A peer-volunteer led active ageing programme to prevent decline in physical function in older people at risk of mobility disability (Active, Connected, Engaged [ACE]): study protocol for a randomised controlled trial.

BACKGROUND: The Active Connected Engaged [ACE] study is a multi-centre, pragmatic, two-arm, parallel-group randomised controlled trial [RCT] with an internal pilot phase. The ACE study incorporates a multi-level mixed methods process evaluation including a systems mapping approach and an economic evaluation. ACE aims to test the effectiveness and cost-effectiveness of a peer-volunteer led active ageing intervention designed to support older adults at risk of mobility disability to become more physically and socially active within their communities and to reduce or reverse, the progression of functional limitations associated with ageing. METHODS/DESIGN: Community-dwelling, older adults aged 65 years and older (n = 515), at risk of mobility disability due to reduced lower limb physical functioning (Short Physical Performance Battery (SPPB) score of 4-9 inclusive) will be recruited. Participants will be randomised to receive either a minimal control intervention or ACE, a 6-month programme underpinned by behaviour change theory, whereby peer volunteers are paired with participants and offer them individually tailored support to engage them in local physical and social activities to improve lower limb mobility and increase their physical activity. Outcome data will be collected at baseline, 6, 12 and 18 months. The primary outcome analysis (difference in SPPB score at 18 months) will be undertaken blinded to group allocation. Primary comparative analyses will be on an intention-to-treat (ITT) basis with due emphasis placed on confidence intervals. DISCUSSION: ACE is the largest, pragmatic, community-based randomised controlled trial in the UK to target this high-risk segment of the older population by mobilising community resources (peer volunteers). A programme that can successfully engage this population in sufficient activity to improve strength, coordination, balance and social connections would have a major impact on sustaining health and independence. ACE is also the first study of its kind to conduct a full economic and comprehensive process evaluation of this type of community-based intervention. If effective and cost-effective, the ACE intervention has strong potential to be implemented widely in the UK and elsewhere. TRIAL REGISTRATION: ISRCTN, ISRCTN17660493. Registered on 30 September 2021. Trial Sponsor: University of Birmingham, Contact: Dr Birgit Whitman, Head of Research Governance and Integrity; Email: researchgovernance@contacts.bham.ac.uk. Protocol Version 5 22/07/22.

The Health Economic Assessment Tool (HEAT) for walking and cycling - experiences from 10 years of application of a health impact assessment tool in policy and practice.

Introduction: In recent years, walking and cycling have moved into the focus as promising approaches to achieve public health, sustainable transport, climate goals and better urban resilience. However, they are only realistic transport and activity options for a large proportion of the population when they are safe, inclusive and convenient. One way to increase their recognition in transport policy is the inclusion of health impacts of walking and cycling into transport economic appraisals. Methods: The Health Economic Assessment Tool (HEAT) for walking and cycling calculates: if x people walk or cycle a distance of y on most days, what is the economic value of impacts on premature mortality, taking into account effects of physical activity, air pollution and road fatalities, as well as effects on carbon emissions. Different data sources were collated to examine how the HEAT in more than 10 years of existence, and to identify lessons learned and challenges. Results: Since its launch in 2009, the HEAT has gained wide recognition as a user friendly, yet robust, evidence-based tool usable by academics, policymakers, and practitioners. Originally designed for use in Europe, it has since been expanded for global use. Discussion: Challenges for a wider uptake of health-impact assessment (HIA) tools including active transport such as HEAT are the promotion and dissemination to local practitioners and policy makers also outside European and English-speaking regions and in low- and middle-income contexts, further increasing usability, and more generally the advancement of systematic data collection and impact quantification related to walking and cycling.

A qualitative exploration of English black adults' views of strength and balance activities in mid-life.

