Is public transport a promising strategy for increasing physical activity? Evidence from a study of objectively measured public transport use and physical activity.

BACKGROUND: Greater public transport use has been linked to higher physical activity levels. However, neither the amount of physical activity associated with each daily public transport trip performed, nor the potential total physical activity gain associated with an increase in trips/day, has been determined. Using objective measures, we aimed to quantify the association between public transport use, physical activity and sedentary time. METHODS: A longitudinal study of Australian adults living in Hobart, Tasmania, who were infrequent bus users (≥ 18 years; used bus ≤ 2 times/week). The number of bus trips performed each day was determined from objective smartcard data provided by the public transportation (bus) provider across a 36-week study timeframe. Accelerometer measured steps/day (primary outcome), moderate-to-vigorous physical activity (min/day), and sedentary time (min/day) were assessed across four separate one-week periods. RESULTS: Among 73 participants across 1483 day-level observations, on days that public transport was used, participants achieved significantly more steps (ß = 2147.48; 95%CI = 1465.94, 2829.03), moderate to vigorous physical activity (ß = 22.79; 95% CI = 14.33, 31.26), and sedentary time (ß = 37.00; 95% CI = 19.80, 54.21) compared to days where no public transport trips were made. The largest increase in steps per day associated with a one-trip increase was observed when the number of trips performed each day increased from zero to one (ß = 1761.63; 95%CI = 821.38, 2701.87). The increase in the number of steps per day was smaller and non-significant when the number of trips performed increased from one to two (ß = 596.93; 95%CI=-585.16, 1779.01), and two to three or more (ß = 632.39; 95%CI=-1331.45, 2596.24) trips per day. Significant increases in sedentary time were observed when the number of trips performed increased from zero to one (ß = 39.38; 95%CI = 14.38, 64.39) and one to two (ß = 48.76; 95%CI = 25.39, 72.12); but not when bus trips increased from two to three or more (ß=-27.81; 95%CI=-76.00, 20.37). CONCLUSIONS: Greater public transport use was associated with higher physical activity and sedentary behaviour. Bus use may yield cumulative increases in steps that amount to 15-30% of the daily recommended physical activity target. A policy and public health focus on intersectoral action to promote public transport may yield meaningful increases in physical activity and subsequent health benefits.

Free bus fares, bus use and physical activity: An exploratory cross-sectional study.

ISSUE ADDRESSED: Public transport (PT) users often accumulate more physical activity (PA) than private motor vehicle users and financial incentives may increase PT use. Responding to rising petrol prices, from 28 March to 1 May 2022, the Tasmanian government made public bus use fare-free. This exploratory study examined the perceived impact of fare-free buses on bus use and PA. METHODS: Tasmanian adults who had used the fare-free buses (N = 548) completed an online survey (4 May-14 June 2022). Quantitative data were analysed using descriptive and inferential methods and responses to open-ended questions categorised. RESULTS: Over the fare-free period, 46% of participants reported more bus use-average weekly bus trips increased from 3.0 to 4.0 (p < 0.001). Most (81%) participants, including 36% (n = 33/93) who were not previous bus users, planned continued bus use despite financial cost. Total PA was reported higher (36%), the same (60%) and lower (4%) than usual during the fare-free period. Higher total PA was more common amongst those reporting increased bus use (n = 186/240; 78%). Responses to open-ended questions revealed: bus use-related PA gain was through walking to/from bus stops, more frequently attending PA settings (e.g., the gym) and unexpected walking due to bus service limitations; household-level cost savings, improved travel opportunities and better social/mental health were additional fare-free benefits. CONCLUSIONS/SO WHAT: Fare-free buses were commonly perceived to increase bus use and PA. Intervention studies would determine if PA and financially incentivised PT have a causal relationship. Individual- and societal-level health economic analysis of free PT is warranted.

The importance of family support to engage and retain girls in male dominated action sports. A qualitative study of young people's perspectives.

