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Abstract Background Regulatory actions are increasingly used to tackle issues such as excessive alcohol or sugar intake, but such actions to reduce sedentary behaviour remain scarce. World Health Organization (WHO) guidelines on sedentary behaviour call for system-wide policies. The Chinese government introduced the world’s first nation-wide multi-setting regulation on multiple types of sedentary behaviour in children and adolescents in July 2021. This regulation restricts when (and for how long) online gaming businesses can provide access to pupils; the amount of homework teachers can assign to pupils according to their year groups; and when tutoring businesses can provide lessons to pupils. We evaluated the effect of this regulation on sedentary behaviour safeguarding pupils. Methods With a natural experiment evaluation design, we used representative surveillance data from 9- to 18-year-old pupils before and after the introduction of the regulation, for longitudinal (n = 7,054, matched individuals, primary analysis) and repeated cross-sectional (n = 99,947, exploratory analysis) analyses. We analysed pre-post differences for self-reported sedentary behaviour outcomes (total sedentary behaviour time, screen viewing time, electronic device use time, homework time, and out-of-campus learning time) using multilevel models, and explored differences by sex, education stage, residency, and baseline weight status. Results Longitudinal analyses indicated that pupils had reduced their mean total daily sedentary behaviour time by 13.8% (95% confidence interval [CI]: -15.9 to -11.7%, approximately 46 min) and were 1.20 times as likely to meet international daily screen time recommendations (95% CI: 1.01 to 1.32) one month after the introduction of the regulation compared to the reference group (before its introduction). They were on average 2.79 times as likely to meet the regulatory requirement on homework time (95% CI: 2.47 to 3.14) than the reference group and reduced their daily total screen-viewing time by 6.4% (95% CI: -9.6 to -3.3%, approximately 10 min). The positive effects were more pronounced among high-risk groups (secondary school and urban pupils who generally spend more time in sedentary behaviour) than in low-risk groups (primary school and rural pupils who generally spend less time in sedentary behaviour). The exploratory analyses showed comparable findings. Conclusions This regulatory intervention has been effective in reducing total and specific types of sedentary behaviour among Chinese children and adolescents, with the potential to reduce health inequalities. International researchers and policy makers may explore the feasibility and acceptability of implementing regulatory interventions on sedentary behaviour elsewhere.

Abstract Background Several reviews have examined the health benefits of participation in specific sports, such as baseball, cricket, cross-country skiing, cycling, downhill skiing, football, golf, judo, rugby, running and swimming. However, new primary studies on the topic have recently been published, and the respective meta-analytic evidence needs to be updated. Objectives To systematically review, summarise and appraise evidence on physical health benefits of participation in different recreational sports. Methods Searches for journal articles were conducted in PubMed/MEDLINE, Scopus, SpoLit, SPORTDiscus, Sports Medicine & Education Index and Web of Science. We included longitudinal and intervention studies investigating physical health outcomes associated with participation in a given sport among generally healthy adults without disability. Results A total of 136 papers from 76 studies conducted among 2.6 million participants were included in the review. Our meta-analyses of available evidence found that: (1) cycling reduces the risk of coronary heart disease by 16% (pooled hazard ratio [HR] = 0.84; 95% confidence interval [CI]: 0.80, 0.89), all-cause mortality by 21% (HR = 0.79; 95% CI: 0.73, 0.84), cancer mortality by 10% (HR = 0.90; 95% CI: 0.85, 0.96) and cardiovascular mortality by 20% (HR = 0.80; 95% CI: 0.74, 0.86); (2) football has favourable effects on body composition, blood lipids, fasting blood glucose, blood pressure, cardiovascular function at rest, cardiorespiratory fitness and bone strength (p

Abstract Background The COVID-19 pandemic significantly impacted children’s physical activity. Recent evidence indicated children’s accelerometer-measured physical activity levels have, on average, returned to near pre-pandemic levels in 2022, though sedentary behaviour remains higher. However, insufficient physical activity levels among children continues to be a critical public health issue in the UK, with only 41% meeting physical activity guidelines. This study aimed to provide in-depth analysis of how the pandemic has shaped children’s physical activity patterns beyond the short-term periods following lockdowns and identify the new challenges to engaging children in physical activity. Methods One-to-one interviews with parents (n = 22), school staff (n = 9), and six focus groups with children aged 10–11 years (n = 45) were conducted between February and July 2022. Topics explored changes to children’s physical activity and sedentary behaviour patterns, including screen-viewing, and factors influencing any changes. The framework method was used for analysis. Results Five themes were generated. Theme 1 described residual lockdown habits, including increased screen-viewing within the home, while activities outside the home continued to feel less spontaneous. Theme 2 highlighted an interrupted development of social, emotional, and physical skills among children compared to what would be expected pre-pandemic. This coincided with Theme 3 which reflected increased mental health challenges among families, creating complex barriers to children’s physical activity. A new normal for child physical activity was evoked and explored in Theme 4, with greater dependence on structured and organised activities. However, Theme 5 highlighted that girls and children with lower socio-economic position may be especially at risk of decreased physical activity. Conclusions There is a new normal for children’s physical activity that is characterised by increased dependence on structured and organised physical activities, such as active clubs, and less on unstructured and spontaneous physical activities, such as physical play. While this may suit many children, girls and children from lower socio-economic households face barriers to participating in the new normal. It is important that affordable and equitable opportunities are provided to all children to prevent physical activity and health inequalities.

Abstract Background In 2020, 1.4 and 2.3 million new cases of prostate cancer and breast cancer respectively were diagnosed globally. In the UK, prostate cancer is the most common male cancer, while breast cancer is the most common female cancer. Engaging in physical activity (PA) is a key component of treatment. However, rates of PA are low in these clinical populations. This paper describes the protocol of CRANK-P and CRANK-B, two pilot randomised controlled trials, involving an e-cycling intervention aimed at increasing PA in individuals with prostate cancer or breast cancer respectively. Methods These two trials are single-centre, stratified, parallel-group, two-arm randomised waitlist-controlled pilot trials in which forty individuals with prostate cancer (CRANK-P) and forty individuals with breast cancer (CRANK-B) will be randomly assigned, in a 1:1 allocation ratio, to an e-cycling intervention or waitlist control. The intervention consists of e-bike training with a certified cycle instructor, followed by the provision of an e-bike for 12 weeks. Following the intervention period, participants in the e-bike condition will be directed to community-based initiatives through which they can access an e-bike. Data will be collected at baseline (T0), immediately post intervention (T1) and at 3-month follow-up (T2). In addition, in the intervention group, data will be collected during the intervention and follow-up periods. Quantitative and qualitative methods will be used. The primary objectives are to determine effective recruitment strategies, establish recruitment and consent rates, adherence and retention in the study, and determine the feasibility and acceptability of the study procedures and intervention. The potential impact of the intervention on clinical, physiological and behavioural outcomes will be assessed to examine intervention promise. Data analyses will be descriptive. Discussion The findings from these trials will provide information on trial feasibility and highlight the potential of e-cycling as a strategy to positively impact the health and behaviour of individuals with prostate cancer and breast cancer. If appropriate, this information can be used to design and deliver a fully powered definitive trial. Trial registration CRANK-B: [ISRCTN39112034]. CRANK-P [ISRCTN42852156]. Registered [08/04/2022] https://www.isrctn.com .

