How long does it take to scale-up obesity prevention interventions?

OBJECTIVE: The scale-up of evidence-based interventions is necessary to reverse high rates of obesity. However, scale-up doesn't occur frequently nor in a timely manner. While it has been estimated that takes 14-17 years for research translation to occur, the time taken to scale-up prevention interventions is largely unknown. This study examined the time taken to scale-up obesity prevention interventions across four scale-up pathways. METHODS: A sample of obesity prevention interventions that had been scaled-up or implemented at scale were found using a structured search strategy. Included interventions were mapped against four scale-up pathways and timeframes associated with each stage of the scale-up pathway were identified to determine the time taken to scale-up. RESULTS: Of the 90 interventions found that were scaled-up to at least a city-wide level, less than half reported a comprehensive research pathway to scale-up and a third did not report any evidence of efficacy or effectiveness prior to scale-up. The time taken to scale-up ranged from 0 to 5 years depending on the pathway taken. Those following a comprehensive pathway took approximately 5 years to scale-up, while interventions that had only one evidence generating step took between 1 and 1.5 years to scale-up. For the remaining interventions, scale-up occurred immediately post-development without evidence generation. CONCLUSIONS: Our findings indicate that the scale-up of obesity prevention interventions can occur more quickly than previous estimates of 14-17 years. Our findings support previous research that scale-up of interventions occurs through a variety of pathways and often scale-up occurs in absence of prior evidence of effectiveness.

Real-world public health interventions demonstrate how research evidence informs program scale-up.

Evidence-based population interventions rely on intervention testing (efficacy and effectiveness trials) to determine what works to improve public health. We investigated the characteristics of real-world public health interventions to address obesity and explored the extent to which research testing was undertaken prior to scale-up. We identified 90 population health interventions targeting physical activity, nutrition or obesity-related health behaviours and collected publicly available information on their key characteristics and outcomes. We then assessed the differences between interventions that followed a research pathway and those that did not. Two-thirds (n = 60) of the interventions were reported as having followed a research pathway. Univariate logistic regression analysis revealed that these interventions were more likely to be health education interventions [odds ratio (OR): 5.56; 95% confidence interval (CI): 1.38-22.38], developed by research institutes (OR: 12.81; 95% CI: 3.47-47.34), delivered in North America (OR: 4.13; 95% CI: 1.61-10.62), and less likely to be owned (OR: 0.35; 95% CI: 0.14-0.88) or funded by government organizations (OR: 0.37; 95% CI: 0.14-0.95). Interventions that followed a research pathway were nearly three times more likely to have a positive impact on population health (OR: 2.72; 95% CI: 1.04-7.14). Interventions that followed a research pathway to scale-up were no more likely to be sustained longer than those that did not. Differences exist across real-world interventions between those that follow a research pathway to population-scale delivery and those that do not, regarding organizational and environmental context. A key benefit of research pathway to scale-up is the impact it has on health outcomes.

COVID-19 and working from home-related changes in physical activity in Sydney, Australia.

ISSUES ADDRESSED: Evidence on how COVID-19 lockdowns impacted physical activity (PA) is mixed. This study explores changes in PA following initial mobility restrictions, and their subsequent relaxation, in a sample of Sydney (Australia) residents using a natural experiment methodology. METHODS: Participants' health and travel behaviours were collected pre-pandemic in late 2019 (n = 1937), with follow-up waves during the pandemic in 2020 (n = 1706) and 2021 (n = 1514). Linear mixed-effects models were used to analyse changes in weekly duration of PA between the three waves. RESULTS: Compared with pre-pandemic, average weekly PA increased in 2021 by 42.6 min total PA (p = .001), 16 min walking PA (p = .02), and 26.4 min moderate-vigorous PA (MVPA) (p = .003). However, average weekly sessions of PA decreased in 2020 and remained lower in 2021. For participants who were sufficiently active in 2019, weekly total PA (-66.3 min) MVPA (-43.8 min) decreased in 2020 compared to pre-pandemic. Conversely, among participants who were insufficiently active in 2019, average weekly PA increased in both 2020 (total PA, +99.1 min; walking PA, +46.4 min; MVPA +52.8 min) and 2021 (total PA, +117.8 min; walking PA, +58.4 min; MVPA +59.2 min), compared to 2019. Participants who did more work from home increased their average weekly total PA in 2021 compared to pre-pandemic (+45.3 min). CONCLUSION: These findings reveal the complex variability in PA behaviour brought about by the pandemic. SO WHAT?: Strategies to support the population in achieving sufficient PA must focus on maintaining an appetite for PA as we move out of the pandemic and on promoting more frequent PA sessions.