ISSUE ADDRESSED: Social support is positively correlated with physical activity (PA), especially amongst girls, but is underexplored in male-dominated action sports (e.g., mountain biking, skateboarding and surfing). This study explored family level social support needs and experiences of girls and boys in three action sports. METHOD: Aspiring, current or former Australian adolescent (12-18 years; girls n = 25; boys n = 17) mountain bikers, skateboarders and/or surfers were individually interviewed (telephone/Skype) in 2018/2020. A socio-ecological framework guided the semi-structured interview schedule. Audio-recordings were transcribed verbatim and data analysed thematically using a constant comparative approach. RESULTS: Family level social support was highly influential in young people's participation in action sports, with its absence a common reason for no or discontinued engagement amongst girls. Parents and siblings were the main social support providers with extended family (e.g., grandparents, aunts/uncles, cousins) also notable. Participation (current/past/co-) was the main social support type followed by emotional (e.g., encouragement), instrumental (e.g., transport, equipment/funding) and informational (e.g., coaching) support. Girls were inspired/encouraged by brothers but boys were not inspired/encouraged by sisters; boys and girls co-participated with both parents but co-participating and being inspired by fathers was most common, especially amongst girls; fathers were more commonly the main transport provider if they co-participated with their child; fathers mostly provided initial coaching; only boys were taught equipment maintenance by parents. CONCLUSIONS AND SO WHAT: Sport-related organisations/groups have numerous opportunities to improve girls' representation in action sports by fostering family level social support through various means. Intervention strategies should be tailored to account for gendered participation differences.

trips4health: a single-blinded randomised controlled trial incentivising adult public transport use for physical activity gain.

BACKGROUND: Public transport users tend to accumulate more physical activity than non-users; however, whether physical activity is increased by financially incentivising public transport use is unknown. The trips4health study aimed to determine the impact of an incentive-based public transport intervention on physical activity. METHODS: A single-blinded randomised control trial of a 16-week incentive-based intervention involved Australian adults who were infrequent bus users (≥ 18 years; used bus ≤ 2 times/week) split equally into intervention and control groups. The intervention group were sent weekly motivational text messages and awarded smartcard bus credit when targets were met. The intervention group and control group received physical activity guidelines. Accelerometer-measured steps/day (primary outcome), self-reported transport-related physical activity (walking and cycling for transport) and total physical activity (min/week and MET-min/week) outcomes were assessed at baseline and follow-up. RESULTS: Due to the COVID pandemic, the trial was abandoned prior to target sample size achievement and completion of all assessments (N = 110). Steps/day declined in both groups, but by less in the intervention group [-557.9 steps (-7.9%) vs.-1018.3 steps/week (-13.8%)]. In the intervention group, transport-related physical activity increased [80.0 min/week (133.3%); 264.0 MET-min/week (133.3%)] while total physical activity levels saw little change [35.0 min/week (5.5%); 25.5 MET-min/week (1.0%)]. Control group transport-related physical activity decreased [-20.0 min/week (-27.6%); -41.3 MET-min/week (-17.3%)], but total physical activity increased [260.0 min/week (54.5%); 734.3 MET-min/week (37.4%)]. CONCLUSION: This study found evidence that financial incentive-based intervention to increase public transport use is effective in increasing transport-related physical activity These results warrant future examination of physical activity incentives programs in a fully powered study with longer-term follow-up. TRIAL REGISTRATION: This trial was registered with the Australian and New Zealand Clinical Trials Registry August 14th, 2019: ACTRN12619001136190; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=377914&isReview=true.

Socio-demographic, behavioural and health-related characteristics associated with active commuting in a regional Australian state: Evidence from the 2016 Tasmanian Population Health Survey.

