Using point-of-sale data to examine tobacco pricing across neighbourhoods in Scotland.

OBJECTIVES: To assess the geographical variation in tobacco price (cigarettes and roll-your-own (RYO) tobacco) in convenience stores across Scotland and how this relates to neighbourhood income deprivation, tobacco retail outlet density and urban/rural status. METHODS: Tobacco price data from 124 566 shopping baskets purchased in 274 convenience stores during 1 week in April 2018 were obtained through an electronic point-of-sale system. These data were combined with neighbourhood-level measures of income deprivation, tobacco retail outlet density and urban/rural status. We examined brand price for 12 of the most popular cigarette brands and 3 RYO brands and variations in purchases by price segment; multivariable regression analysis assessed associations between area variables and tobacco price. RESULTS: Most stores sold tobacco in all price segments. The lowest priced subvalue brands were the most popular in all neighbourhoods but were most dominant in shops in more deprived neighbourhoods. When total sales were assessed, overall purchase price varied significantly by neighbourhood income deprivation; packets of 20 cigarettes were 50 pence (5.6%) lower and RYO 34 pence (2.7%) lower among shops in the two highest income deprivation quintiles relative to the lowest. Analysis of individual brands showed that for 3 of the 12 cigarette brands considered, average prices were 12-17 pence lower in more deprived neighbourhoods with the most popular RYO brand 15 pence lower. There was limited evidence of a relationship with tobacco retail outlet density. CONCLUSION: Across Scottish convenience stores, the purchase price of cigarettes and RYO was lower in more income-deprived neighbourhoods. The lower prices primarily reflect greater sales of cheap brands in these areas, rather than retailers reducing the prices of individual brands.

A whole family-based physical activity promotion intervention: findings from the families reporting every step to health (FRESH) pilot randomised controlled trial.

INTRODUCTION: This study assessed the feasibility and acceptability of FRESH (Families Reporting Every Step to Health), a theory-based child-led family physical activity (PA) intervention delivered online. We also assessed the preliminary effectiveness of the intervention on outcomes of interest and whether pre-specified criteria were met to progress to a full-scale definitive trial. METHODS: In a three-armed randomised pilot trial, 41 families (with a 7-11-year-old index child) were allocated to a: 'family' (FAM), 'pedometer-only' (PED), or a no-treatment control (CON) arm. The FAM arm received access to the FRESH website, allowing participants to select step challenges to 'travel' to target cities around the world, log their steps, and track progress as families virtually globetrot. FAM and PED arms also received family sets of pedometers. All family members could participate in the evaluation. Physical (e.g., fitness, blood pressure), psychosocial (e.g., social support), behavioural (e.g., objectively-measured PA), and economic (e.g., expenditure for PA) data were collected at baseline, 8- and 52-weeks. RESULTS: At 8- and 52-weeks, 98 and 88% of families were retained, respectively. Most children liked participating in the study (> 90%) and thought it was fun (> 80%). Compared to the PED (45%) and CON (39%) arms, a higher percentage of children in the FAM (81%) arm reported doing more activities with their family. Adults agreed that FRESH encouraged their family do more PA and made their family more aware of the amount of PA they do. No notable between-group differences were found for childrens' minutes in moderate-to-vigorous PA. Sizeable changes of 9.4 (95%CI: 0.4, 18.4) and 15.3 (95%CI: 6.0, 24.5) minutes in moderate-to-vigorous PA was found for adults in the FAM group compared to those in the PED or CON groups, respectively. No other notable differences were found. CONCLUSION: This study demonstrates feasibility and acceptability of the FRESH intervention. All progression criteria were at least partially satisfied. However, we failed to recruit the target sample size and did not find a signal of effectiveness on PA particularly long-term or in children. Further refinements are required to progress to a full-scale trial. TRIAL REGISTRATION: This study was prospectively registered ( ISRCTN12789422 ) on 16/03/2016.

The relationship between living in urban and rural areas of Scotland and children's physical activity and sedentary levels: a country-wide cross-sectional analysis.