School-level factors associated with the sustainment of weekly physical activity scheduled in Australian elementary schools: an observational study.

BACKGROUND: We aimed to: (1) identify school-level factors associated with the sustainment of weekly physical activity (PA) scheduled in elementary schools following withdrawal of effective implementation support; and (2) determine teacher's perceived usefulness of suggested strategies for sustaining the scheduling of weekly PA. METHODS: A secondary exploratory analysis was employed of data from the intervention arm (n = 31 schools) of a randomised controlled trial. Self-report survey data from 134 classroom teachers in New South Wales, Australia, collected following withdrawal of initial implementation support (follow-up T1) and six-months following completion of support (follow-up T2) were used. The outcomes of sustainment of weekly overall PA and energisers (short classroom PA breaks) scheduled were measured via teachers' completion of a daily activity logbook, with results presented as the difference in mean minutes of PA and energisers scheduled at T1 and T2. An adapted version of the Program Sustainability Assessment Tool (PSAT) was used to measure capacity for program sustainability across seven key domains at follow-up T2. Linear mixed regressions were conducted to evaluate associations between school-level sociodemographic characteristics (e.g., school size, remoteness, and type), teacher-reported school factors (i.e., seven adapted PSAT domains) and the sustainment of PA and energisers scheduled across the school week. Perceived usefulness of 14 proposed sustainability strategies was measured via the teacher survey at follow-up T2 and reported descriptively. RESULTS: No school-level factor was statistically associated with the sustainment of overall weekly PA or energisers scheduled. Teacher-reported factors in two PSAT domains - 'strategic planning' and 'program evaluation' were statistically negatively associated with the sustainment of weekly energisers scheduled (- 6.74, 95% CI: - 13.02; - 0.47, p = 0.036 and - 6.65, 95% CI: - 12.17; - 1.12, p = 0.019 respectively). The proposed support sustainability strategy - 'provision of PA equipment packs that enable energisers or integrated lessons' was perceived useful by the most teachers (85%). CONCLUSIONS: Further research is required to explore additional contextual-specific, and end-user appropriate factors associated with schools' sustainment of weekly PA scheduled. This will help accurately inform the development of strategies to address these determinants and support the sustainment and long-term benefits of school-based health interventions more broadly.

Understanding the sustainment of population health programmes from a whole-of-system approach.

BACKGROUND: Population health prevention programmes are needed to reduce the prevalence of chronic diseases. Nevertheless, sustaining programmes at a population level is challenging. Population health is highly influenced by social, economic and political environments and is vulnerable to these system-level changes. The aim of this research was to examine the factors and mechanisms contributing to the sustainment of population prevention programmes taking a systems thinking approach. METHODS: We conducted a qualitative study through interviews with population health experts working within Australian government and non-government agencies experienced in sustaining public health programs at the local, state or national level (n = 13). We used a deductive thematic approach, grounded in systems thinking to analyse data. RESULTS: We identified four key barriers affecting program sustainment: 1) short term political and funding cycles; 2) competing interests; 3) silo thinking within health service delivery; and 4) the fit of a program to population needs. To overcome these barriers various approaches have centred on the importance of long-range planning and resourcing, flexible program design and management, leadership and partnerships, evidence generation, and system support structures. CONCLUSION: This study provides key insights for overcoming challenges to the sustainment of population health programmes amidst complex system-wide changes.

How equitable are the distributions of the physical activity and accessibility benefits of bicycle infrastructure?