Abstract Background The COVID-19 pandemic has resulted in marked impacts on children’s physical activity, with large reductions in moderate-to-vigorous physical activity (MVPA) reported during lockdowns. Previous evidence showed children’s activity levels were lower and sedentary time higher immediately post-COVID lockdown, while there was little change in parental physical activity. We need to know if these patterns persist. Methods Active-6 is a natural experiment using repeated cross-sectional data conducted in two waves. Accelerometer data were collected on 393 children aged 10–11 and their parents from 23 schools in Wave 1 (June 2021-December 2021), and 436 children and parents from 27 schools in Wave 2 (January 2022-July 2022). These were compared to a pre-COVID-19 comparator group (March 2017-May 2018) of 1,296 children and parents in the same schools. Mean minutes of accelerometer-measured MVPA and sedentary time were derived for week- and weekend-days and compared across waves via linear multilevel models. We also analysed the date of data collection as a time series, to explore temporal patterns via generalised additive mixed models. Results There was no difference in children’s mean MVPA in Wave 2 (weekdays: -2.3 min; 95% CI: -5.9, 1.3 and weekends: 0.6 min; 95% CI: -3.5, 4.6) when compared to the pre-COVID-19 data. Sedentary time remained higher than pre-pandemic by 13.2 min (95% CI:5.3, 21.1) on weekdays. Differences compared to pre-COVID-19 changed over time, with children’s MVPA decreasing over winter, coinciding with COVID-19 outbreaks, and only returning to pre-pandemic levels towards May/June 2022. Parents’ sedentary time and weekday MVPA was similar to pre-COVID-19 levels, with MVPA higher than pre-pandemic by 7.7 min (95% CI: 1.4, 14.0) on weekends. Conclusion After an initial drop, children’s MVPA returned to pre-pandemic levels by July 2022, while sedentary time remained higher. Parents’ MVPA remained higher, especially at weekends. The recovery in physical activity is precarious and potentially susceptible to future COVID-19 outbreaks or changes in provision, and so robust measures to protect against future disruptions are needed. Furthermore, many children are still inactive, with only 41% meeting UK physical activity guidelines, and so there is still a need to increase children’s physical activity.

Abstract Background Type 2 diabetes mellitus (T2DM) and its associated complications puts considerable strain on healthcare systems. With the global incidence of T2DM increasing, effective disease management is essential. Physical activity (PA) is a key component of T2DM management; however, rates of PA engagement are low in this population. Developing effective and sustainable interventions that encourage PA is a high priority. Electrically assisted bicycles are becoming increasingly popular and may increase PA in healthy adults. This study aimed to provide evidence of the feasibility of conducting a randomized controlled trial to evaluate the efficacy of an e-cycling intervention to increase PA and improve health in individuals with T2DM. Methods A parallel-group two-arm randomized, waitlist-controlled pilot study was conducted. Individuals were randomized to either an e-bike intervention or standard care. The intervention incorporated two one-to-one e-bike skills training and behavioural counselling sessions delivered by a community-based cycling charity, followed by a 12-week e-bike loan with two further sessions with the instructors. Feasibility was assessed via measures related to recruitment, retention and intervention implementation. Post-intervention interviews with instructors and participants explored the acceptability of the study procedures and intervention. Clinical, physiological and behavioural outcomes were collected at baseline and post-intervention to evaluate the intervention’s potential. Results Forty participants (M age = 57) were randomized, of which 34 were recruited from primary care practices. Thirty-five participants were retained in the trial. The intervention was conducted with high fidelity (> 80% content delivered). E-bike training provided participants with the skills, knowledge and confidence needed to e-bike independently. Instructors reported being more confident delivering the skills training than behavioural counselling, despite acknowledging its importance. The study procedures were found to be acceptable to participants. Between-group differences in change during the intervention were indicative of the interventions potential for improving glucose control, health-related quality of life and cardiorespiratory fitness. Increases in overall device measured moderate-to-vigorous PA behaviour following the intervention were found, and there was evidence that this population self-selected to e-cycle at a moderate intensity. Conclusions The study’s recruitment, retention, acceptability and potential efficacy support the development of a definitive trial subject to identified refinements. Trial registration ISRCTN, ISRCTN67421464 . Registered 17/12/2018.

Stories can be a powerful method of exploring complexity, and the factors affecting everyday physical activity within a modern urban setting are nothing if not complex. The first part of our How Do You Move? study focused on the communication of physical activity guidelines to under-served communities. A key finding was that adults especially wanted physical activity messages to come from ‘everyday people, people like us’. This finding also reflects a wider move to use more relatable imagery in health promotion campaigns. Using a portrait vignette approach to create monologues, we set out to explore the experiences of people from diverse backgrounds living in Bristol, all of whom took part in varied leisure time physical activities but would also be considered to lead ‘normal’ lives. We aim to demonstrate that stories of such ‘experts by experience’ can contribute to how physical activity is perceived and elucidate the complex interplay of barriers and enablers in everyday experiences of physical activity.

Abstract Background Community-based programmes [CBPs], targeting increased physical activity and/or healthier eating, have been used in the prevention and management of non-communicable diseases. However, CBPs are only useful, insofar as they can be scaled up and sustained in some meaningful way. Social networks—defined as “social structures that exists between actors, individuals or organizations”—may serve as an important tool to identify underlying mechanisms that contribute to this process. This scoping review aimed to map and collate literature on the role of social network research in scaling-up and sustaining physical activity and/or diet CBPs in low-and middle-income countries [LMICs]. Methods Arksey and O’Malley’s framework and its enhancement were followed. Inclusion criteria were peer-reviewed articles exploring the role of social networks in scaled-up and/or sustained physical activity and/or diet CBPs in adult populations, published in English since 2000, and based in a LMIC. Databases searched were PubMed, Cochrane, Scopus, Web of Science, CINAHL, SocIndex, International Bibliography of the Social Sciences, and Google Scholar. Books, conference abstracts, and programmes focused on children were excluded. Two reviewers independently selected and extracted eligible studies. Included publications were thematically analysed using the Framework Approach. Results Authors identified 12 articles for inclusion, covering 13 CBPs. Most were based in Latin America, with others in the Caribbean, the Pacific Islands, Iran, and India. All articles were published since 2009. Only three used social network analysis methods (with others using qualitative methods). Five main social network themes were identified: centralisation, cliques, leaders, quality over quantity, and shared goals. Contextual factors to be considered when scaling-up programmes in LMICs were also identified. Conclusions This review has shown that the evidence of the use of social network research in programme scale-up has not yet caught up to its theoretical possibilities. Programmes aiming to scale should consider conducting social network research with identified network themes in mind to help improve the evidence-base of what network mechanisms, in what contexts, might best support the strengthening of networks in physical activity and diet programmes. Importantly, the voice of individuals and communities in these networks should not be forgotten.