ISSUE ADDRESSED: Physical activity is lower and rates of preventable common diseases are higher in regional/rural than urban Australia. Active commuting (walking/bicycling to get from one place to another) may benefit health through increased physical activity, but most evidence of its correlates come from urban studies. This study aimed to investigate associations between active commuting, socio-demographic characteristics, behaviours, total physical activity and health in a regional/rural Australian state. METHODS: This study used data from the 2016 Tasmanian Population Health Survey, a representative cross-sectional self-report survey of 6,300 adults in Tasmania, Australia. Logistic regression modelling investigated associations between socio-demographic, behavioural and health characteristics and past week active commuting frequency. RESULTS: In multivariable models, being younger, having tertiary qualifications, living in a socio-economically advantaged area, being physically active, having a healthy body mass index and good/excellent self-rated health were associated with engaging in more active commuting. Inner regional dwellers were no more likely than outer regional dwellers to actively commute after covariate adjustment. CONCLUSION: Strategies to promote active commuting in regional/rural areas might consider targeting older adults, those less educated, those living in socio-economically disadvantaged areas, those less physically active, those with poorer health and those with higher body mass index. Research could further investigate why these groups appear to be less active for commuting purposes. SO WHAT?: Increasing physical activity and active commuting may help to reduce rates of preventable common diseases in regional/remote areas.

Acceptability and perceived feasibility of strategies to increase public transport use for physical activity gain - A mixed methods study.

ISSUE ADDRESSED: Public transport (PT) users typically accumulate more physical activity (PA) than motor vehicle users. This mixed methods study aimed to determine acceptability and perceived effectiveness of strategies to increase bus use for PA gain in a regional Australian setting. METHODS: In a 2017 online survey, Tasmanian adults (n = 1091) rated the likelihood of increasing their bus use according to ten hypothetical strategies (fare-, incentives-, information- or infrastructure-based). Three focus groups and five interviews (n = 31) included infrequent bus users from the survey to determine reasons for strategy preferences and potential impact on PA. RESULTS: The top three strategies in the survey, with supporting rationale from qualitative data, were: provision of real-time bus information ("…because I can better plan…"); bus-only lanes ("…it just speeds the whole thing up…") and employee incentives/rewards for example bus fare credits ("…it really comes down to money…"). Full-time students favoured cost-saving strategies most and residents in outer suburbs favoured infrastructure-based strategies most. Qualitative data indicated that potential for enhanced certainty, efficiency or cost-savings drove strategy preferences and some strategies may lead to PA gain (eg through the location of Park and Ride facilities). CONCLUSIONS: Real-time information, bus-only lanes and employee incentives/rewards appear most promising for increasing bus use in this population, but tailoring strategies may be required. Discrete PT enhancement strategies may result in PA gain. SO WHAT?: Increasing PA through transport behaviour has been underexplored. The potential for PA gain through greater PT use and discrete PT use enhancement strategies is an important public health consideration.

Test-retest reliability of a self-reported physical activity environment instrument for use in rural settings.

OBJECTIVE: Little is known about how the physical environment impacts physical activity behaviour among rural populations, who are typically less active and at higher risk of chronic disease than urban dwellers. The lack of individual-level instruments to assess the physical environment in rural areas limits advancement of this field. Among rural adults, this study aimed to evaluate (a) the test-retest reliability of a self-reported questionnaire of individual-level perceptions of the physical activity environment, and (b) the stability of a self-reported physical activity questionnaire. DESIGN: Cross-sectional questionnaire repeated twice, 2 weeks apart. The questionnaire included 94 items relating to the perceived physical environment (representing nine summary scores), demographic characteristics and physical activity. SETTING: Rural Australia. PARTICIPANTS: Rurally residing adults (≥18 years) across three Australian states. MAIN OUTCOME MEASURES: Test-retest reliability evaluated by weighted Kappa statistics (individual items) and intra-class correlations (summary scores). RESULTS: A total of 292 participants (20% men) completed both questionnaires, on average 22 days apart. Test-retest reliability of individual items ranged from weighted Kappa 0.37-0.85 (median: 0.59). Internal reliability for five summary scores was good to excellent (Cronbach's alpha: 0.81-0.97). Test-retest reliability was good to excellent for six summary scores (intra-class correlations: 0.67-0.77). CONCLUSIONS: The findings indicated good to excellent test-retest reliability for most items, particularly "fixed" constructs for this new questionnaire measuring the perceived physical environment in rural populations. This study represents an important step towards improving measurement of physical activity environments in rural populations, potentially leading to better tailored interventions to promote active and healthy living in rural areas.

Health and broader community benefit of parkrun-An exploratory qualitative study.