BACKGROUND: Cycling for transport provides many health and social benefits - including physical activity and independent access to jobs, education, social opportunities, health care and other services (accessibility). However, some population groups have less opportunity to reach everyday destinations, and public transport stops, by bicycle - owing in part to their greater aversion to riding amongst motor vehicle traffic. Health equity can therefore be improved by providing separated cycleway networks that give more people the opportunity to access places by bicycle using traffic-free routes. The aim of this study was to assess the health equity benefits of two bicycle infrastructure development scenarios - a single cycleway, and a complete network of cycleways - by examining the distributions of physical activity and accessibility benefits across gender, age and income groups. METHODS: Travel survey data collected from residents in Sydney (Australia) were used to train a predictive transport mode choice model, which was then used to forecast the impact of the two intervention scenarios on transport mode choice, physical activity and accessibility. The latter was measured using a utility-based measure derived from the mode choice model. The distributions of the forecast physical activity and accessibility benefits were then calculated across gender, age and income groups. RESULTS: The modelled physical activity and accessibility measures improve in both intervention scenarios. However, in the single cycleway scenario, the benefits are greatest for the male, high-income and older age groups. In the complete network scenario, the benefits are more equally distributed. Forecast increases in cycling time are largely offset by decreases in walking time - though the latter is typically low-intensity physical activity, which confers a lesser health benefit than moderate-intensity cycling. CONCLUSIONS: Separated cycleway infrastructure can be used to improve health equity by providing greater opportunities for transport cycling in population groups more averse to riding amongst motor vehicle traffic. Disparities in the opportunity to access services and economic/social activities by bicycle - and incorporate more physical activity into everyday travel - could be addressed with connected, traffic-free cycleway networks that cater to people of all genders, ages and incomes.

Using natural experiments to improve public health evidence: a review of context and utility for obesity prevention.

BACKGROUND: Natural experiments are increasingly valued as a way to assess the health impact of health and non-health interventions when planned controlled experimental research designs may be infeasible or inappropriate to implement. This study sought to investigate the value of natural experiments by exploring how they have been used in practice. The study focused on obesity prevention research as one complex programme area for applying natural experiment studies. METHODS: A literature search sought obesity prevention research from January 1997 to December 2017 and identified 46 population health studies that self-described as a natural experiment. RESULTS: The majority of studies identified were published in the last 5 years, illustrating a more recent adoption of such opportunities. The majority of studies were evaluations of the impact of policies (n = 19), such as assessing changes to food labelling, food advertising or taxation on diet and obesity outcomes, or were built environment interventions (n = 17), such as the impact of built infrastructure on physical activity or access to healthy food. Research designs included quasi-experimental, pre-experimental and non-experimental methods. Few studies applied rigorous research designs to establish stronger causal inference, such as multiple pre/post measures, time series designs or comparison of change against an unexposed group. In general, researchers employed techniques to enhance the study utility but often were limited in the use of more rigorous study designs by ethical considerations and/or the particular context of the intervention. CONCLUSION: Greater recognition of the utility and versatility of natural experiments in generating evidence for complex health issues like obesity prevention is needed. This review suggests that natural experiments may be underutilised as an approach for providing evidence of the effects of interventions, particularly for evaluating health outcomes of interventions when unexpected opportunities to gather evidence arise.

Closing the loop: short term impacts on physical activity of the completion of a loop trail in Sydney, Australia.

