Real-world application of a scalable school-based physical activity intervention: A cross-sectional survey of the implementation of The Daily Mile in Greater London primary schools.

School-based physical activity interventions are considered ideal given their potential to reach most children. They can help children achieve the recommended guidelines of 60 minutes of moderate-to-vigorous physical activity per day. The Daily Mile is a popular school-based active mile intervention with a global reach. It recommends ten core principles for successful implementation, three of which are key for effectiveness: that it is quick (15 minutes), the whole school participates, and that it takes place in the school day during lessons (excluding physical education lessons and scheduled breaks). Studies assessing the impacts of The Daily Mile do not often report implementation of the ten core principles which is crucial to identifying the potential impact and feasibility of scalable interventions in real-world settings. Our aim was to assess adherence to The Daily Mile's ten core principles in Greater London primary schools. We created and distributed a survey to 1717 primary schools during September 2020 and achieved a 21% (n = 369/1717) response rate by September 2021. Our sample was representative of Greater London primary schools with responses from every London borough. A total of 196/369 (53%) schools reported implementing The Daily Mile but none of them reported adherence to all ten core principles. Adherence to at least 6/10 principles in various combinations was reported by 54/196 (28%) schools. Only 19/196 (10%) schools that reported implementing The Daily Mile reported adherence to the three key principles recommended for effectiveness. Despite its popularity and global reach, our findings suggest that an implementation gap exists when The Daily Mile is adopted in real-world settings which is likely to challenge its intended purpose. Further research in school settings is needed to understand factors that can improve adherence to increase the potential public health impact of The Daily Mile and other similar interventions.

Developing a core outcome set for physical activity interventions in primary schools: a modified-Delphi study.

OBJECTIVES: To develop a core outcome set (COS) for physical activity interventions in primary schools. DESIGN: Modified-Delphi study. SETTING: The UK and international. PARTICIPANTS: 104 participants from four stakeholder groups (educators, public health professionals, health researchers, parents); 16 children (aged 8-9 years) from 1 London primary school. INTERVENTIONS: Physical activity interventions. METHODS: Four-stage process: (1) outcomes extracted from relevant studies identified from an umbrella review and a focus group; (2) list of outcomes produced and domains established; (3) stakeholders completed a two-round Delphi survey by rating (Round 1) and re-rating (Round 2) each outcome on a nine-point Likert Scale from 'not important' to 'critical': a>70% participant threshold identified the outcomes rated 'critical' to measure, and outcomes important to children were identified through a workshop; and (4) a stakeholder meeting to achieve consensus of the outcomes to include in the COS. RESULTS: In total, 74 studies were extracted from 53 reviews. A list of 50 outcomes was produced and three domains were established: 'physical activity and health' (16 outcomes), 'social and emotional health' (22 outcomes) and 'educational performance' (12 outcomes). 104 participants completed survey Round 1; 65 participants completed both rounds. In total, 13 outcomes met the threshold; children identified 8 outcomes. Fourteen outcomes achieved consensus to produce the COS: five outcomes for physical activity and health (diet (varied and balanced), energy, fitness, intensity of physical activity, sleep (number of hours)); seven outcomes for social and emotional health (anxiety, depression, enjoyment, happiness, self-esteem, stress, well-being); and two outcomes for educational performance (concentration, focus). CONCLUSIONS: We have developed the first COS for physical activity interventions in primary schools in consultation with those interested in the development and application of an agreed standardised set of outcomes. Future studies including these outcomes will reduce heterogeneity across studies. TRIAL REGISTRATION NUMBER: Core Outcome Measures in Effectiveness Trials Initiative registration number 1322; Results.

Identifying local authority need for, and uptake of, school-based physical activity promotion in England-a cluster analysis.

