes advising participants to gradually add '3000 steps in 30 minutes' most days weekly and PA diaries. The nurse group was offered three dedicated PA consultations.

MAIN OUTCOME MEASURES

The primary and main secondary outcomes were changes from baseline to 12 months in average daily step counts and time in MVPA (in ≥ 10-minute bouts), respectively, from 7-day accelerometry. Individual resource-use data informed the within-trial economic evaluation and the Markov model for simulating long-term cost-effectiveness. Qualitative evaluations assessed nurse and participant views. A 3-year follow-up was conducted.

RESULTS

Baseline average daily step count was 7479 [standard deviation (SD) 2671], average minutes per week in MVPA bouts was 94 minutes (SD 102 minutes) for those randomised. PA increased significantly at 12 months in both intervention groups compared with the control group, with no difference between interventions; additional steps per day were 642 steps [95% confidence interval (CI) 329 to 955 steps] for the postal group and 677 steps (95% CI 365 to 989 steps) for nurse support, and additional MVPA in bouts (minutes per week) was 33 minutes per week (95% CI 17 to 49 minutes per week) for the postal group and 35 minutes per week (95% CI 19 to 51 minutes per week) for nurse support. Intervention groups showed no increase in adverse events. Incremental cost per step was 19p and £3.61 per minute in a ≥ 10-minute MVPA bout for nurse support, whereas the postal group took more steps and cost less than the control group. The postal group had a 50% chance of being cost-effective at a £20,000 per quality-adjusted life-year (QALY) threshold within 1 year and had both lower costs [-£11M (95% CI -£12M to -£10M) per 100,000 population] and more QALYs [759 QALYs gained (95% CI 400 to 1247 QALYs)] than the nurse support and control groups in the long term. Participants and nurses found the interventions acceptable and enjoyable. Three-year follow-up data showed persistent intervention effects (nurse support plus postal vs. control) on steps per day [648 steps (95% CI 272 to 1024 steps)] and MVPA bouts [26 minutes per week (95% CI 8 to 44 minutes per week)].

LIMITATIONS

The 10% recruitment level, with lower levels in Asian and socioeconomically deprived participants, limits the generalisability of the findings. Assessors were unmasked to the group.

CONCLUSIONS

A primary care pedometer-based walking intervention in 45- to 75-year-olds increased 12-month step counts by around one-tenth, and time in MVPA bouts by around one-third, with similar effects for the nurse support and postal groups, and persistent 3-year effects. The postal intervention provides cost-effective, long-term quality-of-life benefits. A primary care pedometer intervention delivered by post could help address the public health physical inactivity challenge.

FUTURE WORK

Exploring different recruitment strategies to increase uptake. Integrating the Pedometer And Consultation Evaluation-UP (PACE-UP) trial with evolving PA monitoring technologies.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN98538934.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 37. See the NIHR Journals Library website for further project information.

Mass media to communicate public health messages in six health topic areas: a systematic review and other reviews of the evidence

Background

Mass media campaigns can be used to communicate public health messages at the population level. Although previous research has shown that they can influence health behaviours in some contexts, there have been few attempts to synthesise evidence across multiple health behaviours.

Objectives

To (1) review evidence on the effective use of mass media in six health topic areas (alcohol, diet, illicit drugs, physical activity, sexual and reproductive health and tobacco), (2) examine whether or not effectiveness varies with different target populations, (3) identify characteristics of mass media campaigns associated with effectiveness and (4) identify key research gaps.

Design

The study comprised (1) a systematic review of reviews, (2) a review of primary studies examining alcohol mass media campaigns, (3) a review of cost-effectiveness evidence and (4) a review of recent primary studies of mass media campaigns conducted in the UK. A logic model was developed to inform the reviews. Public engagement activities were conducted with policy, practitioner and academic stakeholders and with young people.