BACKGROUND: In Australia, an estimated 57% of the population do not meet physical activity recommendations for health. The built environment is important for active living, and recreational trails provide safe and pleasant settings for this purpose. However, evidence for positive impacts on physical activity from real world natural experiments is sparse. We describe the impact of transforming a recreational trail into a loop on usage by cyclists and pedestrians and users' physical activity levels. METHOD: We conducted time series analyses of pre and post-completion (November 2013-July 2015) counts taken from infrared electronic counters of pedestrians and cyclists on two established sections of the trail adjusted for underlying trend, trend change, weather, holidays and trail closures. Chi-square analyses of pre and post-completion visual counts examined change in the distribution of pedestrian/cyclist, adult/child, and male/female users. Descriptive and bivariate analyses of post-completion intercept survey data of 249 trail users were conducted to examine user characteristics and impact on physical activity. RESULTS: Pedestrian and cyclist counts on established trail sections increased by between 200 and 340% from pre to post-completion. Visual count data showed a significant 7% increase in children (vs adults) using the trail at one site pre to post (p = 0.008). Of previous users, 48% reported doing more physical activity at the trail and this was additional to (not replacing) physical activity done elsewhere. Those users not meeting physical activity recommendations were more likely to report increased total physical activity since the loop was created (55.5% vs 39.2%, p = 0.031). The connected loop nature of the trail and its length was perceived to encourage more and different forms of physical activity. CONCLUSION: Creating an accessible loop trail away from motorised traffic can lead to increased trail use and potentially total physical activity. The modification to the trail encouraged proportionate and real increases in usage among vulnerable populations such as children and perhaps greater total physical activity especially for people not meeting physical activity recommendations. The findings suggest that the benefits of environmental changes such as these can accrue to those most in need of support for being physically active.

Evaluation of Get Healthy at Work, a state-wide workplace health promotion program in Australia.

BACKGROUND: Workplace health programs (WHPs) may improve adult health but very little evidence exists on multi-level WHPs implemented at-scale and so the relationship between program implementation factors and outcomes of WHPs are poorly understood. This study evaluated Get Healthy at Work (GHaW), a state-wide government-funded WHP in Australia. METHODS: A mixed-method design included a longitudinal quasi-experimental survey of businesses registered with GHaW and a comparison group of businesses surveyed over a 12-month period. Semi-structured interviews and focus groups with key contacts and employees of selected intervention group businesses and the service providers of the program were conducted to assess program adoption and adaptation. RESULTS: Positive business-level changes in workplace culture were observed over time among GHaW businesses compared with the control group. Multilevel regression modelling revealed perceptions that employees were generally healthy (p = 0.045 timeXgroup effect) and that the workplace promoted healthy behaviours (p = 0.004 timeXgroup effect) improved significantly while the control group reported no change in work culture perceptions. Changes in perceptions about work productivity were not observed; however only one third of businesses registered for the program had adopted GHaW during the evaluation period. Qualitative results revealed a number of factors contributing to program adoption: which depended on program delivery (e.g., logistics, technology and communication channels), design features of the program, and organisational factors (primarily business size and previous experience of WHPs). CONCLUSIONS: Evaluation of program factors is important to improve program delivery and uptake and to ensure greater scalability. GHaW has the potential to improve workplace health culture, which may lead to better health promoting work environments. These results imply that government can play a central role in enabling prioritisation and incentivising health promotion in the workplace.

Applying pragmatic approaches to complex program evaluation: A case study of implementation of the New South Wales Get Healthy at Work program.

ISSUE ADDRESSED: Complex health promotion programs, which can have multilevels of implementation and multi-components with nonlinear causal pathways, present many evaluation challenges. Traditional evaluation methods often fail to account for the complexity inherent in assessing these programs. In real-world settings, evaluations of complex programs are often beset by additional constraints of limited budgets and short timeframes. Determining whether a complex program is successful and how a program worked requires evaluators of complex programs to adopt a level of pragmatism. METHODS: This paper describes a pragmatic evaluation approach used to evaluate the Get Healthy at Work workplace health promotion program, implemented in New South Wales, Australia. Using the program as a case study, we describe some key principles for applying a pragmatic evaluation approach and use these principles to develop an appropriate evaluation strategy. RESULTS: The evaluation includes multiple research methods to assess program outputs and implementation; and identify emergent program impacts, within constrained resources. The evaluation was guided by epistemological flexibility, methodological comprehensiveness and operational practicality. CONCLUSION: Health promotion programs, such as state-wide obesity prevention programs, require appropriate evaluation methods which address their inherent complexity amidst the real-world evaluation constraints, and focuses on the essential evaluation needs. SO WHAT: The main complex program evaluation principles are applicable to other multilevel health promotion programs, challenged by methodological and practical or political constraints.

The unrealised potential of bike share schemes to influence population physical activity levels - A narrative review.