BACKGROUND: School-based physical activity interventions such as The Daily Mile (TDM) are widely promoted in children's physical activity guidance. However, targeting such interventions to areas of greatest need is challenging since determinants vary across geographical areas. Our study aimed to identify local authorities in England with the greatest need to increase children's physical activity and assess whether TDM reaches school populations in areas with the highest need. METHODS: This was a cross-sectional study using routinely collected data from Public Health England. Datasets on health, census and the built environment were linked. We conducted a hierarchical cluster analysis to group local authorities by 'need' and estimated the association between 'need' and registration to TDM. RESULTS: We identified three clusters of high, medium and low need for physical activity interventions in 123 local authorities. Schools in high-need areas were more likely to be registered with TDM (incidence rate ratio 1.25, 95% confidence interval: 1.12-1.39) compared with low-need areas. CONCLUSIONS: Determinants of children's physical activity cluster geographically across local authorities in England. TDM appears to be an equitable intervention reaching schools in local authorities with the highest needs. Health policy should account for clustering of health determinants to match interventions with populations most in need.

Impact of The Daily Mile on children's physical and mental health, and educational attainment in primary schools: iMprOVE cohort study protocol.

INTRODUCTION: School-based active mile initiatives such as The Daily Mile (TDM) are widely promoted to address shortfalls in meeting physical activity recommendations. The iMprOVE Study aims to examine the impact of TDM on children's physical and mental health and educational attainment throughout primary school. METHODS AND ANALYSIS: iMprOVE is a longitudinal quasi-experimental cohort study. We will send a survey to all state-funded primary schools in Greater London to identify participation in TDM. The survey responses will be used for non-random allocation to either the intervention group (Daily Mile schools) or to the control group (non-Daily Mile schools). We aim to recruit 3533 year 1 children (aged 5-6 years) from 77 primary schools and follow them up annually until the end of their primary school years. Data collection taking place at baseline (children in school year 1) and each primary school year thereafter includes device-based measures of moderate-to-vigorous physical activity (MVPA) and questionnaires to measure mental health (Strengths and Difficulties Questionnaire) and educational attainment (ratings from 'below expected' to 'above expected levels'). The primary outcome is the mean change in MVPA minutes from baseline to year 6 during the school day among the intervention group compared with controls. We will use multilevel linear regression models adjusting for sociodemographic data and participation in TDM. The study is powered to detect a 10% (5.5 min) difference between the intervention and control group which would be considered clinically significant. ETHICS AND DISSEMINATION: Ethics has been approved from Imperial College Research Ethics Committee, reference 20IC6127. Key findings will be disseminated to the public through research networks, social, print and media broadcasts, community engagement opportunities and schools. We will work with policy-makers for direct application and impact of our findings.

Weekend and weekday associations between the residential built environment and physical activity: Findings from the ENABLE London study.

BACKGROUND: We assessed whether the residential built environment was associated with physical activity (PA) differently on weekdays and weekends, and contributed to socio-economic differences in PA. METHODS: Measures of PA and walkability, park proximity and public transport accessibility were derived for baseline participants (n = 1,064) of the Examining Neighbourhood Activities in Built Living Environments in London (ENABLE London) Study. Multilevel-linear-regressions examined associations between weekend and weekday steps and Moderate to Vigorous PA (MVPA), residential built environment factors, and housing tenure status as a proxy for socio-economic position. RESULTS: A one-unit decrease in walkability was associated with 135 (95% CI [28; 242]) fewer steps and 1.2 (95% CI [0.3; 2.1]) fewer minutes of MVPA on weekend days, compared with little difference in steps and minutes of MVPA observed on weekdays. A 1km-increase in distance to the nearest local park was associated with 597 (95% CI [161; 1032]) more steps and 4.7 (95% CI [1.2; 8.2]) more minutes of MVPA on weekend days; 84 fewer steps (95% CI [-253;420]) and 0.3 fewer minutes of MVPA (95%CI [-2.3, 3.0]) on weekdays. Lower public transport accessibility was associated with increased steps on a weekday (767 steps, 95%CI [-13,1546]) compared with fewer steps on weekend days (608 fewer steps, 95% CI [-44, 1658]). None of the associations between built environment factors and PA on either weekend or weekdays were modified by socio-economic status. However, socio-economic differences in PA related moderately to socio-economic disparities in PA-promoting features of the residential neighbourhood. CONCLUSIONS: The residential built environment is associated with PA differently at weekends and on weekdays, and contributes moderately to socio-economic differences in PA.

Longitudinal impact of changes in the residential built environment on physical activity: findings from the ENABLE London cohort study.