BACKGROUND: Public health guidelines state that all adults should undertake muscle and bone strengthening and balance training activities at least twice a week to support their physical function and maintain independent health. This is intended to maintain strength in adulthood and offset natural declines in bone density and muscle mass. Most older adults do not meet this guideline with low levels of compliance among older black people. This study explored the experiences of physical activity relating to strength and balance activities, amongst black men and women living in England, aged 50-70. METHODS: Participants were recruited by phone via a network of research recruitment specialists across England. In-depth qualitative interviews were conducted with 25 black people aged 50-70 living in England. An inductive thematic analysis was conducted. RESULTS: We found there was only a very general understanding of the importance of maintaining body strength and balance, and low salience: strength and balance activities were not seen to be an important part of participants' lives. Most participants only wanted to be strong enough to get on with 'normal life' and not to build strength or balance. Participants aged 50-70 were likely to think they were too young to worry about strength and balance, which tended to be mentioned only if someone had experienced a problem. Participants reported that NHS staff, especially physiotherapists are a key source of information on the topic and could therefore be useful in future prevention strategies. CONCLUSION: Public health recommendations stress the importance of increasing participation in regular strength and balance activities as people age, to reduce the risk of falls and maintain independence. This study has shown that among the black middle-aged adults we interviewed, the knowledge and salience of this message is low. Public health approaches should be taken to communicate the importance of enhancing strength and balance as people approach older age, including communication and education programmes led by health professionals, who were viewed with authority amongst these participants.

The Physical Activity Messaging Framework (PAMF) and Checklist (PAMC): International consensus statement and user guide.

Effective physical activity messaging plays an important role in the pathway towards changing physical activity behaviour at a population level. The Physical Activity Messaging Framework (PAMF) and Checklist (PAMC) are outputs from a recent modified Delphi study. This sought consensus from an international expert panel on how to aid the creation and evaluation of physical activity messages. In this paper, we (1) present an overview of the various concepts within the PAMF and PAMC, (2) discuss in detail how the PAMF and PAMC can be used to create physical activity messages, plan evaluation of messages, and aid understanding and categorisation of existing messages, and (3) highlight areas for future development and research. If adopted, we propose that the PAMF and PAMC could improve physical activity messaging practice by encouraging evidence-based and target population-focused messages with clearly stated aims and consideration of potential working pathways. They could also enhance the physical activity messaging research base by harmonising key messaging terminologies, improving quality of reporting, and aiding collation and synthesis of the evidence.

"Getting Ireland Active"-Application of a Systems Approach to Increase Physical Activity in Ireland Using the GAPPA Framework.

Physical activity (PA) promotion is a complex challenge, with the Global Action Plan on Physical Activity (GAPPA) endorsing a systems approach and recommending countries assess existing areas of progress which can be strengthened. This paper reports a process facilitating a systems approach for identifying current good practice and gaps for promoting PA in Ireland. Elements of participatory action research were enabled through 3 stages: (1) aligning examples of actions from Irish policy documents (n = 3) to the GAPPA, (2) workshop with stakeholders across multiple sectors, and (3) review of outputs. Data collected through the workshop were analyzed using a deductive thematic analysis guided by the GAPPA. The policy context in Ireland aligns closely to the GAPPA with the creation of Active Systems the most common strategic objective across policy documents. Forty participants (50% male) took part in the systems approach workshop, which after revision resulted in 80 examples of good practice and 121 actions for greater impact. A pragmatic and replicable process facilitating a systems approach was adopted and showed current Irish policy and practices align with the GAPPA "good practices." The process provides existing areas of progress which can be strengthened, as well as the policy opportunities and practice gaps.

Eight Investments That Work for Physical Activity.

BACKGROUND: The International Society for Physical Activity and Health (ISPAH) is a leading global organization working to advance research, policy, and practice to promote physical activity. Given the expanding evidence base on interventions to promote physical activity, it was timely to review and update a major ISPAH advocacy document-Investments that Work for Physical Activity (2011). METHODS: Eight investment areas were agreed upon through consensus. Literature reviews were conducted to identify key evidence relevant to policymakers in each sector or setting. RESULTS: The 8 investment areas were as follows: whole-of-school programs; active transport; active urban design; health care; public education; sport and recreation; workplaces; and community-wide programs. Evidence suggests that the largest population health benefit will be achieved by combining these investments and implementing a systems-based approach. CONCLUSIONS: Establishing consensus on 'what works' to change physical activity behavior is a cornerstone of successful advocacy, as is having appropriate resources to communicate key messages to a wide range of stakeholders. ISPAH has created a range of resources related to the new investments described in this paper. These resources are available in the 'advocacy toolkit' on the ISPAH website (www.ispah.org/resources).