The recent proliferation of bike share schemes (BSS, also known as public bicycle use programs) in many cities has focused attention on their potential for reducing motorised traffic congestion, improving air quality and reducing car use. Since 2005, hundreds of bike share schemes have been implemented in many cities, with bike share usage patterns monitored in many of them. This paper assesses the development of BSS and provides a rationale for their potential health benefits. The key research question, as yet unanswered, is whether BSS themselves can contribute to improving population health, particularly through increasing population cycling, which would increase population levels of health-enhancing physical activity. This paper presents a framework for evaluating the contribution of BSS to population physical activity, and uses examples of new data analyses to indicate the challenges in answering this question. These illustrative analyses examine cycling in Australia, and [i] compares rates of cycling to work in BSS cities compared to the rest of Australia over time, and [ii] modelling trends in bike counts in Central Melbourne before and after introduction of the BSS in 2010, and compared to adjacent regions in nearby suburbs unexposed to a BSS. These indicative examples point to difficulties in attributing causal increases in cycling for transport to the introduction of a BSS alone. There is an evidence gap, and a need to identify opportunities to improve the health-related components of BSS evaluations, to answer the question whether they have any impact on population physical activity levels.

General practitioners' perceptions of population based bowel screening and their influence on practice: a qualitative study.

BACKGROUND: Although largely preventable, Australia has one of the highest rates of bowel cancer in the world. General Practitioners (GPs) have an important role to play in prevention and early detection of bowel cancer, however in Australia this is yet to be optimised and participation remains low. This study sought to understand how GPs' perceptions of bowel screening influence their attitudes to, and promotion of the faecal occult blood test (FOBT), to identify opportunities to enhance their role. METHODS: Interviews were conducted with 31 GPs from metropolitan and regional New South Wales (NSW), Australia. Discussions canvassed GPs' perceptions of their role in bowel screening and the national screening program; perceptions of screening tests; practices regarding discussing screening with patients; and views on opportunities to enhance their role. Transcripts were coded using Nvivo and thematically analysed. RESULTS: The study revealed GPs' perceptions of screening did not always align with broader public health definitions of 'population screening'. While many GPs reportedly understood the purpose of population screening, notions of the role of asymptomatic screening for bowel cancer prevention were more limited. Descriptions of screening centred on two major uses: the use of a screening 'process' to identify individual patients at higher risk; and the use of screening 'tools', including the FOBT, to aid diagnosis. While the FOBT was perceived as useful for identifying patients requiring follow up, GPs expressed concerns about its reliability. Colonoscopy by comparison, was considered by many as the gold standard for both screening and diagnosis. This perception reflects a conceptualisation of the screening process and associated tools as an individualised method for risk assessment and diagnosis, rather than a public health strategy for prevention of bowel cancer. CONCLUSION: The results show that GPs' perceptions of screening do not always align with broader public health definitions of 'population screening'. Furthermore, the way GPs understood screening was shown to impact their clinical practice, influencing their preferences for, and use of 'screening' tools such as FOBT. The findings suggest emphasising the preventative opportunity of FOBT screening would be beneficial, as would formally engaging GPs in the promotion of bowel screening.

Correcting bias in self-rated quality of life: an application of anchoring vignettes and ordinal regression models to better understand QoL differences across commuting modes.

PURPOSE: Likert scales are frequently used in public health research, but are subject to scale perception bias. This study sought to explore scale perception bias in quality-of-life (QoL) self-assessment and assess its relationships with commuting mode in the Sydney Travel and Health Study. METHODS: Multilevel ordinal logistic regression analysis was used to analyse the association between two global QoL items about overall QoL and health satisfaction, with usual travel mode to work or study. Anchoring vignettes were applied using parametric and simpler nonparametric methods to detect and adjust for differences in reporting behaviour across age, sex, education, and income groups. RESULTS: The anchoring vignettes exposed differences in scale responses across demographic groups. After adjusting for these biases, public transport users (OR = 0.37, 95 % CI 0.21-0.65), walkers (OR = 0.44, 95 % CI 0.24-0.82), and motor vehicle users (OR = 0.47, 95 % CI 0.25-0.86) were all found to have lower odds of reporting high QoL compared with bicycle commuters. Similarly, the odds of reporting high health satisfaction were found to be proportionally lower amongst all competing travel modes: motor vehicle users (OR = 0.31, 95 % CI 0.18-0.56), public transport users (OR = 0.34, 95 % CI 0.20-0.57), and walkers (OR = 0.35, 95 % CI 0.20-0.64) when compared with cyclists. Fewer differences were observed in the unadjusted models. CONCLUSION: Application of the vignettes by the two approaches removed scaling biases, thereby improving the accuracy of the analyses of the associations between travel mode and quality of life. The adjusted results revealed higher quality of life in bicycle commuters compared with all other travel mode users.