BACKGROUND: Previous research has reported associations between features of the residential built environment and physical activity but these studies have mainly been cross-sectional, limiting inference. This paper examines whether changes in a range of residential built environment features are associated with changes in measures of physical activity in adults. It also explores whether observed effects are moderated by socio-economic status. METHODS: Data from the Examining Neighbourhood Activity in Built Living Environments in London (ENABLE London) study were used. A cohort of 1278 adults seeking to move into social, intermediate, and market-rent East Village accommodation was recruited in 2013-2015, and followed up after 2 years. Accelerometer-derived steps (primary outcome), and GIS-derived measures of residential walkability, park proximity and public transport accessibility were obtained both at baseline and follow-up. Daily steps at follow-up were regressed on daily steps at baseline, change in built environment exposures and confounding variables using multilevel linear regression to assess if changes in neighbourhood walkability, park proximity and public transport accessibility were associated with changes in daily steps. We also explored whether observed effects were moderated by housing tenure as a marker of socio-economic status. RESULTS: Between baseline and follow-up, participants experienced a 1.4 unit (95%CI 1.2,1.6) increase in neighbourhood walkability; a 270 m (95%CI 232,307) decrease in distance to their nearest park; and a 0.7 point (95% CI 0.6,0.9) increase in accessibility to public transport. A 1 s.d. increase in neighbourhood walkability was associated with an increase of 302 (95%CI 110,494) daily steps. A 1 s.d. increase in accessibility to public transport was not associated with any change in steps overall, but was associated with a decrease in daily steps amongst social housing seekers (- 295 steps (95%CI - 595, 3), and an increase in daily steps for market-rent housing seekers (410 95%CI -191, 1010) (P-value for effect modification = 0.03). CONCLUSION: Targeted changes in the residential built environment may result in increases in physical activity levels. However, the effect of improved accessibility to public transport may not be equitable, showing greater benefit to the more advantaged.

Evaluating the effect of change in the built environment on mental health and subjective well-being: a natural experiment.

BACKGROUND: Neighbourhood characteristics may affect mental health and well-being, but longitudinal evidence is limited. We examined the effect of relocating to East Village (the former London 2012 Olympic Athletes' Village), repurposed to encourage healthy active living, on mental health and well-being. METHODS: 1278 adults seeking different housing tenures in East village were recruited and examined during 2013-2015. 877 (69%) were followed-up after 2  years; 50% had moved to East Village. Analysis examined change in objective measures of the built environment, neighbourhood perceptions (scored from low to high; quality -12 to 12, safety -10 to 10 units), self-reported mental health (depression and anxiety) and well-being (life satisfaction, life being worthwhile and happiness) among East Village participants compared with controls who did not move to East Village. Follow-up measures were regressed on baseline for each outcome with group status as a binary variable, adjusted for age, sex, ethnicity, housing tenure and household clustering (random effect). RESULTS: Participants who moved to East Village lived closer to their nearest park (528 m, 95% CI 482 to 575 m), in more walkable areas, and had better access to public transport, compared with controls. Living in East Village was associated with marked improvements in neighbourhood perceptions (quality 5.0, 95% CI 4.5 to 5.4 units; safety 3.4, 95% CI 2.9 to 3.9 units), but there was no overall effect on mental health and well-being outcomes. CONCLUSION: Despite large improvements in the built environment, there was no evidence that moving to East Village improved mental health and well-being. Changes in the built environment alone are insufficient to improve mental health and well-being.

The effect of moving to East Village, the former London 2012 Olympic and Paralympic Games Athletes' Village, on mode of travel (ENABLE London study, a natural experiment).