BACKGROUND: Living in urban or rural environments may influence children's levels of physical activity and sedentary behaviours. We know little about variations in device-measured physical activity and sedentary levels of urban and rural children using nationally representative samples, or if these differences are moderated by socioeconomic factors or seasonal variation. Moreover, little is known about the influence of 'walkability' in the UK context. A greater understanding of these can better inform intervention strategies or policy initiatives at the population level. METHODS: Country-wide cross-sectional study in Scotland in which 774 children (427 girls, 357 boys), aged 10/11 years, wore an accelerometer on one occasion for at least four weekdays and one weekend day. Mean total physical activity, time spent in sedentary, light, and moderate-to-vigorous physical activity (MVPA), per day were extracted for weekdays, weekend days, and all days combined. Regression analyses explored associations between physical activity outcomes, urban/rural residence, and a modified walkability index (dwelling density and intersection density); with interactions fitted for household equivalised income and season of data collection. Sensitivity analyses assessed variation in findings by socioeconomic factors and urbanicity. RESULTS: Rural children spent an average of 14 min less sedentary (95% CI of difference: 2.23, 26.32) and 13 min more in light intensity activity (95% CI of difference, 2.81, 24.09) per day than those from urban settlements. No urban-rural differences were found for time spent in MVPA or in total levels of activity. Our walkability index was not associated with any outcome measure. We found no interactions with household equivalised income, but there were urban/rural differences in seasonal variation; urban children engaged in higher levels of MVPA in the spring months (difference: 10 mins, p = 0.06, n.s) and significantly lower levels in winter (difference: 8.7 mins, p = 0.036). CONCLUSIONS: Extrapolated across one-year, rural children would accumulate approximately 79 h (or just over 3 days) less sedentary time than urban children, replacing this for light intensity activity. With both outcomes having known implications for health, this finding is particularly important. Future work should prioritise exploring the patterns and context in which these differences occur to allow for more targeted intervention/policy strategies.

Primary care referral for knee MRI in the United Kingdom: Association with demography and subsequent surgical intervention.

BACKGROUND: Since 2008 primary care physicians (GPs) in our region have been allowed open access to knee MRI scans. There are questions about whether this changes referral practice and if it is an effective use of resources. PURPOSE: To describe the change in demographics of patients referred for knee MRI following implementation of a new referral pathway. STUDY TYPE: Retrospective observational study. POPULATION: All primary care referrals between 2008 and 2015 for knee MRI from a population of 900,000. FIELD STRENGTH/SEQUENCE: Not applicable. ASSESSMENT: Demographic profile and number of knee MRI referrals and subsequent arthroscopies. STATISTICAL TESTS: Comparisons between urban and rural populations used the t-test. Test for normality used Shapiro-Wilks. Comparison between abnormal MRI proportions used a chi-squared test. RESULTS: There were 23,928 knee MRI referrals (10,695 from GPs) between 2000 and 2015. MRI knee referrals rose from 210 in 2008 to 2379 in 2015. The average age of the patient decreased from 46.8 (SD = 14.9) in 2008 to 41.3 (SD = 14.7) in 2015. Conversion to arthroscopy declined from 15.4% to 10.2%, but there was no significant change in abnormal scan proportion. Conversion rates showed no significant difference between rural (9.6%) and urban populations (10.5%). Referral rates were significantly higher in low socioeconomic status areas (47.3% vs. 34.6%). The median referral rate per 1000 patients was 13.8 (interquartile range = 8.4). Referral rates varied widely between practices. DATA CONCLUSION: Despite a large rise in knee MRI referrals from primary care, there has been no substantial change in the age profile, suggesting that there has been no increase in inappropriate referral of elderly patients in whom MRI is unlikely to influence management. A modest decrease in the conversion rate to arthroscopy may be reasonably offset against a decrease in secondary care referrals. Socioeconomic status of the target population must be considered when planning primary care knee MRI services. LEVEL OF EVIDENCE: 4 Technical Efficacy Stage: 6 J. Magn. Reson. Imaging 2019.

Prevalence of asthma, aspirin sensitivity and allergy in chronic rhinosinusitis: data from the UK National Chronic Rhinosinusitis Epidemiology Study.