ISSUE ADDRESSED: parkrun is a free, weekly, timed, international mass community 5-km walk/run event. Unlike other paid events, parkrun attracts populations harder to engage in physical activity (PA) (eg, women, those with overweight/obesity or illness/injury/disability). This exploratory qualitative study investigated the individual, social and environmental factors associated with parkrun's broad appeal in Australia. METHODS: Tasmanian parkrunners who completed a quantitative survey (2016) were purposively recruited for a 2017 interview study. Semistructured interviews focused on reasons for parkrun participation. Data saturation was achieved by the tenth interview. Data were analysed thematically. RESULTS: Four themes emerged: (a) participation facilitators and barriers; (b) PA gain and broader community benefit; (c) social connections/networks; and (d) organisational issues. Appealing characteristics of parkrun included strong social support, performance gain opportunities, socialising, inclusivity (eg, all ages/abilities), sense of community, positive atmosphere and accessibility (eg, no cost and convenience). Some participants reported that parkrun had stimulated gains in their total PA (not always limited to walking/running) and that parkrun may also result in other community benefits (eg, supporting local businesses, fee-based running club/event participation and "parkrun tourism"). Most participants first attended parkrun because of encouragement from their social networks, and participants subsequently encouraged others to attend. Participants found parkrun events well organised, but identified some potential threats (eg, local politics). CONCLUSIONS: Social factors appeared critical in driving initial and ongoing parkrun participation. parkrun may lead to wider community benefits beyond that gained through increased individual PA. These findings highlight the "success factors" driving parkrun participation and provide insights for other community-based PA promotion activities.

A qualitative investigation of the health economic impacts of bariatric surgery for obesity and implications for improved practice in health economics.

Obesity is an economic problem. Bariatric surgery is cost-effective for severe and resistant obesity. Most economic evaluations of bariatric surgery use administrative data and narrowly defined direct medical costs in their quantitative analyses. Demand far outstrips supply for bariatric surgery. Further allocation of health care resources to bariatric surgery (particularly public) could be stimulated by new health economic evidence that supports the provision of bariatric surgery. We postulated that qualitative research methods would elicit important health economic dimensions of bariatric surgery that would typically be omitted from the current economic evaluation framework, nor be reported and therefore not considered by policymakers with sufficient priority. We listened to patients: Focus group data were analysed thematically with software assistance. Key themes were identified inductively through a dialogue between the qualitative data and pre-existing economic theory (perspective, externalities, and emotional capital). We identified the concept of emotional capital where participants described life-changing desires to be productive and participate in their communities postoperatively. After self-funding bariatric surgery, some participants experienced financial distress. We recommend a mixed-methods approach to the economic evaluation of bariatric surgery. This could be operationalised in health economic model conceptualisation and construction, through to the separate reporting of qualitative results to supplement quantitative results.

What are the support experiences and needs of patients who have received bariatric surgery?

OBJECTIVE: To explore the support needs and experiences of patients who had received publicly or privately funded bariatric surgery and the importance of this support in mediating outcomes of surgery. METHODS: Seven semi-structured focus groups were conducted. A broad interview schedule guided the discussions which were audio-recorded and transcribed verbatim. Data were analysed thematically. RESULTS: Twenty-six women and 15 men with a mean age of 54 years (range 24-72) participated in the study. Participants described support needs from health professionals, significant others (family and friends), peers (bariatric surgery recipients) and the general community. Peer, dietetic and psychological support were identified as important factors influencing the outcomes (e.g. weight reduction or health improvement) or experience of bariatric surgery but were identified as infrequently received or inadequately provided. Psychological support was proposed as one of the most significant but commonly overlooked components of care. Support needs appeared higher in the first year post-surgery, when subsequent related or unrelated surgeries were required and following significant life change such as worsening health. For some participants, deficits in support appeared to negatively influence the experience or outcomes of surgery. CONCLUSION: Providers of bariatric surgery should discuss support needs and accessibility regularly with patients especially in the first year post-surgery and following significant change in a patient's life (e.g. declined health or childbirth). Nutrition, psychological and peer support (e.g. through support groups) may be especially important for some patients.