BACKGROUND: Interventions to encourage active modes of travel (walking, cycling) may improve physical activity levels, but longitudinal evidence is limited and major change in the built environment / travel infrastructure may be needed. East Village (the former London 2012 Olympic Games Athletes Village) has been repurposed on active design principles with improved walkability, open space and public transport and restrictions on residential car parking. We examined the effect of moving to East Village on adult travel patterns. METHODS: One thousand two hundred seventy-eight adults (16+ years) seeking to move into social, intermediate, and market-rent East Village accommodation were recruited in 2013-2015, and followed up after 2 years. Individual objective measures of physical activity using accelerometry (ActiGraph GT3X+) and geographic location using GPS travel recorders (QStarz) were time-matched and a validated algorithm assigned four travel modes (walking, cycling, motorised vehicle, train). We examined change in time spent in different travel modes, using multilevel linear regresssion models adjusting for sex, age group, ethnicity, housing group (fixed effects) and household (random effect), comparing those who had moved to East Village at follow-up with those who did not. RESULTS: Of 877 adults (69%) followed-up, 578 (66%) provided valid accelerometry and GPS data for at least 1 day (≥540 min) at both time points; half had moved to East Village. Despite no overall effects on physical activity levels, sizeable improvements in walkability and access to public transport in East Village resulted in decreased daily vehicle travel (8.3 mins, 95%CI 2.5,14.0), particularly in the intermediate housing group (9.6 mins, 95%CI 2.2,16.9), and increased underground travel (3.9 mins, 95%CI 1.2,6.5), more so in the market-rent group (11.5 mins, 95%CI 4.4,18.6). However, there were no effects on time spent walking or cycling. CONCLUSION: Designing walkable neighbourhoods near high quality public transport and restrictions on car usage, may offer a community-wide strategy shift to sustainable transport modes by increasing public transport use, and reducing motor vehicle travel.

Protocol for developing a core outcome set for evaluating school-based physical activity interventions in primary schools.

INTRODUCTION: Primary school-based physical activity interventions, such as The Daily Mile initiative, have the potential to increase children's physical activity levels over time, which is associated with a variety of health benefits. Comparing interventions or combining results of several studies of a single intervention is challenging because previous studies have examined different outcomes or used different measures that are not feasible or relevant for researchers in school settings. The development and implementation of a core outcome set (COS) for primary school-based physical activity interventions would ensure outcomes important to those involved in implementing and evaluating interventions are standardised. METHODS AND ANALYSIS: Our aim is to develop a COS for studies of school-based physical activity interventions. We will achieve this by undertaking a four-stage process:(1) identify a list of outcomes assessed in studies through a systematic review of international literature; (2) establish domains from these outcomes to produce questionnaire items; (3) prioritise outcomes through a two-stage Delphi survey with four key stakeholder groups (researchers, public health professionals, educators and parents), where stakeholders rate the importance of each outcome on a 9-point Likert scale (consensus that the outcomes should be included in the COS will be determined as 70% or more of all stakeholders scoring the outcome 7%-9% and 15% or less scoring 1 to 3); (4) achieve consensus on a final COS in face-to-face meetings with a sample of stakeholders and primary school children. ETHICS AND DISSEMINATION: We have received ethical approval from Imperial College London (ref: 19IC5428). The results of this study will be disseminated via conference presentations/public health meetings, peer-reviewed publications and through appropriate media channels. TRIAL REGISTRATION NUMBER: Core Outcome Measures in Effectiveness Trials Initiative (COMET) number: 1322.

The effect of moving to East Village, the former London 2012 Olympic and Paralympic Games Athletes' Village, on physical activity and adiposity (ENABLE London): a cohort study.

BACKGROUND: The built environment can affect health behaviours, but longitudinal evidence is limited. We aimed to examine the effect of moving into East Village, the former London 2012 Olympic and Paralympic Games Athletes' Village that was repurposed on active design principles, on adult physical activity and adiposity. METHODS: In this cohort study, we recruited adults seeking new accommodation in East Village and compared physical activity and built environment measures with these data in control participants who had not moved to East Village. At baseline and after 2 years, we objectively measured physical activity with accelerometry and adiposity with body-mass index and bioimpedance, and we assessed objective measures of and participants' perceptions of change in their built environment. We examined the change in physical activity and adiposity between the East Village and control groups, after adjusting for sex, age group, ethnicity, housing tenure, and household (as a random effect). FINDINGS: We recruited participants for baseline assessment between Jan 24, 2013, and Jan 7, 2016, and we followed up the cohort after 2 years, between Feb 24, 2015, and Oct 24, 2017. At baseline, 1819 households (one adult per household) consented to initial contact by the study team. 1278 adults (16 years and older) from 1006 (55%) households participated at baseline; of these participants, 877 (69%) adults from 710 (71%) households were assessed after 2 years, of whom 441 (50%) participants from 343 (48%) households had moved to East Village. We found no effect associated with moving to East Village on daily steps, the time spent doing moderate-to-vigorous physical activity (either in total or in 10-min bouts or more), daily sedentary time, body-mass index, or fat mass percentage between participants who had moved to East Village and those in the control group, despite sizeable improvements in walkability and neighbourhood perceptions of crime and quality among the East Village group relative to their original neighbourhood at baseline. INTERPRETATION: Despite large improvements in neighbourhood perceptions and walkability, we found no clear evidence that moving to East Village was associated with increased physical activity. Improving the built environment on its own might be insufficient to increase physical activity. FUNDING: National Institute for Health Research and National Prevention Research Initiative.

