Matt Egan

Promoting walking and cycling as an alternative to using cars: systematic review

Abstract Objectives To assess what interventions are effective in promoting a population shift from using cars towards walking and cycling and to assess the health effects of such interventions. Data sources Published and unpublished reports in any language identified from electronic databases, bibliographies, websites, and reference lists. Review methods Systematic search and appraisal to identify experimental or observational studies with a prospective or controlled retrospective design that evaluated any intervention applied to an urban population or area by measuring outcomes in members of the local population. Results 22 studies met the inclusion criteria. We found some evidence that targeted behaviour change programmes can change the behaviour of motivated subgroups, resulting (in the largest study) in a shift of around 5% of all trips at a population level. Single studies of commuter subsidies and a new railway station also showed positive effects. The balance of best available evidence about publicity campaigns, engineering measures, and other interventions suggests that they have not been effective. Participants in trials of active commuting experienced short term improvements in certain measures of health and fitness, but we found no good evidence on effects on health of any effective intervention at population level. Conclusions The best available evidence of effectiveness in promoting a modal shift is for targeted behaviour change programmes, but the social distribution of their effects is unclear and some other types of intervention have yet to be rigorously evaluated.

Evidence for public health policy on inequalities: 1: The reality according to policymakers

Objective: To explore with UK and international policy advisors how research evidence influences public health policy making, and how its relevance and utility could be improved, with specific reference to the evidence on the production and reduction of health inequalities. Design, setting, and participants: Qualitative residential workshop involving senior policy advisors with a substantive role in policy development across a range of sectors (mainly public health, but also including education, social welfare, and health services). In four in depth sessions, facilitated by the authors, focused questions were presented to participants. Their responses were then analysed thematically to identify key themes, relating to the availability and utility of existing evidence on health inequalities. Main results: The lack of an equity dimension in much aetiological and evaluative research was highlighted by participants. Much public health research was also felt to have weak underlying theoretical underpinnings. As well as evaluations of the effectiveness and cost-effectiveness of policy and other interventions, they identified a need for predictive research, and for methodological research to further develop methods for assessing the impact on health of clusters of interventions. Conclusions: This study reinforces the view that there is a lack of information on the effectiveness and cost-effectiveness of policies, and it uncovered additional gaps in the health inequalities evidence base. A companion paper discusses researchers’ views of how the production of more relevant public health evidence can be stimulated.

The psychosocial and health effects of workplace reorganisation. 2. A systematic review of task restructuring interventions

Objective: To systematically review the health and psychosocial effects (with reference to the demand–control–support model) of changes to the work environment brought about by task structure work reorganisation, and to determine whether those effects differ for different socioeconomic groups. Design: Systematic review (QUORUM) of experimental and quasi-experimental studies (any language) reporting health and psychosocial effects of such interventions. Data sources: Seventeen electronic databases (medical, social science and economic), bibliographies and expert contacts. Results: Nineteen studies were reviewed. Some task-restructuring interventions failed to alter the psychosocial work environment significantly, and so could not be expected to have a measurable effect on health. Those that increased demand and decreased control tended to have an adverse effect on health, while those that decreased demand and increased control resulted in improved health, although some effects were minimal. Increases in workplace support did not appear to mediate this relationship. Conclusion: This systematic review suggests that task-restructuring interventions that increase demand or decrease control adversely affect the health of employees, in line with observational research. It lends support to policy initiatives such as the recently enforced EU directive on participation at work, which aims to increase job control and autonomy.

Reviewing evidence on complex social interventions: appraising implementation in systematic reviews of the health effects of organisational-level workplace interventions.

Background: The reporting of intervention implementation in studies included in systematic reviews of organisational-level workplace interventions was appraised. Implementation is taken to include such factors as intervention setting, resources, planning, collaborations, delivery and macro-level socioeconomic contexts. Understanding how implementation affects intervention outcomes may help prevent erroneous conclusions and misleading assumptions about generalisability, but implementation must be adequately reported if it is to be taken into account. Methods: Data on implementation were obtained from four systematic reviews of complex interventions in workplace settings. Implementation was appraised using a specially developed checklist and by means of an unstructured reading of the text. Results: 103 studies were identified and appraised, evaluating four types of organisational-level workplace intervention (employee participation, changing job tasks, shift changes and compressed working weeks). Many studies referred to implementation, but reporting was generally poor and anecdotal in form. This poor quality of reporting did not vary greatly by type or date of publication. A minority of studies described how implementation may have influenced outcomes. These descriptions were more usefully explored through an unstructured reading of the text, rather than by means of the checklist. Conclusions: Evaluations of complex interventions should include more detailed reporting of implementation and consider how to measure quality of implementation. The checklist helped us explore the poor reporting of implementation in a more systematic fashion. In terms of interpreting study findings and their transferability, however, the more qualitative appraisals appeared to offer greater potential for exploring how implementation may influence the findings of specific evaluations. Implementation appraisal techniques for systematic reviews of complex interventions require further development and testing.