Get BusActive!: Protocol of a single-blinded randomised controlled trial incentivising public transport use for physical activity gain among young people and adults.

Background: Population level physical activity generally does not meet recommended targets. Compared with private motor vehicle users, public transport users tend to be more physically active and financial incentives may encourage more public transport use, but these relationships are under-investigated. This paper describes the protocol of a randomised controlled trial that aimed to determine the effect of financially incentivising public transport use on physical activity in a regional Australian setting. Methods: Get BusActive! is a 9.5-month single-blinded randomised controlled trial. A convenience sample of Tasmanians aged ≥15 years will be randomised to a 14-week incentive-based intervention (bus trip target attainment rewarded by bus trip credits and weekly supportive text messages) or an active control following baseline measures and will be followed up ∼24 weeks later (maintenance phase). Both groups will receive written physical activity guidelines. The primary outcome is change in accelerometer-measured steps/day from baseline to immediately post intervention phase and maintenance phase. Secondary outcomes are change in: smartcard-measured bus trips/week; measured and self-reported minutes/week of physical activity and sitting; transport-related behaviour (using one-week travel diary), perspectives (e.g. enablers/barriers) and costs; health. Linear mixed model regression will determine group differences. Participant-level process evaluation will be conducted and intervention cost to the public transport provider determined. Conclusion: Get BusActive! will fill an important knowledge gap about the causal relationship between financially incentivised public transport use and physical activity-the findings will benefit health and transport-related decision makers. Trial registration: ACTRN12623000613606. Universal trial number: U1111-1292-3414.

A prospective study of the impact of COVID-19-related restrictions on activities and mobility upon physical activity, travel behaviour and attitudes.

Background and aims: Public health measures adopted to contain the spread of COVID-19 included restrictions on activities and mobility as people were asked to stay at home and schools moved to online learning. This may have increased risk of non-communicable disease by limiting recreational and transport-related physical activity. Building on an existing study, we assessed changes in self-reported and device-measured physical activity and travel behaviour before, during and after the peak of local COVID-19 outbreak and restrictions (March-July 2020). We examined beliefs in effectiveness of strategies to increase active and public transport after restrictions were reduced. Methods: A longitudinal study of adult infrequent bus users (average ≤ 2 trips per week; n = 70; 67% women) in Hobart, Australia. One-week assessment periods at four separate timepoints (before, during, 0-3 months after, and 3-6 months after the peak restrictions period) involved wearing an accelerometer, daily transport diaries, online surveys and tracking bus smartcard boardings. Results: Physical activity (especially among older participants), bus use and private motor vehicle use declined significantly during or 0-3 months after the peak restrictions period and returned to pre-restrictions levels by 3-6 months after the peak restrictions period, except bus use which remained significantly lower. Retrospective surveys overstated declines in bus use and active transport and self-reports understated declines in physical activity. Social distancing and improving service efficiency and frequency were seen as effective strategies for increasing bus use after restrictions but belief in effectiveness of distancing decreased over time. Conclusions: When restrictions on mobility are increased, supportive health promotion measures are needed to prevent declines in physical activity, particularly for older adults. Public transport systems need capacity to implement temporary distancing measures to prevent communicable disease transmission. Providing convenient, flexible, and efficient options for public transport may help to replenish public transport use after restrictions are reduced.

Childhood factors related to diverging body mass index trajectories from childhood into mid-adulthood: A mixed methods study.