Results

The amount and strength of evidence varies across the six topics, and there was little evidence regarding diet campaigns. There was moderate evidence that mass media campaigns can reduce sedentary behaviour and influence sexual health-related behaviours and treatment-seeking behaviours (e.g. use of smoking quitlines and sexual health services). The impact on tobacco use and physical activity was mixed, there was limited evidence of impact on alcohol use and there was no impact on illicit drug behaviours. Mass media campaigns were found to increase knowledge and awareness across several topics, and to influence intentions regarding physical activity and smoking. Tobacco and illicit drug campaigns appeared to be more effective for young people and children but there was no or inconsistent evidence regarding effectiveness by sex, ethnicity or socioeconomic status. There was moderate evidence that tobacco mass media campaigns are cost-effective, but there was weak or limited evidence in other topic areas. Although there was limited evidence on characteristics associated with effectiveness, longer or greater intensity campaigns were found to be more effective, and messages were important, with positive and negative messages and social norms messages affecting smoking behaviour. The evidence suggested that targeting messages to target audiences can be effective. There was little evidence regarding the role that theory or media channels may play in campaign effectiveness, and also limited evidence on new media.

Limitations

Statistical synthesis was not possible owing to considerable heterogeneity across reviews and studies. The focus on review-level evidence limited our ability to examine intervention characteristics in detail.

Conclusions

Overall, the evidence is mixed but suggests that (1) campaigns can reduce sedentary behaviour, improve sexual health and contribute to smoking cessation, (2) tobacco control campaigns can be cost-effective, (3) longer and more intensive campaigns are likely to be more effective and (4) message design and targeting campaigns to particular population groups can be effective.

Future work

Future work could fill evidence gaps regarding diet mass media campaigns and new-media campaigns, examine cost-effectiveness in areas other than tobacco and explore the specific contribution of mass media campaigns to multicomponent interventions and how local, regional and national campaigns can work together.

Study registration

This study is registered as PROSPERO CRD42015029205 and PROSPERO CRD42017054999.

Funding

The National Institute for Health Research Public Health Research programme.

Moving healthcare professionals - a whole system approach to embed physical activity in clinical practice

BACKGROUND

Healthcare professionals are key informants to support individual behaviour change, and although there has been some progress in empowering clinicians to promote physical activity and health at work, an effective strategy overarching the whole medical educational journey is still lacking. This report provides an overview from the Moving Healthcare Professionals programme (MHPP), a whole-system educational approach to embed prevention and physical activity promotion into clinical practice.

METHODS

The MHPP model integrates educational resources into three core domains of medical education: undergraduate education, postgraduate education and continuing professional development. The interventions are designed to spiral through existing educational approaches rather than as additional special study modules or bolt-on courses, thus reducing self-selection bias in exposure. Interventions include spiral undergraduate education materials, e-learning, embedded post-graduate resources and face-to-face peer-to-peer education.

RESULTS

To date the MHPP model has been applied in two key areas, physical activity and health and work. The physical activity programme in a partnership between Public Health England and Sport England has delivered face-to-face training to 17,105 healthcare professionals, embedded materials in almost three quarters of English medical schools and overseen > 95,000 e-learning modules completed over two and half years. Evaluation of the individual elements of the model is ongoing and aims to show improvements in knowledge, skills and practice. Further evaluation is planned to assess patient impact.

CONCLUSIONS

The MHPP model offers a coherent whole-system approach to embed public health action into existing healthcare education models, and as such provides a framework for rapid change as well as upstream implementation to support the clinicians of today and tomorrow.

The impact of a park refurbishment in a low socioeconomic area on physical activity: a cost-effectiveness study

Background

Physical inactivity is the fourth highest cause of death globally and is a major contributor to increases in healthcare expenditure. Improving public open spaces such as parks in areas of low socio-economic position (SEP) may increase recreational physical activity in disadvantaged populations. We assessed the cost-effectiveness of the installation of a play-space in a large metropolitan park in a low socioeconomic area based on changes in physical activity.

Methods

Observational data of visitor counts and activities undertaken in the park before the installation of the new play-scape (T1), at two months (T2) and 14 months post-installation (T3) were obtained for the intervention and a control park (with no refurbishment) located in a high SEP metropolitan area. Observed sitting, standing, and moderate and vigorous-intensity physical activity were converted to yearly MET-h according to age. Costs of the play-scape and ongoing maintenance were obtained from the organisation managing the refurbishment. The incremental cost-effectiveness ratio (ICER) (ratio of incremental cost to incremental effect) was calculated based on the incremental increase in MET-h from T1 to T3 assuming a 20-year lifetime of the play-scape. Observation counts combining moderate and vigorous activity were used in the sensitivity analysis.