An open-source tool to identify active travel from hip-worn accelerometer, GPS and GIS data.

BACKGROUND: Increases in physical activity through active travel have the potential to have large beneficial effects on populations, through both better health outcomes and reduced motorized traffic. However accurately identifying travel mode in large datasets is problematic. Here we provide an open source tool to quantify time spent stationary and in four travel modes(walking, cycling, train, motorised vehicle) from accelerometer measured physical activity data, combined with GPS and GIS data. METHODS: The Examining Neighbourhood Activities in Built Living Environments in London study evaluates the effect of the built environment on health behaviours, including physical activity. Participants wore accelerometers and GPS receivers on the hip for 7 days. We time-matched accelerometer and GPS, and then extracted data from the commutes of 326 adult participants, using stated commute times and modes, which were manually checked to confirm stated travel mode. This yielded examples of five travel modes: walking, cycling, motorised vehicle, train and stationary. We used this example data to train a gradient boosted tree, a form of supervised machine learning algorithm, on each data point (131,537 points), rather than on journeys. Accuracy during training was assessed using five-fold cross-validation. We also manually identified the travel behaviour of both 21 participants from ENABLE London (402,749 points), and 10 participants from a separate study (STAMP-2, 210,936 points), who were not included in the training data. We compared our predictions against this manual identification to further test accuracy and test generalisability. RESULTS: Applying the algorithm, we correctly identified travel mode 97.3% of the time in cross-validation (mean sensitivity 96.3%, mean active travel sensitivity 94.6%). We showed 96.0% agreement between manual identification and prediction of 21 individuals' travel modes (mean sensitivity 92.3%, mean active travel sensitivity 84.9%) and 96.5% agreement between the STAMP-2 study and predictions (mean sensitivity 85.5%, mean active travel sensitivity 78.9%). CONCLUSION: We present a generalizable tool that identifies time spent stationary and time spent walking with very high precision, time spent in trains or vehicles with good precision, and time spent cycling with moderate precisionIn studies where both accelerometer and GPS data are available this tool complements analyses of physical activity, showing whether differences in PA may be explained by differences in travel mode. All code necessary to replicate, fit and predict to other datasets is provided to facilitate use by other researchers.

Housing, neighbourhood and sociodemographic associations with adult levels of physical activity and adiposity: baseline findings from the ENABLE London study.