Body mass index (BMI) trajectories that improve over the lifecourse result in better cardiometabolic profiles, but only a small proportion of children of an unhealthy weight show improving BMI trajectories. This study aimed to examine the childhood factors related to diverging BMI trajectories from childhood into adulthood using data from the Childhood Determinants of Adult Health study. A convergent parallel mixed methods design was used. Quantitative data (n = 2206) came from the first (2004-06) and second (2009-11) adult follow-ups of 8498 Australian children (7-15 years) assessed in 1985. Using BMI z-scores, group-based trajectory modelling identified five trajectory groups: Persistently Low, Persistently Average, High Decreasing, Average Increasing and High Increasing. Qualitative data (n = 50) were collected from a sub-group (2016; 38-46 years). Semi-structured interviews with 6-12 participants from each BMI trajectory group focused on individual, social and environmental influences on weight, diet and physical activity across the lifecourse. Log multinomial regression modelling estimated relative risks of trajectory group membership across childhood demographic, behavioural, health, parental and school factors. Qualitative data were thematically analysed using a constant comparative approach. Childhood factors influenced BMI trajectories. Paternal education, main language spoken, alcohol and self-rated health were significant quantitative childhood predictors of BMI trajectory. A distinct 'legacy effect' of parental lifestyle influences during childhood was apparent among interview participants in the Stable and High Decreasing groups, a strong and mostly positive concept discussed by both men and women in these groups and persisting despite phases of unhealthy behaviours. In contrast, the 'legacy effect' was much weaker in the two Increasing BMI groups. This study is the first to simultaneously identify important quantitative and qualitative childhood factors related to divergent BMI trajectories, and to observe a legacy effect of parents' lifestyle behaviours on divergent BMI trajectories. This work provides direction for further exploration of the factors driving divergent BMI trajectories.

Is greater public transport use associated with higher levels of physical activity in a regional setting? Findings from a pilot study.

BACKGROUND: Public transport users often accumulate more physical activity than motor vehicle users, but most studies have been conducted in large metropolitan areas with multiple public transport options with limited knowledge of the relationship in regional and rural areas. In a regional city, this pilot study aimed to (1) test the feasibility of preliminary hypotheses to inform future research, (2) test the utility of survey items, and (3) establish stakeholder engagement. METHODS: Data were collected via a cross-sectional online survey of 743 Tasmanian adults. Physical activity outcomes were walking (min/week), total moderate- to vigorous-intensity physical activity (min/week) and attainment of physical activity guidelines (yes/no). Transport variables were frequency of public and private transport use per week. Truncated and log binomial regression examined associations between public/private transport use and physical activity. RESULTS: Neither frequency of public nor private transport use was associated with minutes of walking (public transport: B - 24.4, 95% CI: - 110.7, 61.9; private transport: B - 1.1, 95% CI: - 72.4, 70.1), minutes of total physical activity (public transport: B - 90.8, 95% CI: - 310.0, 128.5; private transport: B 0.4, 95% CI: - 134.0, 134.9) or not meeting physical activity guidelines (public transport: RR 1.02, 95%CI: 0.95, 1.09; private transport: RR 1.02, 95%CI: 0.96, 1.08). CONCLUSIONS: The hypothesis that public transport users would be more physically active than private transport users was not supported in this pilot study. Stakeholders were engaged and involved in various phases of the research including development of research questions, participant recruitment, and interpretation of findings. Further studies using representative samples and refined measures are warranted to confirm or refute findings.

Exploring the Health-Promoting Potential of the "parkrun" Phenomenon: What Factors are Associated With Higher Levels of Participation?

PURPOSE: " parkrun" is a free and increasingly popular weekly 5-km walk/run international community event, representing a novel setting for physical activity (PA) promotion. However, little is known about who participates or why. This study aimed to identify sociodemographic, health, behavioral, individual, social, and environmental factors associated with higher levels of participation. DESIGN: Cross-sectional. SETTING: Tasmania, Australia; June 2016. PARTICIPANTS: Three hundred seventy two adult parkrun participants. MEASURES: Online survey measuring sociodemographic, health, individual, social and environmental factors, parkrun participation, and PA. ANALYSIS: Descriptive statistics, zero-truncated Poisson regression models. RESULTS: Respondents (n = 371) were more commonly women (58%), aged 35 to 53 years (54%), and occasional or nonwalkers/runners (53%) at registration. A total of 44% had overweight/obesity. Half had non-adult children, most spoke English at home, and 7% reported PA-limiting illness/injury/disability. Average run/walk time was 30.2 ± 7.4 minutes. Compared to regular walkers/runners at registration, nonwalkers/runners were less commonly partnered, more commonly had overweight/obesity, less physically active, and had poorer self-rated health. Multivariate analyses revealed relative parkrun participation was inversely associated with education level and positively associated with interstate parkrun participation, perceived social benefits, self-efficacy for parkrun, and intentions to participate. CONCLUSION: parkrun attracts nonwalkers/runners and population groups hard to engage in physical activity. Individual- and social-level factors were associated with higher relative parkrun participation. parkrun's scalability, accessibility, and wide appeal confers a research imperative to investigate its potential for public health gain.