BACKGROUND: Chronic rhinosinusitis (CRS) is a common disorder associated with other respiratory tract diseases such as asthma and inhalant allergy. However, the prevalence of these co-morbidities varies considerably in the existing medical literature and by phenotype of CRS studied. The study objective was to identify the prevalence of asthma, inhalant allergy and aspirin sensitivity in CRS patients referred to secondary care and establish any differences between CRS phenotypes. METHODS: All participants were diagnosed in secondary care according to international guidelines and invited to complete a questionnaire including details of co-morbidities and allergies. Data were analysed for differences between controls and CRS participants and between phenotypes using chi-squared tests. RESULTS: The final analysis included 1470 study participants: 221 controls, 553 CRS without nasal polyps (CRSsNPs), 651 CRS with nasal polyps (CRSwNPs) and 45 allergic fungal rhinosinusitis (AFRS). The prevalence of asthma was 9.95, 21.16, 46.9 and 73.3% respectively. The prevalence of self-reported confirmed inhalant allergy was 13.1, 20.3, 31.0 and 33.3% respectively; house dust mite allergy was significantly higher in CRSwNPs (16%) compared to CRSsNPs (9%, p < 0.001). The prevalence of self- reported aspirin sensitivity was 2.26, 3.25, 9.61 and 40% respectively. The odds ratio for aspirin sensitivity amongst those with AFRS was 28.8 (CIs 9.9, 83.8) p < 0.001. CONCLUSIONS: The prevalence of asthma and allergy in CRS varies by phenoytype, with CRSwNPs and AFRS having a stronger association with both. Aspirin sensitivity has a highly significant association with AFRS. All of these comorbidities are significantly more prevalent than in non-CRS controls and strengthen the need for a more individualised approach to the combined airway.

Longitudinal association between change in the neighbourhood built environment and the wellbeing of local residents in deprived areas: an observational study.

BACKGROUND: Features of the urban neighbourhood influence the physical, social and mental wellbeing of residents and communities. We explored the longitudinal association between change to the neighbourhood built environment and the wellbeing of local residents in deprived areas of Glasgow, Scotland. METHODS: A cohort of residents (n = 365; mean age 50 years; 44% male; 4.1% of the 9000 mailed surveys at baseline) responded to a postal survey in 2005 and 2013. Wellbeing was assessed with the mental (MCS-8) and physical (PCS-8) components of the SF-8 scale. We developed software to aid identification of visible changes in satellite imagery occurring over time. We then used a Geographical Information System to calculate the percentage change in the built environment occurring within an 800 m buffer of each participant's home. RESULTS: The median change in the neighbourhood built environment was 3% (interquartile range 6%). In the whole sample, physical wellbeing declined by 1.5 units on average, and mental wellbeing increased by 0.9 units, over time. In multivariable linear regression analyses, participants living in neighbourhoods with a greater amount of change in the built environment (unit change = 1%) experienced significantly reduced physical (PCS-8: -0.13, 95% CI -0.26 to 0.00) and mental (MCS-8: -0.16, 95% CI -0.31 to - 0.02) wellbeing over time compared to those living in neighbourhoods with less change. For mental wellbeing, a significant interaction by baseline perception of financial strain indicated a larger reduction in those experiencing greater financial strain (MCS-8: -0.22, 95% CI -0.39 to - 0.06). However, this relationship was reversed in those experiencing lower financial strain, whereby living in neighbourhoods with a greater amount of change was associated with significantly improved mental wellbeing over time (MCS-8: 0.38, 95% CI 0.04 to 0.72). CONCLUSIONS: Overall, we found some evidence that living in neighbourhoods experiencing higher levels of physical change worsened wellbeing in local residents. However, we found a stronger negative relationship in those with lower financial security and a positive relationship in those with higher financial security. This is one of few studies exploring the longitudinal relationship between the environment and health.

Conserving tropical biodiversity via market forces and spatial targeting.