Integrated Impact Assessment of Active Travel: Expanding the Scope of the Health Economic Assessment Tool (HEAT) for Walking and Cycling.

The World Health Organization's Health Economic Assessment Tool (HEAT) for walking and cycling is a user-friendly web-based tool to assess the health impacts of active travel. HEAT, developed over 10 years ago, has been used by researchers, planners and policymakers alike in appraisals of walking and cycling policies at both national and more local scales. HEAT has undergone regular upgrades adopting the latest scientific evidence. This article presents the most recent upgrades of the tool. The health impacts of walking and/or cycling in a specified population are quantified in terms of premature deaths avoided (or caused). In addition to the calculation of benefits derived from physical activity, HEAT was recently expanded to include assessments of the burden associated with air pollution exposure and crash risks while walking or cycling. Further, the impacts on carbon emissions from mode shifts to active travel modes can now be assessed. The monetization of impacts using Value of Statistical Life and Social Costs of Carbon now uses country-specific values. As active travel inherently results in often substantial health benefits as well as not always negligible risks, assessments of active travel behavior or policies are incomplete without considering health implications. The recent developments of HEAT make it easier than ever to obtain ballpark estimates of health impacts and carbon emissions related to walking and cycling.

Using system mapping to help plan and implement city-wide action to promote physical activity.

Background: There is growing interest in conceptualising public health problems such as physical inactivity as the outcome of multiple interacting factors within complex systems. A systems approach includes consideration of the indirect as well as direct impacts of interventions, the contexts within which they take place, the relations between the multiple factors at play, and the ways in which systems adapt in response to changes. This study involved working with stakeholders involved in a city-wide physical activity promotion programme in Derby, UK to investigate whether a conceptual map of the local physical activity system could be a useful tool to help improve the planning and implementation of the programme. Methods: We produced draft conceptual maps of the major modifiable drivers of physical activity in the city, based on the existing literature on determinants and correlates of physical activity, then refined them in a series of stakeholder meetings. The maps were used to explore ways in which the existing programme took a systems approach, and how it might be enhanced. Semistructured interviews were subsequently undertaken with stakeholders to assess their views on the contribution of the mapping approach. Results: Feedback from stakeholders described the mapping as valuable, especially in helping to identify the limitations of the original approach taken in the city. Conclusions: Even a very simple application of systems thinking can be a useful tool for disaggregating the key factors driving a system, helping to identify areas that merit greater attention, and supporting effective action.

The development of the Comprehensive Analysis of Policy on Physical Activity (CAPPA) framework.

BACKGROUND: Policy analysis is considered essential for achieving successful reforms in health promotion and public health. The only framework for physical activity (PA) policy analysis was developed at a time when the field of PA policy research was in its early stages. PA policy research has since grown, and our understanding of what elements need to be included in a comprehensive analysis of PA policy is now more refined. This study developed a new conceptual framework for PA policy analysis - the Comprehensive Analysis of Policy on Physical Activity (CAPPA) framework. METHODS: The development of the CAPPA framework was based on: (i) an extensive review of literature; (ii) an open discussion between the authors; (iii) three rounds of a Delphi process; and (iv) two-rounds of consultations with PA policy stakeholders. RESULTS: The CAPPA framework specifies 38 elements of a comprehensive analysis of PA policies in the following six categories, which comprise the building blocks of the framework: (i) purpose of analysis (including auditing and assessment of policies); (ii) policy level (including: international; national; subnational; local; and institutional policies); (iii) policy sector (including: health; sport; recreation and leisure; education; transport; environment; urban/rural planning and design; tourism; work and employment; public finance; and research sectors); (iv) type of policy (including: formal written policies; unwritten formal statements; written standards and guidelines; formal procedures; and informal policies); (v) stage of policy cycle (including: agenda setting; formulation; endorsement/legitimisation; implementation; evaluation; maintenance; termination; and succession); and (vi) scope of analysis (including availability; context; processes; actors; political will; content; and effects). Based on the CAPPA framework, we also proposed broad and inclusive definitions of PA policy and PA policy analysis. CONCLUSION: The CAPPA framework may be used to guide future studies related to PA policy and to provide a context for the analysis of its specific components. The framework could be used in the same way for sedentary behaviour policy research. Future research should examine the extent to which PA policy analysis has covered each of the elements specified in the CAPPA framework and analyse the elements for which evidence is lacking. Future studies should also determine whether the existing tools allow for auditing and assessment of all the CAPPA elements and develop new tools if needed to allow for a more comprehensive PA policy analysis.