Abstract Background Restrictions during the COVID-19 pandemic have led to increased screen-viewing among children, especially during strict periods of lockdown. However, the extent to which screen-viewing patterns in UK school children have changed post lockdowns is unclear. The aim of this paper is to examine how screen-viewing changed in 10–11-year-old children over the 2020–21 COVID-19 pandemic, how this compares to before the pandemic, and the influences on screen-viewing behaviour. Methods This is a mixed methods study with 10–11-year-olds from 50 schools in the Greater Bristol area, UK. Cross-sectional questionnaire data on minutes of weekday and weekend television (TV) viewing and total leisure screen-viewing were collected pre-COVID-19 in 2017–18 (N = 1,296) and again post-lockdowns in 2021 (N = 393). Data were modelled using Poisson mixed models, adjusted for age, gender, household education and seasonality, with interactions by gender and household education. Qualitative data were drawn from six focus groups (47 children) and 21 one-to-one parent interviews that explored screen-viewing behaviour during the pandemic and analysed using the framework method. Results Total leisure screen-viewing was 11% (95% CI: 12%-18%) higher post-lockdown compared to pre-COVID-19 on weekdays, and 8% (95% CI: 6%-10%) on weekends, equating to around 12–15 min. TV-viewing (including streaming) was higher by 68% (95% CI: 63%-74%) on weekdays and 80% (95% CI: 75%-85%) on weekend days. Differences in both were higher for girls and children from households with lower educational attainment. Qualitative themes reflected an unavoidable increase in screen-based activities during lockdowns, the resulting habitualisation of screen-viewing post-lockdown, and the role of the parent in reducing post-2020/21 lockdown screen-viewing. Conclusions Although screen-viewing was higher post-lockdown compared to pre-COVID-19, the high increases reported during lockdowns were not, on average, sustained post-lockdown. This may be attributed to a combination of short-term fluctuations during periods of strict restrictions, parental support in regulating post-lockdown behaviour and age-related, rather than COVID-19-specific, increases in screen-viewing. However, socio-economic differences in our sample suggest that not all families were able to break the COVID-19-related adoption of screen-viewing, and that some groups may need additional support in managing a healthy balance of screen-viewing and other activities following the lockdowns.

Abstract 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.

A systems approach to obesity prevention is increasingly urged. However, confusion exists on what a systems approach entails in practice, and the empirical evidence on this new approach is unclear. This scoping review aimed to identify and synthesise studies/programmes that have comprehensively applied a systems approach to obesity prevention in intervention development, delivery/implementation, and evaluation. By searching international databases and grey literature, only three studies (10 publications) met inclusion criteria, which might be explained partially by suboptimal reporting. No conclusion on the effectiveness of this approach can be drawn yet due to the limited evidence base. We identified common features shared by the included studies, such as measuring ongoing changes, in addition to endpoint outcomes, and supporting capacity building. Some facilitators and barriers to applying a comprehensive systems approach in practice were identified. More well-designed and reported studies are needed, especially from low- and middle-income countries.

Abstract Background Low childhood physical activity levels constitute an important modifiable risk for adult non-communicable disease incidence and subsequent socio-economic burden, but few publications have explored age and sex related patterns within the UK population. The aims were to profile child physical activity data from the Health Survey for England from 2012 (1,732 respondents) and 2015 (5,346 respondents). Methods Reported physical activity episodes were converted to metabolic equivalents with reference to child-specific compendiums. Physical activity levels were aggregated for each domain, and again to produce total physical activity estimates. Contributions from each domain to total physical activity were explored, stratifying for age, sex, socio-economic deprivation, ethnicity, and weight status. Further analyses were run stratifying for physical activity levels. Few differences were detected between the survey iterations. Results Boys reported higher absolute levels of physical activity at all ages and across all domains. For boys and girls, informal activity reduces with age. For boys this reduction is largely mitigated by increased formal sport, but this is not the case for girls. Absolute levels of school activity and active travel remained consistent regardless of total physical activity, thereby comprising an increasingly important proportion of total physical activity for less active children. Conclusions We recommend a specific focus on establishing and maintaining girl’s participation in formal sport thorough their teenage years, and a recognition and consolidation of the important role played by active travel and school-based physical activity for the least active children.

Abstract Background Active-6 is exploring how the COVID-19 pandemic has impacted physical activity behaviour among Year 6 children (aged 10–11 years) and their parents in Southwest England. Initial findings from the Active-6 project have shown a 7–8 min decrease in moderate-to-vigorous physical activity and an increase in sedentary behaviour among children following the easing of restrictions in the UK in latter half of 2021. This finding suggests that the pandemic has had a persistent impact on child physical activity behaviour. This paper explored the possible mechanisms behind these changes. Methods Interviews with parents (n = 21), members of school staff (n = 9) and focus groups with children aged 10–11 years (n = 47) were conducted between August and December 2021 to discuss the impact of the pandemic on child physical activity behaviour. The framework method was used for analysis. Results Five themes spanning two key stages of the pandemic were described. Three themes related to the period of lockdowns and fluctuating restrictions (March 2020 – April 2021). These included: Theme 1) Lockdown: A short-lived adventure; Theme 2) Access to facilities during restrictions; and Theme 3) The importance of the parent. A further two themes were identified related to the period following the gradual easing of restrictions in April 2021. These included: Theme 4) An overwhelming return to normal; and Theme 5) Reopening fatigue. Conclusions The analysis suggested that feelings of novelty experienced during the initial stages of lockdown waned as restrictions were prolonged, creating an increasingly challenging period for parents and their children. However, during periods of restrictions, the importance of parental encouragement and access to appropriate facilities in the local and home environment helped facilitate physical activity. Following the easing of COVID-19 restrictions, emotional overwhelm and physical fatigue among children, stemming from a sedentary and socially isolated life in lockdown and other restrictions, were key contributors to the decreased moderate to vigorous physical activity and increased sedentary behaviour that was observed in a related quantitative study.