Population estimates and characteristics of Australians potentially eligible for bariatric surgery: findings from the 2011-13 Australian Health Survey.

Objective The aim of the present study was to determine the potential demand for publicly and privately funded bariatric surgery in Australia. Methods Nationally representative data from the 2011-13 Australian Health Survey were used to estimate the numbers and characteristics of Australians meeting specific eligibility criteria as recommended in National Health and Medical Research Council guidelines for the management of overweight and obesity. Results Of the 3352037 adult Australians (aged 18-65 years) estimated to be obese in 2011-13, 882441 (26.3%; 95% confidence interval (CI) 23.0-29.6) were potentially eligible for bariatric surgery (accounting for 6.2% (95% CI 5.4-7.1) of the adult population aged 18-65 years (n=14122020)). Of these, 396856 (45.0%; 95% CI 40.4-49.5) had Class 3 obesity (body mass index (BMI) ≥40kgm-2), 470945 (53.4%; 95% CI 49.0-57.7) had Class 2 obesity (BMI 35-39.9kgm-2) with obesity-related comorbidities or risk factors and 14640 (1.7%; 95% CI 0.6-2.7) had Class 1 obesity (BMI 30-34.9kgm-2) with poorly controlled type 2 diabetes and increased cardiovascular risk; 458869 (52.0%; 95% CI 46.4-57.6) were female, 404594 (45.8%; 95% CI 37.3-54.4) had no private health insurance and 309983 (35.1%; 95% CI 28.8-41.4) resided outside a major city. Conclusion Even if only 5% of Australian adults estimated to be eligible for bariatric surgery sought this intervention, the demand, particularly in the public health system and outside major cities, would far outstrip current capacity. Better guidance on patient prioritisation and greater resourcing of public surgery are needed. What is known about this topic? In the period 2011-13, 4million Australian adults were estimated to be obese, with obesity disproportionately more prevalent in areas of socioeconomic disadvantage. Bariatric surgery is considered to be cost-effective and the most effective treatment for adults with obesity, but is mainly privately funded in Australia (>90%), with 16650 primary privately funded procedures performed in 2015. The extent to which the supply of bariatric surgery is falling short of demand in Australia is unknown. What does this paper add? The present study provides important information for health service planners. For the first time, population estimates and characteristics of those potentially eligible for bariatric surgery in Australia have been described based on the best available evidence, using categories that best approximate the national recommended eligibility criteria. What are the implications for practitioners? Even if only 5% of those estimated to be potentially eligible for bariatric surgery in Australia sought a surgical pathway (44122 of 882441), the potential demand, particularly in the public health system and outside major cities, would still far outstrip current capacity, underscoring the immediate need for better guidance on patient prioritisation. The findings of the present study provide a strong signal that more funding of public surgery and other effective interventions to assist this population group are necessary.

Proprioceptive neuromuscular facilitation stretching : mechanisms and clinical implications.

Proprioceptive neuromuscular facilitation (PNF) stretching techniques are commonly used in the athletic and clinical environments to enhance both active and passive range of motion (ROM) with a view to optimising motor performance and rehabilitation. PNF stretching is positioned in the literature as the most effective stretching technique when the aim is to increase ROM, particularly in respect to short-term changes in ROM. With due consideration of the heterogeneity across the applied PNF stretching research, a summary of the findings suggests that an 'active' PNF stretching technique achieves the greatest gains in ROM, e.g. utilising a shortening contraction of the opposing muscle to place the target muscle on stretch, followed by a static contraction of the target muscle. The inclusion of a shortening contraction of the opposing muscle appears to have the greatest impact on enhancing ROM. When including a static contraction of the target muscle, this needs to be held for approximately 3 seconds at no more than 20% of a maximum voluntary contraction. The greatest changes in ROM generally occur after the first repetition and in order to achieve more lasting changes in ROM, PNF stretching needs to be performed once or twice per week. The superior changes in ROM that PNF stretching often produces compared with other stretching techniques has traditionally been attributed to autogenic and/or reciprocal inhibition, although the literature does not support this hypothesis. Instead, and in the absence of a biomechanical explanation, the contemporary view proposes that PNF stretching influences the point at which stretch is perceived or tolerated. The mechanism(s) underpinning the change in stretch perception or tolerance are not known, although pain modulation has been suggested.