Evidence for public health policy on inequalities: 2: Assembling the evidence jigsaw

Study objective: To garner research leaders’ perceptions and experiences of the types of evidence that influence policy on health inequalities, and their reflections on how the flow of such research evidence could be increased. Design, setting, and participants: Qualitative two day residential workshop with senior research leaders, most of whom were currently involved in evaluations of the health effects of major policies. In four in depth sessions, facilitated by the authors in turn, focused questions were presented to participants to reveal their views and experiences concerning evidence synthesis for policy on inequalities. These were analysed thematically. Main results: Five types of evidence for policy on health inequalities were felt to be particularly persuasive with policymakers: observational evidence showing the existing of a problem; narrative accounts of the impacts of policies from the household perspective; controlled evaluations; natural policy experiments; and historical evidence. Methods of improving the availability and use of these sources of information were put forward. Conclusions: This paper and its companion have considered the current evidence base for policies to reduce health inequalities, and how this could be improved. There is striking congruence between the views of the researchers in this study and policy advisers in paper 1, suggesting that a common understanding may be emerging. The findings suggest significant potential for rapid progress to be made in developing both evidence based policy, and policy relevant evidence to tackle inequalities in health.

Psychosocial risk factors in home and community settings and their associations with population health and health inequalities: A systematic meta-review

BackgroundThe effects of psychosocial risk factors on population health and health inequalities has featured prominently in epidemiological research literature as well as public health policy strategies. We have conducted a meta-review (a review of reviews) exploring how psychosocial factors may relate to population health in home and community settings.MethodsSystematic review (QUORUM) of literature reviews (published in any language or country) on the health associations of psychosocial risk factors in community settings. The literature search included electronic and manual searches. Two reviewers appraised included reviews using criteria for assessing systematic reviews. Data from the more robust reviews were extracted, tabulated and synthesised.ResultsThirty-one reviews met our inclusion criteria. These explored a variety of psychosocial factors including social support and networks, social capital, social cohesion, collective efficacy, participation in local organisations – and less favourable psychosocial risk factors such as demands, exposure to community violence or anti-social behaviour, exposure to discrimination, and stress related to acculturation to western society. Most of the reviews focused on associations between social networks/support and physical or mental health. We identified some evidence of favourable psychosocial environments associated with better health. Reviews also found evidence of unfavourable psychosocial risk factors linked to poorer health, particularly among socially disadvantaged groups. However, the more robust reviews each identified studies with inconclusive findings, as well as studies finding evidence of associations. We also identified some evidence of apparently favourable psychosocial risk factors associated with poorer health.ConclusionFrom the review literature we have synthesised, where associations have been identified, they generally support the view that favourable psychosocial environments go hand in hand with better health. Poor psychosocial environments may be health damaging and contribute to health inequalities. The evidence that underpins our understanding of these associations is of variable quality and consistency. Future research should seek to improve this evidence base, with more longitudinal analysis (and intervention evaluations) of the effects of apparently under-researched psychosocial factors such as control and participation within communities. Future policy interventions relevant to this field should be developed in partnership with researchers to enable a better understanding of psychosocial mechanisms and the effects of psychosocial interventions.

Systematic reviews of health effects of social interventions: 1. Finding the evidence: how far should you go?

Study objective: There is little guidance on how to identify useful evidence about the health effects of social interventions. The aim of this study was to assess the value of different ways of finding this type of information. Design: Retrospective analysis of the sources of studies for one systematic review. Setting: Case study of a systematic review of the effectiveness of interventions in promoting a population shift from using cars towards walking and cycling. Main results: Only four of the 69 relevant studies were found in a “first-line” health database such as Medline. About half of all relevant studies were found through the specialist Transport database. Nine relevant studies were found through purposive internet searches and seven relevant studies were found by chance. The unique contribution of experts was not to identify additional studies, but to provide more information about those already found in the literature. Conclusions: Most of the evidence needed for this review was not found in studies indexed in familiar literature databases. Applying a sensitive search strategy across multiple databases and interfaces is very labour intensive. Retrospective analysis suggests that a more efficient method might have been to search a few key resources, then to ask authors and experts directly for the most robust reports of studies identified. However, internet publications and serendipitous discoveries did make a significant contribution to the total set of relevant evidence. Undertaking a comprehensive search may provide unique evidence and insights that would not be obtained using a more focused search.