Abstract Background Restrictions due to the coronavirus disease 2019 (COVID-19) pandemic reduced physical activity provision for both children and their parents. Recent studies have reported decreases in physical activity levels during lockdown restrictions, but these were largely reliant on self-report methods, with data collected via unrepresentative self-report surveys. The post-pandemic impacts on children’s activity levels remain unknown. A key question is how active children become once lockdown restrictions are lifted. Methods Active-6 is a repeated cross-sectional natural experiment. Accelerometer data from 1296 children aged 10–11 and their parents were collected in 50 schools in the Greater Bristol area, UK in March 2017-May 2018 (pre-COVID-19 comparator group), and compared to 393 children aged 10–11 and parents in 23 of the same schools, collected in May-December 2021. Mean minutes of accelerometer-measured moderate-to-vigorous physical activity (MVPA) were derived for weekdays and weekend and compared pre- and post-lockdown via linear multilevel models. Results After adjusting for seasonality, accelerometer wear time and child/parent demographics, children’s mean weekday and weekend MVPA were 7.7 min (95% CI: 3.5 to 11.9) and 6.9 min (95% CI: 0.9 to 12.9) lower in 2021 than in 2018, respectively, while sedentary time was higher by 25.4 min (95% CI: 15.8 to 35.0) and 14.0 min (95% CI: 1.5 to 26.5). There was no evidence that differences varied by child gender or household education. There was no significant difference in parents’ MVPA or sedentary time, either on weekdays or weekends. Conclusions Children’s MVPA was lower by 7–8 min/day in 2021 once restrictions were lifted than before the pandemic for all groups, on both weekdays and weekends. Previous research has shown that there is an undesirable age-related decline in children’s physical activity. The 8-min difference reported here would be broadly comparable to the decline that would have previously been expected to occur over a three-year period. Parents’ physical activity was similar to pre-pandemic levels. Our results suggest that despite easing of restrictions, children’s activity levels have not returned to pre-pandemic levels. There is an urgent need to understand why these changes have occurred and how long they are maintained.

Abstract Background Walking is a simple activity that could help to reduce the prevalence of chronic diseases in all populations. Furthermore, an inverse dose–response relationship exists between steps taken and risk of premature death and cardiovascular events in middle-aged and older adults. There is a lack of information on how to effectively engage older adults around retirement age in walking. This qualitative study explored attitudes towards walking in older people with regard to habits, intensity, preferences and strategies for increasing walking behaviour. Methods In-depth qualitative interviews were conducted with 26 older adults who were either close to retirement or recently retired. An inductive thematic analysis was conducted. Results Three themes were identified from the data; 1) Engagement and perceived value of walking; was focused on the meaning of walking for the participant and the attributes they associate with their walking practice. 2) Integration and connectivity of walking; was focused on how participants integrate walking in their daily lives and whether walking can be practiced as a viable means of connectivity. 3) Strategies to increase walking; was focused on what factors motivate participants in their walking practice and what strategies they perceived to be beneficial to increase walking distance and intensity at an individual level. Discussion The views of walking in people of retirement age were represented within 3 key themes. The factors contained in these themes that may influence future walking practice are discussed with regard to future strategies to promote walking in the retirement life change. Conclusion It may be beneficial to promote qualitative aspects of walking practice and strive for regularity rather than intensity of walking to accrue the social, psychological and intellectual benefits reported by individuals in the retirement life change.

Abstract Background Systems approaches are currently being advocated and implemented to address complex challenges in Public Health. These approaches work by bringing multi-sectoral stakeholders together to develop a collective understanding of the system, and then to identify places where they can leverage change across the system. Systems approaches are unpredictable, where cause-and-effect cannot always be disentangled, and unintended consequences – positive and negative – frequently arise. Evaluating such approaches is difficult and new methods are warranted. Methods Ripple Effects Mapping (REM) is a qualitative method which can capture the wider impacts, and adaptive nature, of a systems approach. Using a case study example from the evaluation of a physical activity-orientated systems approach in Gloucestershire, we: a) introduce the adapted REM method; b) describe how REM was applied in the example; c) explain how REM outputs were analysed; d) provide examples of how REM outputs were used; and e) describe the strengths, limitations, and future uses of REM based on our reflections. Results Ripple Effects Mapping is a participatory method that requires the active input of programme stakeholders in data gathering workshops. It produces visual outputs (i.e., maps) of the programme activities and impacts, which are mapped along a timeline to understand the temporal dimension of systems change efforts. The REM outputs from our example were created over several iterations, with data collected every 3–4 months, to build a picture of activities and impacts that have continued or ceased. Workshops took place both in person and online. An inductive content analysis was undertaken to describe and quantify the patterns within the REM outputs. Detailed guidance related to the preparation, delivery, and analysis of REM are included in this paper. Conclusion REM may help to advance our understanding and evaluation of complex systems approaches, especially within the field of Public Health. We therefore invite other researchers, practitioners and policymakers to use REM and continuously evolve the method to enhance its application and practical utility.

Abstract Background Core outcome sets are standardised sets of outcomes that should be collected and reported for all clinical trials. They have been widely developed and are increasingly influential in clinical research, but despite this, their use in public health has been limited to date. The aim of this study was to develop a core outcome set for public health trials evaluating interventions to promote physical activity in the general adult population. Methods The core outcome set was developed using a three-stage approach: stage one: a review of literature to identify potential domains for inclusion in the core outcome set; stage two: a Delphi survey was carried out to reach consensus about which outcome domains to include in the core outcome set; and stage three: a second Delphi survey was conducted to determine how best to measure the outcome domains included in the core outcome set. Results A classification of 13 outcome domains of physical activity was developed (stage one). Twenty people completed round one of the first Delphi survey (stage two), reaching a consensus to include two domains in the core outcome set, ‘device-based level of physical activity’ (80.0%, n = 16) and ‘health-related quality of life’ (70.0%, n = 14). No further consensus on the remaining outcome domains was reached in round two. Nineteen people completed the second Delphi survey (stage three). Participants rated the accelerometer (mean rating = 3.89, on a scale of 1 (do not recommend) to 5 (highly recommend)) as the best device to measure level of physical activity, and the EQ-5D (73.7%, n = 14) as the most appropriate measure of health-related quality of life. Conclusions This study has made progress towards the development of a core outcome set for use in physical activity trials, however, there was limited consensus about which domains to include. The development of the core outcome set was challenged by the need for trial-specific outcomes, and the complexities of collecting, processing and reporting device-based data.