The recent report from the Secretariat of the Convention on Biological Diversity [(2010) Global Biodiversity Outlook 3] acknowledges that ongoing biodiversity loss necessitates swift, radical action. Protecting undisturbed lands, although vital, is clearly insufficient, and the key role of unprotected, private land owned is being increasingly recognized. Seeking to avoid common assumptions of a social planner backed by government interventions, the present work focuses on the incentives of the individual landowner. We use detailed data to show that successful conservation on private land depends on three factors: conservation effectiveness (impact on target species), private costs (especially reductions in production), and private benefits (the extent to which conservation activities provide compensation, for example, by enhancing the value of remaining production). By examining the high-profile issue of palm-oil production in a major tropical biodiversity hotspot, we show that the levels of both conservation effectiveness and private costs are inherently spatial; varying the location of conservation activities can radically change both their effectiveness and private cost implications. We also use an economic choice experiment to show that consumers' willingness to pay for conservation-grade palm-oil products has the potential to incentivize private producers sufficiently to engage in conservation activities, supporting vulnerable International Union for Conservation of Nature Red Listed species. However, these incentives vary according to the scale and efficiency of production and the extent to which conservation is targeted to optimize its cost-effectiveness. Our integrated, interdisciplinary approach shows how strategies to harness the power of the market can usefully complement existing--and to-date insufficient--approaches to conservation.

Does home neighbourhood supportiveness influence the location more than volume of adolescent's physical activity? An observational study using global positioning systems.

BACKGROUND: Environmental characteristics of home neighbourhoods are hypothesised to be associated with residents' physical activity levels, yet many studies report only weak or equivocal associations. We theorise that this may be because neighbourhood characteristics influence the location of activity more than the volume. Using a sample of UK adolescents, we examine the role of home neighbourhood supportiveness for physical activity, both in terms of volume of activity undertaken and a measure of proximity to home at which activity takes place. METHODS: Data were analysed from 967 adolescents living in and around the city of Bristol, UK. Each participant wore an accelerometer and a GPS device for 7 days during school term time. These data were integrated into a Geographical Information System containing information on the participants' home neighbourhoods and measures of environmental supportiveness. We then identified the amount of out-of-school activity of different intensities that adolescents undertook inside their home neighbourhood and examined how this related to home neighbourhood supportiveness. RESULTS: We found that living in a less supportive neighbourhood did not negatively impact the volume of physical activity that adolescents undertook. Indeed these participants recorded similar amounts of activity (e.g. 20.5 mins per day of moderate activity at weekends) as those in more supportive neighbourhoods (18.6 mins per day). However, the amount of activity adolescents undertook inside their home neighbourhood did differ according to supportiveness; those living in less supportive locations had lower odds of recording activity inside their home neighbourhood. This was observed across all intensities of activity including sedentary, light, moderate, and vigorous. CONCLUSIONS: Our findings suggest that the supportiveness of the neighbourhood around home may have a greater influence on the location of physical activity than the volume undertaken. This finding is at odds with the premise of the socio-ecological models of physical activity that have driven this research field for the last two decades, and has implications for future research, as by simply measuring volumes of activity we may be underestimating the impact of the environment on physical activity behaviours.

A case-control study of medical, psychological and socio-economic factors influencing the severity of chronic rhinosinusitis.

BACKGROUND: Chronic rhinosinusitis (CRS) is a common and debilitating disorder. Little is known about the epidemiology of this disease. The aims of the study were to identify differences in socio-economic variables and quality of life between patients with chronic rhinosinusitis and healthy controls, to identify any significant associations between CRS and other medical co-morbidities, psychiatric disease or environmental exposure and to explore the experience of CRS from the perspective of CRS sufferers. METHODS: Participants were recruited from ENT clinics from 30 centres across the UK. They completed a study-specific questionnaire considering environmental, medical and socio-economic factors, and SF-36 and SNOT-22 scores. All participants with CRS were diagnosed by a clinician and categorised as having CRS (with polyposis, without polyposis or allergic fungal rhinosinusitis (AFRS)). Controls included family and friends of those attending ENT outpatient clinics and hospital staff who had no diagnosis of nose or sinus problems and had not been admitted to hospital in the previous 12 months. RESULTS: A total of 1470 study participants (1249 patients and 221 controls) were included in the final analysis. Highly significant differences were seen in generic and disease-specific quality of life scores between CRS sufferers and controls; mean SNOT-22 score 45.0 for CRS compared with 12.1 amongst controls. There were no clear differences in socioeconomic variables including social class, index of multiple deprivation and educational attainment between cases and controls. Common comorbidities with a clear association included respiratory and psychiatric disorders, with a higher frequency of reported upper respiratory tract infections. CONCLUSIONS: CRS is associated with significant impairment in quality of life and with certain medical co-morbidities. In contrast to other common ENT disorders, no socioeconomic differences were found between patients and controls in this study.