Results

When compared with T1, at T3 the new play-scape resulted in an overall incremental net gain of 114,114 MET-h (95% UI: 80,476 − 146,096) compared with the control park and an incremental cost effectiveness ratio (or cost per MET-h gained per park visitor) of AUD $0.58 (95% UI: $0.44–$0.80).

The sensitivity analysis combining moderate and vigorous activity into one category showed an increase in estimated incremental MET-h of 118,190 (95% CI: 83,528 − 149,583) and a lower incremental cost per MET-h gained of AUD $0.56 (95% UI: $0.43–$0.77).

Conclusions

Using a benchmark of cost-effectiveness for physical activity interventions of AUD $0.60–$1.30, this study suggests that the installation of a play-scape located in a low SEP area is cost-effective based on its potential to facilitate increases in MET-h. It provides much needed preliminary evidence and requires replication elsewhere.

Electronic supplementary material

The online version of this article (10.1186/s12966-019-0786-5) contains supplementary material, which is available to authorized users.

Short-term and long-term cost-effectiveness of a pedometer-based exercise intervention in primary care: a within-trial analysis and beyond-trial modelling

OBJECTIVES

A short-term and long-term cost-effectiveness analysis (CEA) of two pedometer-based walking interventions compared with usual care.

DESIGN

(A) Short-term CEA: parallel three-arm cluster randomised trial randomised by household. (B) Long-term CEA: Markov decision model.

SETTING

Seven primary care practices in South London, UK.

PARTICIPANTS

(A) Short-term CEA: 1023 people (922 households) aged 45-75 years without physical activity (PA) contraindications. (b) Long-term CEA: a cohort of 100 000 people aged 59-88 years.

INTERVENTIONS

Pedometers, 12-week walking programmes and PA diaries delivered by post or through three PA consultations with practice nurses.

PRIMARY AND SECONDARY OUTCOME MEASURES

Accelerometer-measured change (baseline to 12 months) in average daily step count and time in 10 min bouts of moderate to vigorous PA (MVPA), and EQ-5D-5L quality-adjusted life-years (QALY).

METHODS

Resource use costs (£2013/2014) from a National Health Service perspective, presented as incremental cost-effectiveness ratios for each outcome over a 1-year and lifetime horizon, with cost-effectiveness acceptability curves and willingness to pay per QALY. Deterministic and probabilistic sensitivity analyses evaluate uncertainty.

RESULTS

(A) Short-term CEA: At 12 months, incremental cost was £3.61 (£109)/min in ≥10 min MVPA bouts for nurse support compared with control (postal group). At £20 000/QALY, the postal group had a 50% chance of being cost saving compared with control. (B) Long-term CEA: The postal group had more QALYs (+759 QALYs, 95% CI 400 to 1247) and lower costs (-£11 million, 95% CI -12 to -10) than control and nurse groups, resulting in an incremental net monetary benefit of £26 million per 100 000 population. Results were sensitive to reporting serious adverse events, excluding health service use, and including all participant costs.

CONCLUSIONS

Postal delivery of a pedometer intervention in primary care is cost-effective long term and has a 50% chance of being cost-effective, through resource savings, within 1 year. Further research should ascertain maintenance of the higher levels of PA, and its impact on quality of life and health service use.

TRIAL REGISTRATION NUMBER

ISRCTN98538934; Pre-results.

Bringing health into transportation and land use scenario planning: Creating a National Public Health Assessment Model (N-PHAM)

There is mounting evidence linking land development and transportation investments to physical activity with resulting implications for chronic disease prevention. Links between the physical environment and health have traditionally focused on harmful exposures such as air pollution, noise, and traffic injury. Given limited funds and competition for how and where investments are made, there is a need to prioritize and target resources to maximize health benefits that can include activity related chronic disease prevention. The ability to apply this evidence to decision making has been limited by the complexity and inconsistency of research methods, and lack of a direct connection with the planning contexts in which decisions are made. Scenario planning tools provide a method to apply evidence with spatial planning decisions at a range of geographic scales. The US Environmental Protection Agency commissioned the development of a National Public Health Assessment Model (N-PHAM). This project utilized built and natural environment data at the block-group level and large population surveys to model the relationships of the environment with several health outcomes for a range of age and income groups. N-PHAM is the first health assessment tool that can connect to multiple existing scenario planning platforms utilizing nationally available data and can be consistently applied nationally. Such tools can empower communities to choose investments that have the greatest potential to improve public health and quality of life, reduce health care costs, and address environmental justice related disparities.