Knowledge of the signs and symptoms and risk factors of lung cancer in Australia: mixed methods study.

BACKGROUND: Lung cancer is the leading cause of cancer death in Australia. There is potential that health promotion about the risks and warning signs of lung cancer could be used to reduce delays in symptom presentation when symptoms are first detected. This study investigated knowledge, attitudes and beliefs which might impact help-seeking behaviour and could provide insight into possible public health interventions in New South Wales (NSW). METHODS: A convergent mixed method study design was used wherein data from 16 qualitative focus groups of residents (40+ years), purposefully recruited and stratified by smoking status, age and geography (metropolitan/regional), were compared with a CATI administered population-wide telephone survey (n = 1,000) using the Cancer Research UK cancer awareness measure (LungCAM). Qualitative findings were analysed thematically using NVIVO. Logistic regression analysis was used to investigate predictors of symptom knowledge in STATA. Findings were integrated using triangulation techniques. RESULTS: Across focus groups, haemoptysis was the only symptom creating a sense of medical urgency. Life experiences evoked a 'wait and see' attitude to any health deterioration. Perceived risk was low amongst those at risk with current smokers preferring to deny their risk while former smokers were generally unaware of any ongoing risk. The quantitative sample consisted of females (62 %), 40-65 years (53 %), low SES (53 %), former (46 %) and current smokers (14 %). In quantitative findings, haemoptysis and dyspnoea were the most recognised symptoms across the sample population. Age (<65 years), sex (female) and high socio-economic status contributed to a higher recognition of symptoms. Smoking was recognised as a cause of lung cancer, yet ever-smokers were less likely to recognise the risk of lung cancer due to second-hand smoke (OR 0.7 95 % CI 0.5-0.9). CONCLUSION: While there was some recognition of risk factors and symptoms indicative of lung cancer, there was disparity across the sample population. The qualitative findings also suggest that knowledge may not lead to earlier presentation; a lack of urgency about symptoms considered trivial, and smoking-related barriers such as stigma may also contribute to time delays in presentation. Public health interventions may be required to increase awareness of risk and emphasise the importance of seeking medical attention for ongoing symptoms.

A qualitative investigation of factors influencing participation in bowel screening in New South Wales.

Issue addressed Bowel cancer is Australia's second biggest cancer killer. Yet, despite the existence of a free national bowel-screening program, participation in this program remains low. The aim of the present study was to understand the current factors contributing to this trend to help inform future strategies to increase participation. Methods Eight focus groups (n=61 in total) were conducted with participants aged 45 years and over from metropolitan and regional New South Wales (NSW). Discussions canvassed awareness, knowledge, attitudes and beliefs regarding bowel cancer and screening, and explored how these factors influenced decisions to screen. Results The low public profile of bowel cancer compared with other cancers, together with poor knowledge of its prevalence and treatability, has contributed to a low perception of risk in the community. Minimal understanding of the often-asymptomatic presentation of bowel cancer and the role of screening in prevention has appeared to compromise the perceived value of screening. In addition, confusion regarding when, and how often, individuals should screen was apparent. Knowledge of bowel cancer and screening, and its role in motivating intention to screen, emerged as a dominant theme in the data. Conclusions The present study highlights specific knowledge gaps and confusion with regard to bowel cancer and screening. Addressing these gaps through the provision of clear, coordinated information may shift attitudes to screening and increase participation. So what? Given the Australian Government's recent commitment to expand the National Bowel Cancer Screening Program, insight into what is driving current perceptions, attitudes and subsequent participation in bowel cancer screening is crucial to the development and targeting of new approaches and initiatives.