Spatially explicit integrated modeling and economic valuation of climate driven land use change and its indirect effects.

We present an integrated model of the direct consequences of climate change on land use, and the indirect effects of induced land use change upon the natural environment. The model predicts climate-driven shifts in the profitability of alternative uses of agricultural land. Both the direct impact of climate change and the induced shift in land use patterns will cause secondary effects on the water environment, for which agriculture is the major source of diffuse pollution. We model the impact of changes in such pollution on riverine ecosystems showing that these will be spatially heterogeneous. Moreover, we consider further knock-on effects upon the recreational benefits derived from water environments, which we assess using revealed preference methods. This analysis permits a multi-layered examination of the economic consequences of climate change, assessing the sequence of impacts from climate change through farm gross margins, land use, water quality and recreation, both at the individual and catchment scale.

An assessment of the relevance of the home neighbourhood for understanding environmental influences on physical activity: how far from home do people roam?

BACKGROUND: The choice of geographical unit of analysis in studies of the built environment and physical activity has typically been restricted to the home neighbourhood where only a small proportion of physical activity may actually be undertaken. This study aimed to examine the distance from home at which physical activity takes place and how this varies by personal and neighbourhood characteristics. METHODS: A cross-sectional, population based study of 195 people in the North West region of England, aged 18 to 91 years, clustered in 60 localities (small geographical areas of ~125 households). Individual socio-demographic data were collected by computer-aided personal interviews and physical activity was characterised by accelerometer and Global Positioning System (GPS) data. The locations of periods of light, moderate and vigorous intensity physical activity (LMVPA) undertaken outdoors were linked to measures of the neighbourhood around the home and distance from home. RESULTS: Sixty per cent of outdoors LMVPA took place outside of the proximal home neighbourhood (800 m buffer). Distances from home where median levels of LMVPA were undertaken varied by gender (p < 0.05), home location, area deprivation, and car ownership (all p < 0.001). CONCLUSIONS: Objectively measured physical activity appears to vary appreciably by participant characteristics and home location, although for many settings a large proportion is undertaken outside of the home neighbourhood, suggesting the characterisation of neighbourhoods close to home will fail to properly capture the environmental influences on physical activity.

Developing and testing a street audit tool using Google Street View to measure environmental supportiveness for physical activity.

BACKGROUND: Walking for physical activity is associated with substantial health benefits for adults. Increasingly research has focused on associations between walking behaviours and neighbourhood environments including street characteristics such as pavement availability and aesthetics. Nevertheless, objective assessment of street-level data is challenging. This research investigates the reliability of a new street characteristic audit tool designed for use with Google Street View, and assesses levels of agreement between computer-based and on-site auditing. METHODS: The Forty Area STudy street VIEW (FASTVIEW) tool, a Google Street View based audit tool, was developed incorporating nine categories of street characteristics. Using the tool, desk-based audits were conducted by trained researchers across one large UK town during 2011. Both inter and intra-rater reliability were assessed. On-site street audits were also completed to test the criterion validity of the method. All reliability scores were assessed by percentage agreement and the kappa statistic. RESULTS: Within-rater agreement was high for each category of street characteristic (range: 66.7%-90.0%) and good to high between raters (range: 51.3%-89.1%). A high level of agreement was found between the Google Street View audits and those conducted in-person across the nine categories examined (range: 75.0%-96.7%). CONCLUSION: The audit tool was found to provide a reliable and valid measure of street characteristics. The use of Google Street View to capture street characteristic data is recommended as an efficient method that could substantially increase potential for large-scale objective data collection.

