Jane E Powell

Evaluating the travel, physical activity and carbon impacts of a 'natural experiment' in the provision of new walking and cycling infrastructure: methods for the core module of the iConnect study

Introduction Improving infrastructure to support walking and cycling is often regarded as fundamental to encouraging their widespread uptake. However, there is little evidence that specific provision of this kind has led to a significant increase in walking or cycling in practice, let alone wider impacts such as changes in overall physical activity or carbon emissions. Connect2 is a major new project that aims to promote walking and cycling in the UK by improving local pedestrian and cycle routes. It therefore provides a useful opportunity to contribute new evidence in this field by means of a natural experimental study. Methods and analysis iConnect is an independent study that aims to integrate the perspectives of public health and transport research on the measurement and evaluation of the travel, physical activity and carbon impacts of the Connect2 programme. In this paper, the authors report the study design and methods for the iConnect core module. This comprised a cohort study of residents living within 5 km of three case study Connect2 projects in Cardiff, Kenilworth and Southampton, supported by a programme of qualitative interviews with key informants about the projects. Participants were asked to complete postal questionnaires, repeated before and after the opening of the new infrastructure, which collected data on demographic and socioeconomic characteristics, travel, car fuel purchasing and physical activity, and potential psychosocial and environmental correlates and mediators of those behaviours. In the absence of suitable no-intervention control groups, the study design drew on heterogeneity in exposure both within and between case study samples to provide for a counterfactual. Ethics and dissemination The study was approved by the University of Southampton Research Ethics Committee. The findings will be disseminated through academic presentations, peer-reviewed publications and the study website (http://www.iconnect.ac.uk) and by means of a national seminar at the end of the study.

An Applied Ecological Framework for Evaluating Infrastructure to Promote Walking and Cycling: The iConnect Study

Improving infrastructure for walking and cycling is increasingly recommended as a means to promote physical activity, prevent obesity, and reduce traffic congestion and carbon emissions. However, limited evidence from intervention studies exists to support this approach. Drawing on classic epidemiological methods, psychological and ecological models of behavior change, and the principles of realistic evaluation, we have developed an applied ecological framework by which current theories about the behavioral effects of environmental change may be tested in heterogeneous and complex intervention settings. Our framework guides study design and analysis by specifying the most important data to be collected and relations to be tested to confirm or refute specific hypotheses and thereby refine the underlying theories.

Behavior change techniques used to promote walking and cycling: a systematic review

Objective: Evidence on the effectiveness of walking and cycling interventions is mixed. This may be partly attributable to differences in intervention content, such as the cognitive and behavioral techniques (BCTs) used. Adopting a taxonomy of BCTs, this systematic review addressed two questions: (a) What are the behavior change techniques used in walking and cycling interventions targeted at adults? (b) What characterizes interventions that appear to be associated with changes in walking and cycling in adults? Method: Previous systematic reviews and updated database searches were used to identify controlled studies of individual-level walking and cycling interventions involving adults. Characteristics of intervention design, context, and methods were extracted in addition to outcomes. Intervention content was independently coded according to a 26-item taxonomy of BCTs. Results: Studies of 46 interventions met the inclusion criteria. Twenty-one reported a statistically significant effect on walking and cycling outcomes. Analysis revealed substantial heterogeneity in the vocabulary used to describe intervention content and the number of BCTs coded. “Prompt self-monitoring of behavior” and “prompt intention formation” were the most frequently coded BCTs. Conclusion: Future walking and cycling intervention studies should ensure that all aspects of the intervention are reported in detail. The findings lend support to the inclusion of self-monitoring and intention formation techniques in future walking and cycling intervention design, although further exploration of these and other BCTs is required. Further investigation of the interaction between BCTs and study design characteristics would also be desirable.

The impact of addiction on the family: Estimates of prevalence and costs

The negative impact of alcohol or drug misuse on the family has been well documented. However, the predominantly individualistic approach to treatment and policy has led to lack of accurate calculations of the numbers of affected family members and the associated costs to families and society of their suffering, the stress they experience and the care they provide to the substance misuser. For the practice and policy agendas to continue to evolve, such estimates are vital. This article summarizes what is currently known about the numbers of affected family members and the associated costs to families and society. The main findings from the first piece of research undertaken in the UK to model the numbers of adult family members of illegal drug misusers and associated costs are then presented. Finally, this article discusses the strengths and limitations of such models and the implications for both service development and policy.