Enablers and barriers to older people's participation in strength and balance activities: A review of reviews.

OBJECTIVES: This review sought to investigate the question: what are the key barriers to, and enablers for, older adults undertaking muscle strengthening and balance activities, and how can these be addressed by individuals and practitioners? METHODS: A search of PubMed for review-level evidence on professional and personal barriers and motivators for strength and balance activities among older people. RESULTS: The search and expert consultation found 46 studies; after screening, twelve papers were included. Many of the barriers and motivators to strength and balance activities are familiar ones that can also apply to physical activity more generally, such as not having the time. More specific barriers to strength and balance activities for older people were perceived risk of a heart attack, stroke, or death, and fear of looking too muscular; with motivators being improved ability to complete daily activities, preventing deterioration and disability, and decreasing the risk or fear of falling. CONCLUSIONS: This review of reviews has found a small but consistent body of literature describing the motivators and barriers to older adults taking part in strength and balance activities. This may be used as the basis for planning and delivering physical activity programmes for older adults.

A review of global surveillance on the muscle strengthening and balance elements of physical activity recommendations.

INTRODUCTION: Despite the importance of muscle strengthening and balance activities for health, these elements of the physical activity recommendations are often omitted from communication campaigns and national surveillance systems. This paper reviews national physical activity surveillance systems to determine which tools assess muscle strengthening and balance activities. METHODS: We reviewed each tool that was used to inform the Global Observatory for Physical Activity (GoPA) country card prevalence estimates. RESULTS: Of the 139 countries with GoPA country cards, 21 countries reported having no physical activity prevalence data. The prevalence estimates for 74 countries came from the World Health Organization 2014 Global Status Report on Non-Communicable Diseases. For the remaining 44 countries, a range of national and international surveys were used. A limited number of tools sought to assess muscle strengthening activities, and even fewer assessed balance and coordination activities. DISCUSSION: Several issues arise from this review, including the need to: verify the strength of the evidence to inform whether muscle strength and balance should be given equal prominence to the aerobic recommendation; establish which activities count towards different aspects of the guidelines; and confirm whether the muscle strengthening and balance components of the guidelines are 'in addition' to the aerobic component.

Gesundheitsökonomisches bewertungsinstrument (HEAT) für gehen und für radfahren: methodik und benutzeranleitung für bewertungen der auswirkungen von körperlicher betätigung, luftverschmutzung, verletzungen und kohlenstoffemissionen