Educating children and adolescents about vaccines: a review of current literature

INTRODUCTION

Until recently, research on vaccine hesitancy has focused primarily on parent populations. Although adolescent knowledge and views are gaining momentum within the literature, particularly with regards to the human papillomavirus and influenza, children remain a virtually unstudied population with regards to vaccine hesitancy.

AREAS COVERED

This review focuses on the lack of literature in this area and argues for more vaccine hesitancy research involving child and adolescent populations. It also outlines special issues to consider when framing health promotion messages for children and adolescents. Finally, we explore the use of new and existing technologies as delivery mechanisms for education on vaccines and immunizations in populations of children and adolescents.

EXPERT COMMENTARY

Children undergo cognitive development and experiences with vaccines (e.g. pain or education) have the potential to create future attitudes toward vaccines. This can influence future vaccine behaviour, including their participation in decision-making around adolescent vaccines, their decisions to vaccinate themselves when they are adults, and their decisions to vaccinate their own children. Interventions aimed at children, such as education, can create positive attitudes toward vaccines. These can also potentially influence parental attitudes toward vaccines as children convey this knowledge to them. Both of these impacts require further study.

Cardiovascular, respiratory, and related disorders: key messages from Disease Control Priorities, 3rd edition

Cardiovascular, respiratory, and related disorders (CVRDs) are the leading causes of adult death worldwide, and substantial inequalities in care of patients with CVRDs exist between countries of high income and countries of low and middle income. Based on current trends, the UN Sustainable Development Goal to reduce premature mortality due to CVRDs by a third by 2030 will be challenging for many countries of low and middle income. We did systematic literature reviews of effectiveness and cost-effectiveness to identify priority interventions. We summarise the key findings and present a costed essential package of interventions to reduce risk of and manage CVRDs. On a population level, we recommend tobacco taxation, bans on trans fats, and compulsory reduction of salt in manufactured food products. We suggest primary health services be strengthened through the establishment of locally endorsed guidelines and ensured availability of essential medications. The policy interventions and health service delivery package we suggest could serve as the cornerstone for the management of CVRDs, and afford substantial financial risk protection for vulnerable households. We estimate that full implementation of the essential package would cost an additional US$21 per person in the average low-income country and $24 in the average lower-middle-income country. The essential package we describe could be a starting place for low-income and middle-income countries developing universal health coverage packages. Interventions could be rolled out as disease burden demands and budgets allow. Our outlined interventions provide a pathway for countries attempting to convert the UN Sustainable Development Goal commitments into tangible action.

Development, Implementation, and Evaluation of Active Lions: A Campaign to Promote Active Travel to a University Campus

PURPOSE

To outline the development, implementation, and evaluation of a multistrategy intervention to promote active transportation, on a large university campus.

DESIGN

Single group pilot study.

SETTING

A large university in the Northeastern United States.

PARTICIPANTS

University students (n = 563), faculty and staff (employees, n = 999) were included in the study.

INTERVENTION

The Active Lions campaign aimed to increase active transportation to campus for all students and employees. The campaign targeted active transport participation through the development of a smartphone application and the implementation of supporting social marketing and social media components.

MEASURES

Component-specific measures included app user statistics, social media engagement, and reach of social marketing strategies. Overall evaluation included cross-sectional online surveys preintervention and postintervention of student and employee travel patterns and campaign awareness.

ANALYSIS

Number of active trips to campus were summed, and the percentage of trips as active was calculated. T tests compared the differences in outcomes from preintervention to postintervention.

RESULTS

Students had a higher percentage of active trips postintervention (64.2%) than preintervention (49.2%; t = 3.32, P = .001), although there were no differences for employees (7.9% and 8.91%). Greater awareness of Active Lions was associated with greater active travel.