Bristol Girls Dance Project Feasibility Trial: outcome and process evaluation results

BackgroundMany adolescent girls do not engage in sufficient physical activity (PA). This study examined the feasibility of conducting a cluster randomized controlled trial (RCT) to evaluate an after-school dance program to increase PA among 11–12 year old girls in Bristol, UK.MethodsThree-arm, cluster RCT. Three secondary schools were assigned to intervention arm. Intervention participants received a 9-week dance program with 2, 90-minute dance classes per week. Participants at 2 control schools received incentives for data collection. Participants at 2 additional control schools received incentives and a delayed dance workshop. Accelerometer data were collected at baseline (time 0), during the last week of the dance program (time 1) and 20 weeks after the start of the study (time 2). Weekly attendance, enjoyment and perceived exertion were assessed in intervention participants. Post-study qualitative work was conducted with intervention participants and personnel.Results40.1% of girls provided consent to be in the study. The mean number of girls attending at least one dance session per week ranged from 15.4 to 25.9. There was greater number of participants for whom accelerometer data were collected in control arms. The mean attendance was 13.3 sessions (maximum = 18). Perceived exertion ratings indicated that the girls did not find the sessions challenging. The dance teachers reported that the program content would benefit from revisions including less creative task time, a broader range of dance genres and improved behavioral management policies. At time 2, the 95% confidence intervals suggest between 5 and 12 minutes more weekday MVPA in the intervention group compared with the control incentives only group, and between 6 minutes fewer and 1 minute more compared with the control incentives plus workshop group. Between 14 and 24 schools would be required to detect a difference of 10 minutes in mean weekday MVPA between intervention and control groups.ConclusionsIt is possible to recruit 11–12 year old girls to participate in an after-school dance study. An after-school dance intervention has potential to positively affect the PA levels of 11–12 year old girls but an adequately powered RCT is required to test this intervention approach.

A randomised trial comparing the clinical effectiveness of different emergency department healthcare professionals in soft tissue injury management

Objectives To evaluate the clinical effectiveness of soft tissue injury management by emergency nurse practitioners (ENPs) and extended scope physiotherapists (ESPs) compared to the routine care provided by doctors in a UK emergency department (ED). Design Randomised, pragmatic trial of equivalence. Setting One adult ED in England. Participants 372 patients were randomised; 126 to the ESP group, 123 to the ENP group and 123 to the doctor group. Participants were adults (older than 16 years) presenting to the ED with a peripheral soft tissue injury eligible for management by any of the three professional groups. Patients were excluded if they had any of the following: injury greater than 72 hours old; systemic disease; dislocated joints; recent surgery; unable to give informed consent (eg, dementia), open wounds; major deformities; opiate analgesia required; concurrent chest/rib injury; neurovascular deficits and associated fracture. Interventions Patients were randomised to treatment by ESPs, ENPs or routine care provided by doctors (of all grades). Main outcome measures Upper-limb and lower-limb functional scores, quality of life, physical well-being, preference-based health measures and the number of days off work. Results The clinical outcomes of soft tissue injury treated by ESPs and ENPs in the ED were equivalent to routine care provided by doctors. Conclusions As all groups were clinically equivalent it is other factors such as cost, workforce sustainability, service provision and skill mix that become important. This result validates the role of the ENP, which is becoming established as an integral part of minor injuries care, and demonstrates that the ESP should be considered as part of the clinical skill mix without detriment to outcomes. ISRCTN-ISRCTN trials register number 70891354.

Mechanisms underpinning use of new walking and cycling infrastructure in different contexts: mixed-method analysis.

BackgroundFew studies have evaluated the effects of infrastructural improvements to promote walking and cycling. Even fewer have explored how the context and mechanisms of such interventions may interact to produce their outcomes.MethodsThis mixed-method analysis forms part of the UK iConnect study, which aims to evaluate new walking and cycling routes at three sites — Cardiff, Kenilworth and Southampton. Applying a complementary follow-up approach, we first identified differences in awareness and patterns of use of the infrastructure in survey data from a cohort of adult residents at baseline in spring 2010 (n = 3516) and again one (n = 1849) and two (n = 1510) years later following completion of the infrastructural projects (Analysis 1). We subsequently analysed data from 17 semi-structured interviews with key informants to understand how the new schemes might influence walking and cycling (Analysis 2a). In parallel, we analysed cohort survey data on environmental perceptions (Analysis 2b). We integrated these two datasets to interpret differences across the sites consistent with a theoretical framework that hypothesised that the schemes would improve connectivity and the social environment.ResultsAfter two years, 52% of Cardiff respondents reported using the infrastructure compared with 37% in Kenilworth and 22% in Southampton. Patterns of use did not vary substantially between sites. 17% reported using the new infrastructure for transport, compared with 39% for recreation. Environmental perceptions at baseline were generally unfavourable, with the greatest improvements in Cardiff. Qualitative data revealed that all schemes had a recreational focus to varying extents, that the visibility of schemes to local people might be an important mechanism driving use and that the scale and design of the schemes and the contrast they presented with existing infrastructure may have influenced their use.ConclusionsThe dominance of recreational uses may have reflected the specific local goals of some of the projects and the discontinuity of the new infrastructure from a satisfactory network of feeder routes. Greater use in Cardiff may have been driven by the mechanisms of greater visibility and superior design features within the context of an existing environment that was conducive neither to walking or cycling nor to car travel.