Die Förderung von Radfahren und Zufußgehen zum Zwecke täglicher körperlicher Betätigung kommt nicht nur der Gesundheit zugute, sondern kann sich auch positiv auf die Umwelt auswirken. In dieser Publikation werden die für die Erleichterung einer solchen Umstellung entwickelten Instrumente und Empfehlungen zusammengefasst: die Methodik für die ökonomische Bewertung der Verkehrsinfrastruktur und der Verkehrspolitik in Bezug auf die gesundheitlichen Effekte von Zufußgehen und Radfahren; systematische Sichtungen der ökonomischen und gesundheitsbezogenen Fachliteratur; und Empfehlungen für die Anwendung der gesundheitsökonomischen Bewertungsinstrumente und der ihnen zugrunde liegenden Prinzipien. Es handelt sich hierbei um eine aktualisierte Fassung, in der auch die Gesundheitsfolgen von Straßenverkehrsunfällen, Luftverschmutzung und CO2-Emissionen berücksichtigt werden. Mit dem Instrument lassen sich verschiedene Bewertungen durchführen, wie etwa: das aktuelle Verkehrsaufkommen mit dem Rad oder zu Fuß und der Stellenwert des Radfahrens oder Gehens in einer Stadt oder einem Land; die Veränderungen im Laufe der Zeit durch einen Vergleich von Vorher und Nachher oder von Szenario A mit Szenario B (wie etwa vor und nach einer Maßnahme); und die Auswertung neuer oder laufender Projekte und Bestimmung ihres Kosten-Nutzen-Verhältnisses. HEAT können allein oder gemeinsam mit anderen Instrumenten für eine umfassendere ökonomische Bewertung oder eine Abschätzung der Gesundheitsfolgen herangezogen werden. Dieses Methodik- und Benutzerhandbuch ist von wesentlichem Interesse für Fachkräfte auf nationaler wie kommunaler Ebene, d. h. Verkehrsplaner und Verkehrsingenieure sowie Interessengruppen in den Bereichen Verkehr, Zufußgehen, Radfahren oder Umwelt, aber auch Gesundheitsökonomen und Experten für Bewegung und Gesundheitsförderung.

Outil d’évaluation économique des effets sanitaires (HEAT) liés à la pratique du vélo et de la marche : méthodologie et guide de l’utilisateur sur l’évaluation de l’activité physique, de la pollution atmosphérique, des traumatismes et de l’impact carbone

La promotion de la pratique du vélo et de la marche dans le cadre de l’activité physique quotidienne n’est pas seulement favorable à la santé, mais peut aussi s’avérer bénéfique pour l’environnement. Cette publication résume les outils élaborés afin de faciliter l’adoption de ces pratiques ainsi que les orientations dans ce domaine : méthodologie d’évaluation économique des infrastructures et politiques de transport en termes d’effets sanitaires de la bicyclette et de la marche ; revues systématiques de la littérature économique et sanitaire ; et conseils pour l’application des outils d’évaluation économique des effets sanitaires et principes à l’appui. Elle a été mise à jour afin de tenir compte des effets sanitaires des accidents de la route et de la pollution de l’air, ainsi que de l’impact sur les émissions de carbone. L’outil peut être utilisé pour plusieurs types d’évaluation, par exemple : l’évaluation des niveaux actuels (ou passés) de pratique du vélo ou de la marche, par exemple en montrant l’importance du vélo et de la marche dans une ville ou un pays donnés ; l’évaluation des changements au fil du temps, notamment en comparant les situations avant et après, ou le scénario A par rapport au scénario B (avec ou sans prise de mesures, par exemple) ; l’évaluation de projets nouveaux ou existants, notamment le calcul du rapport coûts-avantages. L’outil HEAT peut être utilisé de manière autonome, voire s’inscrire dans le cadre d’exercices plus complets d’évaluation économique ou d’une analyse prospective de l’impact sanitaire. Cette méthodologie et ce guide de l’utilisateur intéresseront principalement les professionnels aux niveaux national et local : les planificateurs des transports, les ingénieurs de la circulation, et les groupes d’intérêt spéciaux œuvrant dans le domaine du transport, de la marche, de la pratique du vélo ou de l’environnement, ainsi que les économistes de la santé et les experts en activité physique et en promotion de la santé.

Estimating the variation in need for community-based social care by body mass index in England and associated cost: population-based cross-sectional study.