Importance: Cerebrovascular changes are already evident in young adults with hypertension and exercise is recommended to reduce cardiovascular risk. To what extent exercise benefits the cerebrovasculature at an early stage of the disease remains unclear. Objective: To investigate whether structured aerobic exercise increases brain vessel lumen diameter or cerebral blood flow (CBF) and whether lumen diameter is associated with CBF. Design: Open, parallel, two-arm superiority randomized controlled (1:1) trial in the TEPHRA study on an intention-to-treat basis. The MRI sub-study was an optional part of the protocol. The outcome assessors remained blinded until the data lock. Setting: Single-centre trial in Oxford, UK. Participants: Participants were physically inactive (37 weeks). Intervention: Study participants were randomised to a 16 week aerobic exercise intervention targeting 3×60 min sessions per week at 60 to 80 % peak heart rate. Main outcomes and Measures: cerebral blood flow (CBF) maps from ASL MRI scans, internal carotid artery (ICA), middle cerebral artery (MCA) M1 and M2 segments, anterior cerebral artery (ACA), basilar artery (BA), and posterior cerebral artery (PCA) diameters extracted from TOF MRI scans. Results: Of the 135 randomized participants (median age 28 years, 58 % women) who had high quality baseline MRI data available, 93 participants also had high quality follow-up data available. The exercise group showed an increase in ICA (0.1 cm, 95 % CI 0.01 to 0.18, p =.03) and MCA M1 (0.05 cm, 95 % CI 0.01 to 0.10, p =.03) vessel diameter compared to the control group. Differences in the MCA M2 (0.03 cm, 95 % CI 0.0 to 0.06, p =.08), ACA (0.04 cm, 95 % CI 0.0 to 0.08, p =.06), BA (0.02 cm, 95 % CI −0.04 to 0.09, p =.48), and PCA (0.03 cm, 95 % CI −0.01 to 0.06, p =.17) diameters or CBF were not statistically significant. The increase in ICA vessel diameter in the exercise group was associated with local increases in CBF. Conclusions and Relevance: Aerobic exercise induces positive cerebrovascular remodelling in young people with early hypertension, independent of blood pressure. The long-term benefit of these changes requires further study. Trial Registration: Clinicaltrials.gov NCT02723552, 30 March 2016

Abstract 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.

Background: Transport initiatives such as 20-mph (≈30-km/h) speed limits are anticipated to result in fewer road casualties and improve perceptions of safety, leading to increases in active travel. Lower speeds may also lead to more pleasant environments in which to live, work and play. Objectives: The main objective was to evaluate and understand the processes and effects of developing and implementing 20-mph speed limits in Edinburgh and Belfast. The focus was on health-related outcomes (casualties and active travel) that may lead to public health improvements. An additional objective was to investigate the political and policy factors (conditions) that led to the decision to introduce the new speed limits. Design: This was a mixed-methods study that comprised an outcome, process, policy and economic evaluation of two natural experiments. Setting: The study was set in Edinburgh, Scotland, and Belfast, Northern Ireland, from 2000 to 2018. Participants: The whole population of each city were participants, as well as stakeholders involved in implementation and decision-making processes. Intervention: The intervention was the implementation of 20-mph legislation, signage, enforcement, and education and awareness-raising in Edinburgh (citywide) and Belfast (city centre). Main outcome measures: The main outcomes measured were speed; number, type and severity of road collisions; perceptions; and liveability. Data sources: The following data sources were used – routinely and locally collected quantitative data for speed, volume of traffic, casualties and collisions, and costs; documents and print media; surveys; interviews and focus groups; and Google Street View (Google Inc., Mountain View, CA, USA). Results: Collisions and casualties – the overall percentage reduction in casualty rates was 39% (the overall percentage reduction in collision rates was 40%) in Edinburgh. The percentage reduction for each level of severity was 23% for fatal casualties, 33% for serious casualties and 37% for minor casualties. In Belfast there was a 2% reduction in casualties, reflecting differences in the size, reach and implementation of the two schemes. Perceptions – in Edinburgh there was an increase in two factors (support for 20 mph and rule-following after implementation) supported by the qualitative data. Liveability – for both cities, there was a small statistical increase in liveability. Speed – mean and median speeds reduced by 1.34 mph and 0.47 mph, respectively, at 12 months in Edinburgh, with no statistically significant changes in Belfast. History, political context, local policy goals, local priorities and leadership influenced decision-making and implementation in the two cities. Limitations: There was no analysis of active travel outcomes because the available data were not suitable. Conclusions: The pre-implementation period is important. It helps frame public and political attitudes. The scale of implementation and additional activities in the two cities had a bearing on the impacts. The citywide approach adopted by Edinburgh was effective in reducing speeds and positively affected a range of public health outcomes. The city-centre approach in Belfast (where speeds were already low) was less effective. However, the main outcome of these schemes was a reduction in road casualties at all levels of severity. Future work: Future work should develop a statistical approach to public health interventions that incorporates variables from multiple outcomes. In this study, each outcome was analysed independently of each other. Furthermore, population measures of active travel that can be administered simply, inexpensively and at scale should be developed. Study registration: This study is registered as ISRCTN10200526. Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 10, No. 9. See the NIHR Journals Library website for further project information.

Introduction Throughout the life course, there are major life transitions that are associated with reduced physical activity, which may have further implications for health and well-being. Having a child is one such transition that has been identified as a critical transformative experience and window for intervention. We will conduct a scoping review of available evidence exploring the impact of having a child on physical activity in the UK.Methods and analysis We will use best-practice methodological frameworks to map key concepts and available evidence, summarise and disseminate findings to stakeholders, and identify knowledge gaps. A three-step search strategy will identify primary research studies, including reviews, from published and grey literature, exploring the impact of having a child on physical activity in the UK, from the preconception period, throughout pregnancy, the postpartum period, and into parenthood. An initial limited search will identify relevant reviews, from which keywords and index terms will be extracted. We will conduct searches of CINAHL, Embase, Medline, PsycINFO and Web of Science to identify relevant articles written in English from inception to February 2022. Two reviewers will independently screen titles and abstracts of identified studies for inclusion and chart data, with a third reviewer resolving any conflicts. Backwards citation tracking will identify any additional studies. We will conduct numerical and thematic analysis to map data in tabular and diagrammatic format and provide a description of findings by theme.Ethics and dissemination Ethical approval is not required for this scoping review. We will disseminate findings to stakeholders through publications, conferences, social media platforms and in-person communications. Consultations with key stakeholders, with their unique expertise and perspectives, will provide greater insight. We will establish the main priorities for future research to inform the research questions of subsequent studies.Scoping review registration Open Science Framework (https://osf.io/gtqa4/) DOI 10.17605/OSF.IO/GTQA4.