CONCLUSION

This multistrategy approach to increase active transportation on a college campus provided insight on the process of developing and implementing a campaign with the potential for impacting health behaviors among campus members.

Systematic literature review of built environment effects on physical activity and active transport - an update and new findings on health equity

BACKGROUND

Evidence is mounting to suggest a causal relationship between the built environment and people's physical activity behaviours, particularly active transport. The evidence base has been hindered to date by restricted consideration of cost and economic factors associated with built environment interventions, investigation of socioeconomic or ethnic differences in intervention effects, and an inability to isolate the effect of the built environment from other intervention types. The aims of this systematic review were to identify which environmental interventions increase physical activity in residents at the local level, and to build on the evidence base by considering intervention cost, and the differential effects of interventions by ethnicity and socioeconomic status.

METHODS

A systematic database search was conducted in June 2015. Articles were eligible if they reported a quantitative empirical study (natural experiment or a prospective, retrospective, experimental, or longitudinal research) investigating the relationship between objectively measured built environment feature(s) and physical activity and/or travel behaviours in children or adults. Quality assessment was conducted and data on intervention cost and whether the effect of the built environment differed by ethnicity or socioeconomic status were extracted.

RESULTS

Twenty-eight studies were included in the review. Findings showed a positive effect of walkability components, provision of quality parks and playgrounds, and installation of or improvements in active transport infrastructure on active transport, physical activity, and visits or use of settings. There was some indication that infrastructure improvements may predominantly benefit socioeconomically advantaged groups. Studies were commonly limited by selection bias and insufficient controlling for confounders. Heterogeneity in study design and reporting limited comparability across studies or any clear conclusions to be made regarding intervention cost.

CONCLUSIONS

Improving neighbourhood walkability, quality of parks and playgrounds, and providing adequate active transport infrastructure is likely to generate positive impacts on activity in children and adults. The possibility that the benefits of infrastructure improvements may be inequitably distributed requires further investigation. Opportunities to improve the quality of evidence exist, including strategies to improve response rates and representativeness, use of valid and reliable measurement tools, cost-benefit analyses, and adequate controlling for confounders.

The contribution of area-level walkability to geographic variation in physical activity: a spatial analysis of 95,837 participants from the 45 and Up Study living in Sydney, Australia

BACKGROUND

Individual-level studies support a positive relation between walkable built environments and participation in moderate-intensity walking. However, the utility of this evidence for population-level planning is less clear as it is derived at much finer spatial scales than those used for regional programming. The aims of this study were to: evaluate if individual-level relations between walkability and walking to improve health manifest at population-level spatial scales; assess the specificity of area-level walkability for walking relative to other moderate and vigorous physical activity (MVPA); describe geographic variation in walking and other MVPA; and quantify the contribution of walkability to this variation.

METHODS

Data on sufficient walking, sufficient MVPA, and high MVPA to improve health were analyzed for 95,837 Sydney respondents to the baseline survey of the 45 and Up Study between January 2006 and April 2010. We used conditional autoregressive models to create smoothed MVPA "disease maps" and assess relations between sufficient MVPA to improve health and area-level walkability adjusted for individual-level demographic, socioeconomic, and health factors, and area-level relative socioeconomic disadvantage.

RESULTS

Within-cohort prevalence of meeting recommendations for sufficient walking, sufficient MVPA, and high MVPA were 31.7 (95% CI 31.4-32.0), 69.4 (95% CI 69.1-69.7), and 56.1 (95% CI 55.8-56.4) percent. Prevalence of sufficient walking was increased by 1.20 (95% CrI 1.12-1.29) and 1.07 (95% CrI 1.01-1.13) for high and medium-high versus low walkability postal areas, and for sufficient MVPA by 1.05 (95% CrI 1.01-1.08) for high versus low walkability postal areas. Walkability was not related to high MVPA. Postal area walkability explained 65.8 and 47.4 percent of residual geographic variation in sufficient walking and sufficient MVPA not attributable to individual-level factors.

CONCLUSIONS

Walkability is associated with area-level prevalence and geographic variation in sufficient walking and sufficient MVPA to improve health in Sydney, Australia. Our study supports the use of walkability indexes at multiple spatial scales for informing population-level action to increase physical activity and the utility of spatial analysis for walkability research and planning.