Satisfaction with transport and enjoyment of the commute by commuting mode in inner Sydney.

Issue addressed Travel satisfaction has become an increasingly popular construct for the assessment and monitoring of transport systems and services. However, satisfaction may not adequately assess emotion or mood towards walking and cycling, especially when infrastructure is biased towards motor vehicle modes. In this exploratory study we sought to examine the associations of both satisfaction with transport and enjoyment from the commute to work or study by commute mode in an Australian inner city context where transport mode choices are readily available. Methods As part of the Sydney Transport and Health Study, 675 baseline study participants (2013) were invited to complete an online questionnaire in September/October 2014 and 512 did so (76% response rate). Participants who did not travel to work were removed from analyses, giving complete data for 473. Participants provided data on usual travel mode to work or study, satisfaction with transport, enjoyment from their commute, and demographics and neighbourhood factors. Results The main mode of travel to work or study in this inner city sample was public transport (41%), followed by motor vehicle (27%), walking (21%) and cycling (10%). Most participants were satisfied with their transport (82%), with little variation by mode. Walkers (49%) and cyclists (52%) reported far higher levels of enjoyment from their commute than car drivers (14%) or public transport users (10%), with an adjusted odds ratio of 6.18 (95% confidence interval 3.10-12.29, P<0.001) for walking and an adjusted odds ratio of 6.15 (95% confidence interval 2.68-14.08, P<0.001) for cycling. Conclusions People who walked or cycled to work or study in inner Sydney reported higher levels of enjoyment from their commute compared with those who drove. This suggests enjoyment may be another benefit of active travel. So what? Focusing on 'enjoyment' associated with walking or cycling to work may be a positive motivator to encourage active travel.

Use of and short-term impacts of new cycling infrastructure in inner-Sydney, Australia: a quasi-experimental design.

BACKGROUND: Given increasing investment in new cycling infrastructure, it is important to understand its impacts. The Sydney Transport and Health Study evaluates a new 2.4 km bi-directional separated bicycle path in inner-Sydney. This paper describes the users of the new bicycle path, and examines its short-term impacts upon cycling behaviour and perceptions of the local environment. METHODS: Data were collected from two bike counts at two intersections on the new bicycle path in the intervention area in 2013 and 2014. On-line surveys collected individual participant data in the intervention area and a similar comparison area before the bicycle path was built (2013), and 12 months later (four months after completion) (n = 512). The data included self-reported cycling behaviour, use of the new bicycle path and perceptions of changes in the local environment. RESULTS: Bike counts at two sites on the new bicycle path reported an increase of 23% and 97% respectively at 12 months. However, among the participants in the cohort, there was no change in the self-reported weekly frequency of cycling. One in six (approximately 15%) participants reported using the new bicycle path, with most users (76%) living in the intervention area. Bicycle path users were most likely to be frequent riders (at least weekly) [adjusted odds ratio (AOR) = 7.50, 95 % CI 3.93-14.31], be a high intensity recreational rider (AOR = 4.38, 95 % CI 1.53-12.54) or a low intensity transport rider (AOR = 2.42, 95 % CI 1.17-5.04) and live closer to the bicycle path (AOR = 1.24, 1.13-1.37). Perceptions that the neighbourhood was more pleasant, that there were more people walking and cycling were significantly higher in the intervention area at 12 months (both P values <0.05). CONCLUSIONS: Existing cycling behaviour and proximity to the bicycle path were associated with the use of the new bicycle path. Increased use of the new bicycle path as reported by the participants in the intervention area and increased cycling recorded by the bike counts may be due to existing cyclists changing routes to use the new path, and more cyclists from outside the study area using the new path, as study participants did not increase their frequency of cycling. Increases in cycling frequency in the intervention neighbourhood may require a longer lead time, additional promotional activities and further maturation of the Sydney bicycle path network. KEY MESSAGE: Understanding how new cycling infrastructure impacts communities can influence the promotion of such infrastructure.