Microbiota composition is moderately associated with greenspace composition in a UK cohort of twins.

Exposure to natural environments, known as greenspace, appears to positively influence health, yet the mechanisms are unclear. Given that gut microbiota are associated with inflammatory disorders more prevalent in urban areas and individuals with lower greenspace exposure, microbiota may act as a mediator between greenspace and health. Using 2443 participants of the TwinsUK cohort, microbiota differences were compared in relation to rural/urban living and with quantiles of area-level greenspace at three different neighbourhood distances: 800 m, 3000 m and 5000 m. Using microbiota data captured from faecal samples using 16S rRNA marker gene sequencing, small compositional differences in association with 3000 m greenspace (p = 0.003) in models adjusted for confounders of microbiota variance (sequencing depth, antibiotics use, body mass index, frailty, age, diet, region and socioeconomic variables) were observed. Differences in abundances of genus were observed for all measures of greenspace in adjusted models; a key pathogenic genus was increased in abundance in association with urbanicity (Escherichia/Shigella, logFC = 0.73742, padj <0.001). Further, utilising the twin structure, within-pair differences in microbiota composition were compared and associations with 800 m greenspace observed (factor level significance in association with greatest difference, ß = 0.08, p = 0.0162) as were differences in Escherichia/Shigella. The microbiota signature of those with a greater exposure to greenspace, but not necessarily explicitly rural individuals, was distinct from other individuals, suggesting microbiota as a potential mediator for greenspace and health.

Environmental supportiveness for physical activity in English schoolchildren: a study using Global Positioning Systems.

BACKGROUND: There is increasing evidence that the environment plays a role in influencing physical activity in children and adults. As children have less autonomy in their behavioural choices, neighbourhood environment supportiveness may be an important determinant of their ability to be active. Yet we know rather little about the types of environment that children use for bouts of physical activity. This study uses accelerometery and global positioning system technologies to identify the charactieristics of environments being used for bouts of continuous moderate to vigorous physical activity (MVPA) in a sample of English schoolchildren. METHODS: The study used a convenience sample of 100 children from SPEEDY (Sport, Physical activity and Eating behaviour: Environmental Determinants in Young people), a cohort of 2064 9-10 year-olds from Norfolk, England, recruited in 2007. Children wore an ActiGraph GT1M accelerometer and a Garmin Forerunner 205 GPS unit over four consecutive days. Accelerometery data points were matched to GPS locations and bouts (5 minutes or more) of MVPA were identified. Bout locations were overlaid with a detailed landcover dataset developed in a GIS to identify the types of environment supporting MVPA. Findings are presented using descriptive statistics. RESULTS: Boys were also more active than girls, spending an average of 20 (SD 23) versus 11 (SD 15) minutes per day in MVPA bouts. Children who spent more time outside the home were more active (p = 0.002), especially girls and children living in rural locations (both p < 0.05). Children tended to be active close to home, with 63% of all bout time occurring inside neighbourhoods, although boys (p = 0.05) and rural children (p = 0.01) were more likely to roam outside their neighbourhood. Amongst urban children, gardens (28% of bout time) and the street environment (20%) were the most commonly used environments for MVPA bouts. Amongst rural children farmland (22%) and grassland (18%) were most frequently used. CONCLUSION: The study has developed a new methodology for the identification of environments in which bouts of continuous physical activity are undertaken. The results highlight the importance of the provision of urban gardens and greenspaces, and the maintenance of safe street environments as places for children to be active.

Greenspace access, use, and physical activity: understanding the effects of area deprivation.