BACKGROUND: Adult obesity is linked to a greater need for social care because of its association with the development of long term conditions and because obese adults can have physical and social difficulties which inhibit daily living. Obesity thus has considerable social care cost implications but the magnitude of these costs is currently unknown. This paper outlines an approach to estimating obesity-related social care costs in adults aged over 65 in England. METHODS: We used univariable and multivariable logistic regression models to investigate the relation between the self-reported need for social care and potential determinants, including body mass index (BMI), using data from Health Survey for England. We combined these modelled estimates of need for social care with the mean hours of help received, conditional on receiving any help, to calculate the expected hours of social care received per adult by BMI. RESULTS: BMI is positively associated with self-reported need for social care. A one unit (ie 1 kg/m2) increase in BMI is on average associated with a 5% increase in the odds of need for help with social care (odds ratio 1.05, 95% CI 1.04 to 1.07) in an unadjusted model. Adjusting for long term illness and sociodemographic characteristics we estimate the annual cost of local authority funded care for those who receive it is £599 at a BMI of 23 but £1086 at a BMI of 40. CONCLUSION: BMI is positively associated with self-reported need for social care after adjustment for sociodemographic factors and limiting long term illness. The increase in need for care with BMI gives rise to additional costs in social care provision which should be borne in mind when calculating the cost-effectiveness of interventions aimed at reducing obesity.

Evaluation of the implementation of an intervention to improve the street environment and promote walking for transport in deprived neighbourhoods.

BACKGROUND: Levels of physical activity remain low, particularly in deprived areas. Improving the street environment to promote walking for transport using a community engagement approach is a potential strategy to increase physical activity. An understanding of the implementation of this intervention approach is needed to facilitate further research, replication and scale-up. The aim of this study was to evaluate the implementation of the Fitter for Walking (FFW) intervention in deprived neighbourhoods. METHODS: FFW was delivered in five regions of England between August 2008 and March 2012 and aimed to use a community engagement approach to improve the street environment to promote walking for transport. Implementation was assessed in relation to reach; dosage; implementation processes and adaptation; and factors influencing implementation. Three data sources were used: focus groups and face-to-face interviews with coordinators; implementation logs; and participation records. RESULTS: Reach: 155 community groups participated in FFW engaging 30,230 local residents. Dosage: A wide variety of environmental improvements were implemented by local authorities (LAs) (42 projects) and by communities (46 projects). Examples of LA-led improvements included removal of encroaching vegetation, new/improved pedestrian signage, new dropped kerbs/kerb improvements and new, repaired or improved footpaths. Examples of community-led improvements included planting bulbs, shrubs or bedding plants, clean-up days and litter pick-ups. In 32 projects, no environmental improvements were implemented. Promotional and awareness-raising activities were undertaken in 81 projects. Examples included led walks, themed walks, development of maps/resources to promote improved routes and community events. Processes and adaptation: The need for a planning phase, a preparatory phase, and a delivery phase with a four step process were identified. Adaptability to local context was important. Factors influencing implementation: Five key themes were identified in relation to the barriers and facilitators of implementing FFW: local knowledge and contacts; intervention delivery; coordinator role; working with LAs and other partners; and working with communities. CONCLUSIONS: FFW is one of few reported interventions which have used a community engagement approach to change the street environment to promote walking for transport in deprived neighbourhoods. Delivering these types of interventions is complex and requires considerable resource and time. A set of recommendations and an implementation framework are proposed for future delivery of this and similar types of programme.

Health economic assessment tool (HEAT) for walking and for cycling: methods and user guide on physical activity, air pollution, injuries and carbon impact assessments

The promotion of cycling and walking for everyday physical activity not only promotes health but can also have positive effects on the environment. This publication summarizes the tools and guidance developed to facilitate this shift: the methodology for the economic assessment of transport infrastructure and policies in relation to the health effects of walking and cycling; systematic reviews of the economic and health literature; and guidance on applying the health economic assessment tools and the principles underlying it. It has been updated to consider the health effects of road crashes and air pollution and the effects on carbon emissions. The tool can be used for several types of assessment, for example: assessing current (or past) levels of cycling or walking, such as showing the value of cycling or walking in a city or country; assessing changes over time, such as comparing before-and-after situations or scenario A versus scenario B (such as with or without measures taken); and evaluating new or existing projects, including calculating benefit–cost ratios. HEAT can be used as a stand-alone tool or to provide input into more comprehensive economic appraisal exercises or prospective health impact assessment.