Randomised feasibility trial of a teaching assistant led extracurricular physical activity intervention for 9 to 11 year olds: Action 3:30

BackgroundExtracurricular programmes could provide a mechanism to increase the physical activity (PA) of primary-school-aged children. The aim of this feasibility study was to examine whether the Action 3:30 intervention, which is delivered by teaching assistants, holds promise as a means of increasing the PA of Year 5 and 6 children.MethodsA cluster randomised feasibility trial was conducted in 20 primary schools. Ten schools received the Action 3:30 intervention and 10 schools were allocated to the control arm. The intervention was 40 one-hour sessions, delivered twice a week by teaching assistants. The proportion of participants recruited per school was calculated. Session delivery and session attendance was calculated for intervention schools. Weekday and after-school (3.30 to 8.30 pm) moderate to vigorous intensity physical (MVPA) was assessed by accelerometer at baseline (T0), during the last few weeks of the intervention (T1) and four months after the intervention had ended (T2). The costs of delivering the intervention were estimated.ResultsFive intervention schools ran all 40 of the intended sessions. Of the remaining five, three ran 39, one ran 38 and one ran 29 sessions. Mean attendance was 53%. The adjusted difference in weekday MVPA at T1 was 4.3 minutes (95% CI -2.6 to 11.3). Sex-stratified analyses indicated that boys obtained 8.6 more minutes of weekday MVPA than the control group (95% CI 2.8 to 14.5) at T1 with no effect for girls (0.15 minutes, 95% CI -9.7 to 10.0). There was no evidence that participation in the programme increased MVPA once the club sessions ceased (T2). The indicative average cost of this intervention was £2,425 per school or £81 per participating child during its first year and £1,461 per school or £49 per participating child thereafter.ConclusionsThe effect of the Action 3:30 intervention was comparable to previous physical activity interventions but further analysis indicated that there was a marked sex difference with a positive impact on boys and no evidence of an effect on girls. The Action 3:30 intervention holds considerable promise but more work is needed to enhance the effectiveness of the intervention, particularly for girls.Trial registrationISRCTN58502739

The Use of Social Marketing to Influence the Development of Problem Gambling in the UK: Implications for Public Health

In this paper the authors present and debate the theoretical case for the use of social marketing to help reduce problem gambling in the public health context of the UK. Is triangulated between the key theories and principles of social marketing, the key literature and its theoretical application to the debate about reducing problem gambling in the UK. The distinctions between social marketing and health education are outlined. Exchange theory, relationship marketing, and consumer focus and insight are vital to work with the public health implications of problem gambling. Social marketing may have something to offer problem gamblers, professionals in public health and policymakers. However, the self interest of the problem gambler should strongly guide intervention programmes. Such programmes should be designed with the ideal of building relationships such that long term behaviour change is effected.

Taking the long view: a systematic review reporting long-term perspectives on child unintentional injury

Objective The relative significance of child injury as a cause of preventable death has increased as mortality from infectious diseases has declined. Unintentional child injuries are now a major cause of death and disability across the world with the greatest burden falling on those who are most disadvantaged. A review of long-term data on child injury mortality was conducted to explore trends and inequalities and consider how data were used to inform policy, practice and research. Methods The authors systematically collated and quality appraised data from publications and documents reporting unintentional child injury mortality over periods of 20 years or more. A critical narrative synthesis explored trends by country income group, injury type, age, gender, ethnicity and socioeconomic group. Findings 31 studies meeting the inclusion criteria were identified of which 30 were included in the synthesis. Only six were from middle income countries and none were from low income countries. An overall trend in falling child injury mortality masked rising road traffic injury deaths, evidence of increasing vulnerability of adolescents and widening disparities within countries when analysed by ethnic group and socioeconomic status. Conclusions Child injury mortality trend data from high and middle income countries has illustrated inequalities within generally falling trends. There is scope for greater use of existing trend data to inform policy and practice. Similar evidence from low income countries where the burden of injury is greatest is needed.