Objectives Systems approaches aim to change the environments in which people live, through cross-sectoral working, by harnessing the complexity of the problem. This paper sought to identify: (1) the strategies which support the implementation of We Can Move (WCM), (2) the barriers to implementation, (3) key contextual factors that influence implementation and (4) impacts associated with WCM.Design A multi-methods evaluation of WCM was completed between April 2019 and April 2021. Ripple Effects Mapping (REM) and semi-structured interviewers were used. Framework and content analysis were systematically applied to the dataset.Setting WCM—a physical activity orientated systems approach being implemented in Gloucestershire, England.Participants 31 stakeholder interviews and 25 stakeholders involved in 15 REM workshops.Results A white-water rafting analogy was developed to present the main findings. The successful implementation of WCM required a facilitative, well-connected and knowledgeable guide (ie, the lead organisation), a crew (ie, wider stakeholders) who’s vision and agenda aligned with WCM’s purpose, and a flexible delivery approach that could respond to ever-changing nature of the river (ie, local and national circumstances). The context surrounding WCM further strengthened and hampered its implementation. Barriers included evaluative difficulties, a difference in stakeholder and organisational perspectives, misaligned expectations and understandings of WCM, and COVID-19 implications (COVID-19 also presented as a facilitative factor). WCM was said to strengthen cohesion and collaboration between partners, benefit other agendas and policies (eg, mental health, town planning, inequality), and improve physical activity opportunities and environments.Conclusions This paper is one of the first to evaluate a systems approach to increasing physical activity. We highlight key strategies and contextual factors that influenced the implementation of WCM and demonstrate some of the wider benefits from such approaches. Further research and methodologies are required to build the evidence base surrounding systems approaches in Public Health.

Summary: Background: Exercise is advised for young adults with elevated blood pressure, but no trials have investigated efficacy at this age. We aimed to determine whether aerobic exercise, self-monitoring and motivational coaching lowers blood pressure in this group. Methods: The study was a single-centre, open, two-arm, parallel superiority randomized clinical trial with open community-based recruitment of physically-inactive 18–35 year old adults with awake 24 h blood pressure 115/75mmHg-159/99 mmHg and BMI37 weeks) to the intervention group, who received 16-weeks aerobic exercise training (three aerobic training sessions per week of 60 min per session at 60–80% peak heart rate, physical activity self-monitoring with encouragement to do 10,000 steps per day and motivational coaching to maintain physical activity upon completion of the intervention. The control group were sign-posted to educational materials on hypertension and recommended lifestyle behaviours. Investigators performing statistical analyses were blinded to group allocation. The primary outcome was 24 h awake ambulatory blood pressure (systolic and diastolic) change from baseline to 16-weeks on an intention-to-treat basis. Clinicaltrials.gov registered on March 30, 2016 (NCT02723552). Findings: Enrolment occurred between 30/06/2016-26/10/2018. Amongst the 203 randomized young adults (n = 102 in the intervention group; n = 101 in the control group), 178 (88%; n = 76 intervention group, n = 84 control group) completed 16-week follow-up and 160 (79%; n = 68 intervention group, n = 69 control group) completed 52-weeks follow-up. There were no group differences in awake systolic (0·0 mmHg [95%CI, -2·9 to 2·8]; P = 0·98) or awake diastolic ambulatory blood pressure (0·6 mmHg [95%CI, -1·4. to 2·6]; P = 0·58). Aerobic training increased peak oxygen uptake (2·8 ml/kg/min [95%CI, 1·6 to 4·0]) and peak wattage (14·2watts [95%CI, 7·6 to 20·9]) at 16-weeks. There were no intervention effects at 52-weeks follow-up. Intepretation: These results do not support the exclusive use of moderate to high intensity aerobic exercise training for blood pressure control in young adults. Funding: Wellcome Trust, British Heart Foundation, National Institute for Health Research, Oxford Biomedical Research Centre.

Abstract Background International and national committees have started to evaluate the evidence for the effects of physical activity on neurocognitive health in childhood and adolescence to inform policy. Despite an increasing body of evidence, such reports have shown mixed conclusions. We aimed to critically evaluate and synthesise the evidence for the effects of chronic physical activity on academic achievement, cognitive performance and the brain in children and adolescents in order to guide future research and inform policy. Methods MedLine, Embase, PsycINFO, Cochrane Library, Web of Science, and ERIC electronic databases were searched from inception to February 6th, 2019. Articles were considered eligible for inclusion if they were systematic reviews with or without meta-analysis, published in peer-reviewed (English) journals. Reviews had to be on school-aged children and/or adolescents that reported on the effects of chronic physical activity or exercise interventions, with cognitive markers, academic achievement or brain markers as outcomes. Reviews were selected independently by two authors and data were extracted using a pre-designed data extraction template. The quality of reviews was assessed using AMSTAR-2 criteria. Results Of 908 retrieved, non-duplicated articles, 19 systematic reviews met inclusion criteria. One high-quality review reported inconsistent evidence for physical activity-related effects on cognitive- and academic performance in obese or overweight children and adolescents. Eighteen (critically) low-quality reviews presented mixed favourable and null effects, with meta-analyses showing small effect sizes (0.1–0.3) and high heterogeneity. Low-quality reviews suggested physical activity-related brain changes, but lacked an interpretation of these findings. Systematic reviews varied widely in their evidence synthesis, rarely took intervention characteristics (e.g. dose), intervention fidelity or study quality into account and suspected publication bias. Reviews consistently reported that there is a lack of high-quality studies, of studies that include brain imaging outcomes, and of studies that include adolescents or are conducted in South American and African countries. Conclusions Inconsistent evidence exists for chronic physical activity-related effects on cognitive-, academic-, and brain outcomes. The field needs to refocus its efforts towards improving study quality, transparency of reporting and dissemination, and is urged to differentiate between intervention characteristics for its findings to have a meaningful impact on policy.

Introduction The World Health Organisation endorses community-based programmes as a cost-effective, feasible and a best buy in the prevention and management of non-communicable diseases (NCDs). These programmes are particularly successful when the community actively participates in its design, implementation and evaluation. However, they may be only useful insofar as they can be scaled up and sustained in some meaningful way. Social network research may serve as an important tool for determining the underlying mechanisms that contribute to this process. The aim of this planned scoping review is to map and collate literature on the role of social networks in scaling-up and sustaining community-based physical activity and diet programmes in low-income and middle-income countries.Methods and analysis This scoping review protocol has been planned around the Arksey and OMalley framework and its enhancement. Inclusion criteria are peer-reviewed articles and grey literature exploring the role of social networks in the scale-up and/or sustainability of NCD prevention community-based programmes in adult populations. Studies must have been published since 2000, in English, and be based in a low-income or middle-income country. The following databases will be used for this review: PubMed, Cochrane, Scopus, Web of Science, CINAHL, SocIndex, the International Bibliography of the Social Sciences, Google and Google Scholar. Books, conference abstracts and research focused only on children will be excluded. Two reviewers will independently select and extract eligible studies. Included publications will be thematically analysed using the Framework Approach.Ethics and dissemination Ethical approval will not be sought for this review as no individual-level data or human participants will be involved. This protocol is registered on the Open Science Framework (https://doi.org/10.17605/OSF.IO/KG7TX). The findings from the review will be published in an accredited journal. The Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews checklist will be used to support transparency and guide translation of the review.