A Head-to-Head Comparison of the EQ-5D-5L and AQoL-8D Multi-Attribute Utility Instruments in Patients Who Have Previously Undergone Bariatric Surgery.

BACKGROUND: Psychosocial health status is an important and dynamic outcome for bariatric/metabolic surgery patients, as acknowledged in recent international standardised outcomes reporting guidelines. Multi-attribute utility-instruments (MAUIs) capture and assess an individual's health-related quality-of-life (HRQoL) within a single valuation, their utility. Neither MAUIs nor utilities were discussed in the guidelines. Many MAUIs (e.g. EQ-5D) target physical health. Not so the AQoL-8D. OBJECTIVES: Our objective was to explore agreement between, and suitability of, the EQ-5D-5L and AQoL-8D for assessing health state utility, and to determine whether either MAUI could be preferentially recommended for metabolic/bariatric surgery patients. METHODS: Utilities for post-surgical private-sector patients (n = 33) were assessed using both instruments and summary statistics expressed as mean [standard deviation (SD)] and median [interquartile range (IQR)]. Interchangeability of the MAUIs was assessed with Bland-Altman analysis. Discriminatory attributes were investigated through floor/ceiling effects and dimension-to-dimension comparisons. Spearman's rank measured associations between the instruments' utility values and with the body mass index (BMI). RESULTS: Mean (SD) EQ-5D-5L utility value was 0.84 (0.15) and median 0.84 (IQR 0.75-1.00). Mean (SD) AQoL-8D utility value was 0.76 (0.17) and median 0.81 (IQR 0.63-0.88). Spearman's rank was r = 0.68; (p < 0.001); however, Bland-Altman analysis revealed fundamental differences. Neither instrument gave rise to floor effects. A ceiling effect was observed with the EQ-5D-5L, with 36 % of participants obtaining a utility value of 1.00 (perfect health). These same participants obtained a mean utility of 0.87 on the AQoL-8D, primarily driven by the mental-super-dimension score (0.52). CONCLUSIONS: The AQoL-8D preferentially captures psychosocial aspects of metabolic/bariatric surgery patients' HRQoL. We recommend the AQoL-8D as a preferred MAUI for these patients given their complex physical/psychosocial needs.

Review of Publicly-Funded Bariatric Surgery Policy in Australia-Lessons for More Comprehensive Policy Making.

BACKGROUND: The objective of the study was to determine the level of guidance provided by or to government health departments across different regions of Australia on publicly funded bariatric surgery. METHODS: Bariatric surgery policies and guidelines were sought from each Australian state (n = 6) and territory (n = 2) government health department and compared in relation to their origins, level of guidance on patient eligibility and priority, as well as recommendations for patient care, including follow-up surgical services. Comparison with national guidelines on bariatric surgery from Australia, the UK and USA was also made. RESULTS: Five of the eight states and territories had policies or guidelines informing practice. There was little uniformity among regional guidelines and variable consistency with national guidelines (e.g., defining obesity related comorbidity). Recommendations differed on patient eligibility, and none of the state documents mentioned re-operative bariatric or body-contouring surgery. There was limited guidance on prioritisation of eligible patients and gastric banding adjustments. Pre- and post-surgical multidisciplinary care was generally recommended. CONCLUSIONS: Policies and guidelines on publicly funded bariatric surgery are highly variable across Australia and at times inconsistent with national guidelines. Insufficient guidance exists regarding the prioritisation of eligible patients and follow-up surgical services. These findings have implications for policy, research and practice and are particularly important in health service environments with resource constraints and inequitable patient access to services.