New Roads and Human Health: A Systematic Review

We sought to synthesize evidence of the health effects of construction of new roads by systematically reviewing observational studies of such effects. We included and critically appraised 32 studies. The review suggested that out-of-town bypasses decrease injuries on main roads through or around towns, although more robust evidence is needed on effects on secondary roads. New major urban roads have statistically insignificant effects on injury incidence. New major roads between towns decrease injuries. Out-of-town bypasses reduce disturbance and community severance in towns but increase them elsewhere. Major urban roads increase disturbance and severance. More robust research is needed in this area, particularly regarding effects of new roads on respiratory health, mental health, access to health services, and physical activity.

Exploring the relationships between housing, neighbourhoods and mental wellbeing for residents of deprived areas

BackgroundHousing-led regeneration has been shown to have limited effects on mental health. Considering housing and neighbourhoods as a psychosocial environment, regeneration may have greater impact on positive mental wellbeing than mental ill-health. This study examined the relationship between the positive mental wellbeing of residents living in deprived areas and their perceptions of their housing and neighbourhoods.MethodsA cross-sectional study of 3,911 residents in 15 deprived areas in Glasgow, Scotland. Positive mental wellbeing was measured using the Warwick-Edinburgh Mental Wellbeing Scale.ResultsUsing multivariate mulit-nomial logistic regressions and controlling for socio-demographic characteristics and physical health status, we found that several aspects of peoples residential psychosocial environments were strongly associated with higher mental wellbeing. Mental wellbeing was higher when respondents considered the following: their neighbourhood had very good aesthetic qualities (RRR 3.3, 95% CI 1.9, 5.8); their home and neighbourhood represented personal progress (RRR 3.2 95% CI 2.2, 4.8; RRR 2.6, 95% CI 1.8, 3.7, respectively); their home had a very good external appearance (RRR 2.6, 95% CI 1.3, 5.1) and a very good front door (both an aesthetic and a security/control item) (RRR 2.1, 95% CI 1.2, 3.8); and when satisfaction with their landlord was very high (RRR 2.3, 95% CI 2.2,4.8). Perception of poor neighbourhood aesthetic quality was associated with lower wellbeing (RRR 0.4, 95% CI 0.3, 0.5).ConclusionsThis study has shown that for people living in deprived areas, the quality and aesthetics of housing and neighbourhoods are associated with mental wellbeing, but so too are feelings of respect, status and progress that may be derived from how places are created, serviced and talked about by those who live there. The implication for regeneration activities undertaken to improve housing and neighbourhoods is that it is not just the delivery of improved housing that is important for mental wellbeing, but also the quality and manner of delivery.

How do systematic reviews incorporate risk of bias assessments into the synthesis of evidence? A methodological study

Background Systematic reviews (SRs) are expected to critically appraise included studies and privilege those at lowest risk of bias (RoB) in the synthesis. This study examines if and how critical appraisals inform the synthesis and interpretation of evidence in SRs. Methods All SRs published in March–May 2012 in 14 high-ranked medical journals and a sample from the Cochrane library were systematically assessed by two reviewers to determine if and how: critical appraisal was conducted; RoB was summarised at study, domain and review levels; and RoB appraisals informed the synthesis process. Results Of the 59 SRs studied, all except six (90%) conducted a critical appraisal of the included studies, with most using or adapting existing tools. Almost half of the SRs reported critical appraisal in a manner that did not allow readers to determine which studies included in a review were most robust. RoB assessments were not incorporated into synthesis in one-third (20) of the SRs, with their consideration more likely when reviews focused on randomised controlled trials. Common methods for incorporating critical appraisals into the synthesis process were sensitivity analysis, narrative discussion and exclusion of studies at high RoB. Nearly half of the reviews which investigated multiple outcomes and carried out study-level RoB summaries did not consider the potential for RoB to vary across outcomes. Conclusions The conclusions of the SRs, published in major journals, are frequently uninformed by the critical appraisal process, even when conducted. This may be particularly problematic for SRs of public health topics that often draw on diverse study designs.