Abstract Background Regular physical activity improves overall health, and has the capacity to reduce risk of chronic diseases and death. However, better understanding of the relationship between multiple lifestyle risk behaviours and disease outcomes is pertinent for prioritising public health messaging. The aim of this systematic review is to examine the association between physical inactivity in combination with additional lifestyle risk behaviours (smoking, alcohol, diet, or sedentary behaviour) for cardiovascular disease, cancer, and all-cause mortality. Methods We searched Ovid Medline, EMBASE, and the Cochrane Register from 1 January 2010 to 12 December 2017, for longitudinal observational studies of adults (18+ years) in the general population with a publication date of 2010 onwards and no language restriction. Main exposure variables had to include a physical activity measure plus at least one other lifestyle risk factor. In total, 25,639 studies were identified. Titles, abstracts and full-text articles of potentially relevant papers were screened for eligibility. Data was extracted and quality assessment was completed using a modified Newcastle-Ottawa Scale (NOS). Results Across the 25 eligible studies, those participants who reported being physically active combined with achieving other health behaviour goals compared to those who were categorised as physically inactive and did not achieve other positive lifestyle goals, were at least half as likely to experience an incident cardiovascular disease (CVD) event, die from CVD, or die from any cause. These findings were consistent across participant age, sex, and study length of follow-up, and even after excluding lower quality studies. We also observed a similar trend among the few studies which were restricted to cancer outcomes. Most studies did not consider epidemiological challenges that may bias findings, such as residual confounding, reverse causality by pre-existing disease, and measurement error from self-report data. Conclusions High levels of physical activity in combination with other positive lifestyle choices is associated with better health outcomes. Applying new approaches to studying the complex relationships between multiple behavioural risk factors, including physical activity, should be a priority.

Abstract Background The central aim was to examine the accuracy of the full range of daily activities recorded in self-report time-use diaries against data from two objective passive data collection devices (wearable camera and accelerometer) serving as criterion reference instruments. This enabled systematic checks and comparisons on the timing, sequence and duration of activities recorded from the three data sources. Methods Participants (n = 148) were asked to complete a single-day self-report paper time-use diary designed for use in the Harmonised European Time Use Study (HETUS), while simultaneously wearing a camera that continuously recorded images of their activities, and an accelerometer tracking physical movement. In a reconstruction interview shortly after the data collection period, participants viewed the camera images to help researchers interpret the image sequences. Of the initial 148 recruits (multi-seed snowball sample, 59% women, aged 18–91, 43% > 40) 131 returned usable diary and camera records (of whom 124 also provided a usable whole-day accelerometer record. We compare time allocation estimates from the diary and camera records, and also match the diary and camera records to the simultaneously recorded accelerometer vector magnitudes. Results The data were examined at three analytic levels: aggregate, individual diarist and timeslot. The most important finding is that the estimates of mean daily time devoted to 8 of the 10 main activities differ by

Introduction Mothers with gestational diabetes mellitus (GDM) are at increased risk of pregnancy-related complications and developing type 2 diabetes after delivery. Diet and physical activity-based interventions may prevent GDM, but variations in populations, interventions and outcomes in primary trials have limited the translation of available evidence into practice. We plan to undertake an individual participant data (IPD) meta-analysis of randomised trials to assess the differential effects and cost-effectiveness of diet and physical activity-based interventions in preventing GDM and its complications.Methods The International Weight Management in Pregnancy Collaborative Network database is a living repository of IPD from randomised trials on diet and physical activity in pregnancy identified through a systematic literature search. We shall update our existing search on MEDLINE, Embase, BIOSIS, LILACS, Pascal, Science Citation Index, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects and Health Technology Assessment Database without language restriction to identify relevant trials until March 2021. Primary researchers will be invited to join the Network and share their IPD. Trials including women with GDM at baseline will be excluded. We shall perform a one and two stage random-effect meta-analysis for each intervention type (all interventions, diet-based, physical activity-based and mixed approach) to obtain summary intervention effects on GDM with 95% CIs and summary treatment–covariate interactions. Heterogeneity will be summarised using I2 and tau2 statistics with 95% prediction intervals. Publication and availability bias will be assessed by examining small study effects. Study quality of included trials will be assessed by the Cochrane Risk of Bias tool, and the Grading of Recommendations, Assessment, Development and Evaluations approach will be used to grade the evidence in the results. A model-based economic analysis will be carried out to assess the cost-effectiveness of interventions to prevent GDM and its complications compared with usual care.Ethics and dissemination Ethics approval is not required. The study is registered on the International Prospective Register of Systematic Reviews (CRD42020212884). Results will be submitted for publication in peer-reviewed journals.

Objectives The aim of the study is to compare how member states of the European Union (EU) develop their national physical activity (PA) recommendations and to provide an overview of the methodologies they apply in doing so. Information was collected directly from the physical activity focal points of EU member states in 2018. Five countries were chosen for detailed case study analysis of development processes.Design Cross-sectional survey.Participants The representatives of the 28 EU member state governments to the EU physical activity Focal Point Network.Outcome measures From national documents we extracted data on (1) the participants of the development process, (2) the different methods used during development, and (3) on which sources national PA recommendations were based. An additional survey for case study countries provided details on (1) anonymised information on the participants of development process, (2) methods employed and rationale for choosing them, (3) development process and timeline, and (4) main source documents used for recommendation development.Results Eighteen national documents on PA recommendations contained information about development process. The results showed that countries used different approaches to develop national recommendations. The main strategies were (1) adoption of WHO 2010 recommendations or (2) a combination of analysis and adoption of other national and international recommendations and literature review. All of the five case study countries relied on review processes rather than directly adopting WHO recommendations.Conclusions While there are arguments for the use of particular strategies for PA recommendation development, there is currently no evidence for the general superiority of a specific approach. Instead, our findings highlight the broad spectrum of potential development methods, resources utilisation and final recommendations design currently available to national governments. These results may be a source of inspiration for other countries currently planning the development or update of national PA recommendations.

Background Golf is a sport played worldwide by >60 million people from a variety of backgrounds and abilities. Golf’s contribution to physical and mental health benefits are becoming increasingly recognised. Countries have adopted a range of restrictions to playing golf during the COVID-19 pandemic.Aims The purpose of this narrative review was to (1) explore the literature related to the possible health benefits and risks of playing golf during the COVID-19 pandemic and (2) provide recommendations on golf-related activity from the relevant available literature.Results Golf can provide health-enhancing physical activity. Regular physical activity is associated with physical/mental health, immune system and longevity benefits. Sense of belonging and life satisfaction significantly improved when golfing restrictions were relaxed after the first lockdown in the UK. Golf is an outdoor sport, where social distancing is possible, and if rules are followed, risk of COVID-19 transmission is likely to be low.Conclusions Policy-makers and governing bodies should support the promotion of golf because participation brings wide ranging benefits for physical health and mental well-being. When effective risk reduction measures are used, the benefits of playing golf in most circumstances outweigh the risk of transmission.