Estimating the economic costs of skin cancer in New South Wales, Australia.

BACKGROUND: Skin cancer is one of the most common cancers in the world. The increased incidence of skin cancer, combined with limited health care resources and tight budgetary conditions, has increased the importance of understanding the economic impact of skin cancer. This research estimates the economic cost of skin cancer in the Australian state of New South Wales. METHOD: An incidence based approach is used to estimate lifetime costs of skin cancer. Both direct and indirect costs are considered - direct costs include resources associated with the management of skin cancer and indirect costs refer to productivity costs associated with morbidity and premature mortality. Diagnosis of skin cancer was determined according to ICD-10 codes using principal diagnosis. Linked administrative data and regression modelling are used to calculate costs; presented as Australian dollars for the year 2010. The human capital approach is used to value present and future productivity losses. RESULTS: The lifetime cost of the 150,000 incident cases of skin cancer diagnosed in NSW in 2010 is estimated at $536 million ($44,796 per melanoma and $2459 per non-melanoma). Direct costs accounted for 72 % of costs ($10,230 per melanoma and $2336 per non-melanoma) and indirect costs accounted for 28 % of costs ($34,567 per melanoma and $123 per non-melanoma). Direct costs are, on average, higher for females than males with indirect costs, on average, higher for males than females. CONCLUSION: This research provides new evidence on the economic cost of skin cancer and provides policy makers with information of the potential monetary savings that may arise from efforts to reduce the incidence of skin cancer.

Associations between the frequency of cycling and domains of quality of life.

ISSUE ADDRESSED: This study examined the association between domains of quality of life (QoL) and the frequency of cycling by men and women. METHOD: A cross-sectional survey of 846 healthy adults in Sydney, Australia measured cycling behaviour and self-reported QoL. Participants were aged 18-55 years and were living within 5km of the centre. Cycling frequency for all purposes was recorded as weekly, less than weekly or never cycling. QoL was measured using the four QoL domains of the WHOQOL-BREF: physical psychological, social and environment. Linear regression was used to assess the association between cycling and QoL. RESULTS: Among men, at least weekly cycling was associated with physical QoL (P=0.002) and any cycling was positively associated with psychological wellbeing (at least weekly P=0.01, less than weekly P=0.01) after adjusting for age, education and income. No significant associations were observed for women. CONCLUSION: Frequent cycling was associated with higher physical and psychological QoL in men, but not among women in this sample. No relationship was observed between cycling and the environment and social QoL domains. SO WHAT?: These findings suggest that cycling offers physical and psychological QoL benefits for men.

Knowledge, attitudes and beliefs about lung cancer in three culturally and linguistically diverse communities living in Australia: a qualitative study.

ISSUE ADDRESSED: Knowledge, attitudes and beliefs about lung cancer among Chinese, Vietnamese and Arabic-speaking communities in Sydney, New South Wales (NSW) are explored. METHODS: Seven focus groups were completed with a total of 51 participants (smokers and non-smokers) from three culturally and linguistically diverse communities (CALD). Five topics were discussed and translated summaries from focus groups were thematically analysed. RESULTS: There were variations in perceived susceptibility to lung cancer between the CALD groups and between smokers and non-smokers. Fatalistic views towards lung cancer were apparent across all three CALD communities. There were low levels of awareness of lung cancer signs and symptoms, with the exception of haemoptysis. Differences in help-seeking behaviour and levels of trust of general practitioners (GP) were apparent. CONCLUSION: Limited awareness of the signs and symptoms of lung cancer, combined with cultural perceptions about cancer, impacted on attitudes towards help-seeking behaviour in these three CALD communities. So what? The prevalence of smoking among Chinese men, Vietnamese men and Arabic-speaking communities in NSW puts them at increased risk of lung cancer. Health promotion initiatives for lung cancer should be tailored for CALD communities and could focus on increasing knowledge of key symptoms, awareness that ex-smokers are at risk and awareness of the diagnostic pathway including the importance of avoiding delays in help-seeking.