OBJECTIVES: To understand the patterning of greenspace provision and use by area deprivation, and determine how deprivation moderates relationships with physical activity. METHODS: The responses obtained from 6821 respondents to the 2005 'The Quality of Life in your Neighbourhood Survey' undertaken in Bristol, England, were combined with objective measures of access to greenspaces. Area deprivation was determined using the Index of Multiple Deprivation. Descriptive analyses examined how mean distance, perceived greenspace access and safety, visit frequency, and physical activity varied by deprivation quartile. Logistic regression models examined how relationships were moderated by deprivation. RESULTS: Respondents in more deprived areas lived closer to greenspaces, but reported poorer perceived accessibility, poorer safety, and less frequent use. Frequency of use declined with distance but only in the most affluent areas. Relationships between physical activity and perceived accessibility, safety, and visit frequency were moderated by deprivation. CONCLUSIONS: The accessibility of greenspaces was better in more deprived areas but those residents had more negative perceptions and were less likely to use the greenspaces. Interventions may be most effective if they target the perceptions and needs of residents of deprived neighbourhoods.

The development and feasibility of a randomised family-based physical activity promotion intervention: the Families Reporting Every Step to Health (FRESH) study.

BACKGROUND: There is a need for high-quality research aiming to increase physical activity in families. This study assessed the feasibility and acceptability of FRESH (Families Reporting Every Step to Health), a child-led family-based physical activity intervention delivered online. METHODS: In a two-armed randomised feasibility study, 12 families (with an 8-10-year-old index child) were allocated to a 'child-only' (CO) or 'family' arm (FAM) of the theory-based FRESH intervention. Both received access to the FRESH website, allowing participants to select step challenges to 'travel' to target cities around the world, log their steps, and track their progress as they virtually globetrot. Only index children wore pedometers in CO; in FAM, all family members wore pedometers and worked towards collective goals. All family members were eligible to participate in the evaluation. Mixed-methods process evaluation (questionnaires and family focus groups) at 6-week follow-up consisted of completing questionnaires assessing acceptability of the intervention and accompanying effectiveness evaluation, focussed on physical (e.g. fitness, blood pressure), psychosocial (e.g. social support), and behavioural (e.g. objectively-measured family physical activity) measures. RESULTS: All families were retained (32 participants). Parents enjoyed FRESH and all children found it fun. More FAM children wanted to continue with FRESH, found the website easy to use, and enjoyed wearing pedometers. FAM children also found it easier to reach goals. Most CO families would have preferred whole family participation. Compared to CO, FAM exhibited greater website engagement as they travelled to more cities (36 ± 11 vs. 13 ± 8) and failed fewer challenges (1.5 ± 1 vs. 3 ± 1). Focus groups also revealed that most families wanted elements of competition. All children enjoyed being part of the evaluation, and adults disagreed that there were too many intervention measures (overall, 2.4 ± 1.3) or that data collection took too long (overall, 2.2 ± 1.1). CONCLUSION: FRESH was feasible and acceptable to participating families; however, findings favoured the FAM group. Recruitment, intervention fidelity and delivery and some measurement procedures are particular areas that require further attention for optimisation. Testing the preliminary effectiveness of FRESH on family physical activity is a necessary next step. TRIAL REGISTRATION: This study was registered and given an International Standard Randomised Controlled Trials Number (ISRCTN12789422). Registered 16 March 2016. http://www.isrctn.com/ISRCTN12789422.

Whole family-based physical activity promotion intervention: the Families Reporting Every Step to Health pilot randomised controlled trial protocol.