OBJECTIVES: The neighbourhood environment is increasingly shown to be an important correlate of health. We assessed associations between housing tenure, neighbourhood perceptions, sociodemographic factors and levels of physical activity (PA) and adiposity among adults seeking housing in East Village (formerly London 2012 Olympic/Paralympic Games Athletes' Village). SETTING: Cross-sectional analysis of adults seeking social, intermediate and market-rent housing in East Village. PARTICIPANTS: 1278 participants took part in the study (58% female). Complete data on adiposity (body mass index (BMI) and fat mass %) were available for 1240 participants (97%); of these, a subset of 1107 participants (89%) met the inclusion criteria for analyses of accelerometer-based measurements of PA. We examined associations between housing sector sought, neighbourhood perceptions (covariates) and PA and adiposity (dependent variables) adjusted for household clustering, sex, age group, ethnic group and limiting long-standing illness. RESULTS: Participants seeking social housing had the fewest daily steps (8304, 95% CI 7959 to 8648) and highest BMI (26.0 kg/m2, 95% CI 25.5kg/m2 to 26.5 kg/m2) compared with those seeking intermediate (daily steps 9417, 95% CI 9106 to 9731; BMI 24.8 kg/m2, 95% CI 24.4 kg/m2 to 25.2 kg/m2) or market-rent housing (daily steps 9313, 95% CI 8858 to 9768; BMI 24.6 kg/m2, 95% CI 24.0 kg/m2 to 25.2 kg/m2). Those seeking social housing had lower levels of PA (by 19%-42%) at weekends versus weekdays, compared with other housing groups. Positive perceptions of neighbourhood quality were associated with higher steps and lower BMI, with differences between social and intermediate groups reduced by ~10% following adjustment, equivalent to a reduction of 111 for steps and 0.5 kg/m2 for BMI. CONCLUSIONS: The social housing group undertook less PA than other housing sectors, with weekend PA offering the greatest scope for increasing PA and tackling adiposity in this group. Perceptions of neighbourhood quality were associated with PA and adiposity and reduced differences in steps and BMI between housing sectors. Interventions to encourage PA at weekends and improve neighbourhood quality, especially among the most disadvantaged, may provide scope to reduce inequalities in health behaviour.

Comparisons of depression, anxiety, well-being, and perceptions of the built environment amongst adults seeking social, intermediate and market-rent accommodation in the former London Olympic Athletes' Village.

The Examining Neighbourhood Activities in Built Living Environments in London (ENABLE London) study provides a unique opportunity to examine differences in mental health and well-being amongst adults seeking social, intermediate (affordable rent), and market-rent housing in a purpose built neighbourhood (East Village, the former London 2012 Olympic Athletes' Village), specifically designed to encourage positive health behaviours. Multi-level logistic regression models examined baseline differences in levels of depression, anxiety and well-being across the housing groups. Compared with the intermediate group, those seeking social housing were more likely to be depressed, anxious and had poorer well-being after adjustment for demographic and health status variables. Further adjustments for neighbourhood perceptions suggest that compared with the intermediate group, perceived neighbourhood characteristics may be an important determinant of depression amongst those seeking social housing, and lower levels of happiness the previous day amongst those seeking market-rent housing. These findings add to the extensive literature on inequalities in health, and provide a strong basis for future longitudinal work that will examine change in depression, anxiety and well-being after moving into East Village, where those seeking social housing potentially have the most to gain.

Cohort profile: Examining Neighbourhood Activities in Built Living Environments in London: the ENABLE London-Olympic Park cohort.

PURPOSE: The Examining Neighbourhood Activities in Built Living Environments in London (ENABLE London) project is a natural experiment which aims to establish whether physical activity and other health behaviours show sustained changes among individuals and families relocating to East Village (formerly the London 2012 Olympics Athletes' Village), when compared with a control population living outside East Village throughout. PARTICIPANTS: Between January 2013 and December 2015, 1497 individuals from 1006 households were recruited and assessed (at baseline) (including 392 households seeking social housing, 421 seeking intermediate and 193 seeking market rent homes). The 2-year follow-up rate is 62% of households to date, of which 57% have moved to East Village. FINDINGS TO DATE: Assessments of physical activity (measured objectively using accelerometers) combined with Global Positioning System technology and Geographic Information System mapping of the local area are being used to characterise physical activity patterns and location among study participants and assess the attributes of the environments to which they are exposed. Assessments of body composition, based on weight, height and bioelectrical impedance, have been made and detailed participant questionnaires provide information on socioeconomic position, general health/health status, well-being, anxiety, depression, attitudes to leisure time activities and other personal, social and environmental influences on physical activity, including the use of recreational space and facilities in their residential neighbourhood. FUTURE PLANS: The main analyses will examine the changes in physical activity, health and well-being observed in the East Village group compared with controls and the influence of specific elements of the built environment on observed changes. The ENABLE London project exploits a unique opportunity to evaluate a 'natural experiment', provided by the building and rapid occupation of East Village. Findings from the study will be generalisable to other urban residential housing developments, and will help inform future evidence-based urban planning.