INTRODUCTION: Family-based physical activity (PA) interventions present a promising avenue to promote children's activity; however, high-quality experimental research is lacking. This paper describes the protocol for the FRESH (Families Reporting Every Step to Health) pilot trial, a child-led family-based PA intervention delivered online. METHODS AND ANALYSIS: FRESH is a three-armed, parallel-group, randomised controlled pilot trial using a 1:1:1 allocation ratio with follow-up assessments at 8 and 52 weeks postbaseline. Families will be eligible if a minimum of one child in school Years 3-6 (aged 7-11 years) and at least one adult responsible for that child are willing to participate. Family members can take part in the intervention irrespective of their participation in the accompanying evaluation and vice versa.Following baseline assessment, families will be randomly allocated to one of three arms: (1) FRESH; (2) pedometer-only or (3) no-intervention control. All family members in the pedometer-only and FRESH arms receive pedometers and generic PA promotion information. FRESH families additionally receive access to the intervention website; allowing participants to select step challenges to 'travel' to target cities around the world, log steps and track progress as they virtually globetrot. Control families will receive no treatment. All family members will be eligible to participate in the evaluation with two follow-ups (8 and 52 weeks). Physical (eg, fitness and blood pressure), psychosocial (eg, social support) and behavioural (eg, objectively measured family PA) measures will be collected at each time point. At 8-week follow-up, a mixed methods process evaluation will be conducted (questionnaires and family focus groups) assessing acceptability of the intervention and evaluation. FRESH families' website engagement will also be explored. ETHICS AND DISSEMINATION: This study received ethical approval from the Ethics Committee for the School of the Humanities and Social Sciences at the University of Cambridge. Findings will be disseminated via peer-reviewed publications, conferences and to participating families. TRIAL REGISTRATION NUMBER: ISRCTN12789422.

Gamification of active travel to school: A pilot evaluation of the Beat the Street physical activity intervention.

Beat the Street aims to get children more active by encouraging them to walk and cycle in their neighbourhood using tracking technology with a reward scheme. This pilot study evaluates the impact of Beat the Street on active travel to school in Norwich, UK. Eighty children 8-10 yrs were recruited via an intervention and control school. They wore an accelerometer for 7 days at baseline, mid-intervention and post-intervention (+20 weeks), and completed a travel diary. Physical activity overall was not higher at follow-up amongst intervention children compared to controls. However, there was a positive association between moderate-to-vigorous physical activity (MVPA) during school commute times and the number of days on which children touched a Beat the Street sensor. This equated to 3.46min extra daily MVPA during commute times for children who touched a sensor on 14.5 days (the mean number of days), compared to those who did not engage. We also found weekly active travel increased at the intervention school (+10.0% per child) while it decreased at the control (-7.0%), p=0.056. Further work is needed to understand how improved engagement with the intervention might impact outcomes.

Emergency hospital admissions for asthma and access to primary care: cross-sectional analysis.

BACKGROUND: Access to general practices may be an important determinant of emergency admissions for asthma, as early treatment of exacerbations has been shown to prevent deterioration. AIM: To determine whether access to primary care is associated with emergency admissions for asthma. DESIGN AND SETTING: Cross-sectional analysis of data from English practices in 2010-2011. METHOD: Negative binomial regression was used to explore the associations between emergency admissions for asthma and seven measures of patient-reported access to general practice services taken from the GP Patient Survey, controlled for the characteristics of practice populations. Incidence rate ratios (IRR) were calculated for each association. RESULTS: In total 7806 (95%) of practices had data for all variables. There were 3 134 106 patients with asthma, and there were 55 570 emergency admissions with asthma. Admission rates were lower in practices with a higher composite access score (adjusted IRR for 10% change in variable 0.679, 95% CI = 0.665 to 0.708). Admissions were higher in those practices with higher proportions of the practice population who were white, and in practices with lower performance in the Quality and Outcomes Framework indicator 'asthma review in past 15 months' (Asthma 6). Assuming these associations were causal, a higher access score of 10% was associated with a decrease of 17 837 admissions per year for these practices. CONCLUSION: Practices with higher patient-reported access had lower rates of emergency admissions for asthma. Policymakers should consider improving access to primary care as one potential way to help prevent emergency hospital admissions for asthma.

Is change in environmental supportiveness between primary and secondary school associated with a decline in children׳s physical activity levels?

Using a sample of English schoolchildren, we evaluate whether a change in school local area environmental supportiveness between primary and secondary school is associated with changes in active travel behaviours and physical activity levels. Participant׳s activity levels and travel behaviours were recorded for a week during their primary school final year and secondary school first year. Environmental supportiveness was evaluated using a Geographical Information System. Children attending both a primary and secondary school with a more supportive local environment were more likely to maintain active travel behaviours than those with less supportive environments. However, no trends were apparent with change in school supportiveness and change in physical activity. Policies that focus on the maintenance and uptake of active travel behaviours may help maintain children׳s physical activity levels into adolescence.