Aim To understand the barriers to and motivations for physical activity among second-generation British Indian women. Subject Approximately 50% of British South Asians are UK-born, and this group is increasing as the second-generation also have children. Previous research into the barriers to and facilitators for physical activity has focused on migrant, first-generation populations. Qualitative research is needed to understand a) how we might further reduce the gap in physical activity levels between White British women and British Indian women and b) the different approaches that may be required for different generations. Methods Applying a socioecological model to take into account the wider social and physical contexts, we conducted semi-structured interviews with 28 Indian women living in Manchester, England. Interviews with first-generation British Indian women were also included to provide a comparator. Interviews were audio-recorded, transcribed, thematically coded and analysed using a grounded theory approach. Results Ways of socialising, concerns over appearance while being physically active, safety concerns and prioritising educational attainment in adolescence were all described as barriers to physical activity in second-generation British Indian women. Facilitators for physical activity included acknowledging the importance of taking time out for oneself; religious beliefs and religious groups promoting activity; being prompted by family illness; positive messages in both the media and while at school, and having local facilities to use. Conclusions Barriers to physical activity in second-generation Indian women were very similar to those already reported for White British women. Public health measures aimed at women in the general population may also positively affect second-generation Indian women. First-generation Indian women, second-generation children and Muslim women may respond better to culturally tailored interventions.

Objectives Traffic speed is important to public health as it is a major contributory factor to collision risk and casualty severity. 20mph (32km/h) speed limit interventions are an increasingly common approach to address this transport and health challenge, but a more developed evidence base is needed to understand their effects. This study describes the changes in traffic speed and traffic volume in the City of Edinburgh, pre- and 12 months post-implementation of phased city-wide 20mph speed limits from 2016–2018. Methods The City of Edinburgh Council collected speed and volume data across one full week (24 hours a day) pre- and post-20mph speed limits for 66 streets. The pre- and post-speed limit intervention data were compared using measures of central tendency, dispersion, and basic t-tests. The changes were assessed at different aggregations and evaluated for statistical significance (alpha = 0.05). A mixed effects model was used to model speed reduction, in the presence of key variables such as baseline traffic speed and time of day. Results City-wide, a statistically significant reduction in mean speed of 1.34mph (95% CI 0.95 to 1.72) was observed at 12 months post-implementation, representing a 5.7% reduction. Reductions in speed were observed throughout the day and across the week, and larger reductions in speed were observed on roads with higher initial speeds. Mean 7-day volume of traffic was found to be lower by 86 vehicles (95% CI: -112 to 286) representing a reduction of 2.4% across the city of Edinburgh (p = 0.39) but with the direction of effect uncertain. Conclusions The implementation of the city-wide 20mph speed limit intervention was associated with meaningful reductions in traffic speeds but not volume. The reduction observed in road traffic speed may act as a mechanism to lessen the frequency and severity of collisions and casualties, increase road safety, and improve liveability.

Abstract Background Hypertension prevalence in young adults has increased and is associated with increased incidence of cerebrovascular and cardiovascular events in middle age. However, there is significant debate regards how to effectively manage young adult hypertension with recommendation to target lifestyle intervention. Surprisingly, no trials have investigated whether lifestyle advice developed for blood pressure control in older adults is effective in these younger populations. Methods/Design TEPHRA is an open label, parallel arm, randomised controlled trial in young adults with high normal and elevated blood pressure. The study will compare a supervised physical activity intervention consisting of 16 weeks structured exercise, physical activity self-monitoring and motivational coaching with a control group receiving usual care/minimal intervention. Two hundred young adults aged 18–35 years, including a subgroup of preterm born participants will be recruited through open recruitment and direct invitation. Participants will be randomised in a ratio of 1:1 to either the exercise intervention group or control group. Primary outcome will be ambulatory blood pressure monitoring at 16 weeks with measure of sustained effect at 12 months. Study measures include multimodal cardiovascular assessments; peripheral vascular measures, blood sampling, microvascular assessment, echocardiography, objective physical activity monitoring and a subgroup will complete multi-organ magnetic resonance imaging. Discussion The results of this trial will deliver a novel, randomised control trial that reports the effect of physical activity intervention on blood pressure integrated with detailed cardiovascular phenotyping in young adults. The results will support the development of future research and expand the evidence-based management of blood pressure in young adult populations. Trial Registration Clinicaltrials.gov registration number NCT02723552, registered on 30 March, 2016.

Abstract Background The work of The Global Observatory for Physical Activity-GoPA! is the first global effort to compile standardized country-level surveillance, policy and research data for physical activity in order to better understand how countries and regions address promoting physical activity. GoPA! developed standardized country-specific physical activity profiles (“Country Cards”) to summarize country-level data through 2013. The aim of this study was to assess use of the Country Cards, identify the factors associated with their use, and develop recommendations for supporting country-level physical activity promotion. Methods Cross sectional internet-based survey conducted between August–October 2016. Target study participants were national physical activity leaders and advocates in academia, government and practice from the GoPA! countries, and members of the International Society of Physical Activity and Health. A Country Card use composite score was created based on the diversity and frequency of use. Statistical analyses on the associations between the composite score and respondent characteristics, country characteristics, barriers and opinions were conducted (including descriptive analyses and a logistic regression with robust standard errors). Results One hundred forty three participants from 68 countries completed the survey. Use of the Country Cards was associated with being part of the GoPA! network, knowing about the Country Cards, and on the stage of country capacity for physical activity promotion. Country Card knowledge varied by country income group, region and the country specific context. More diverse and frequent use of the cards (highest tertile of the composite score for use) was associated with: 1. Being a country contact vs general participant (OR 18.32–95% CI 5.63–59.55, p = 0.002), and 2. Collaborating with a government representative working in NCDs on a monthly or more frequent contact vs less frequent contact (OR 3.39–95% CI 1.00–11.54, P

Abstract Aim This descriptive review aimed to assess the characteristics and methodological quality of economic evaluations of cardiac rehabilitation (CR) programs according to updated economic guidelines for healthcare interventions. Recommendations will be made to inform future research addressing the impact of a physical exercise component on cost-effectiveness. Methods Electronic databases were searched for economic evaluations of exercise-based CR programs published in English between 2000 and 2014. The Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement was used to review the methodological quality of included economic evaluations. Results Fifteen economic evaluations met the review inclusion criteria. Assessed study characteristics exhibited wide variability, particularly in their economic perspective, time horizon, setting, comparators and included costs, with significant heterogeneity in exercise dose across interventions. Ten evaluations were based on randomised controlled trials (RCTs) spanning 6–24 months but often with weak or inconclusive results; two were modelling studies; and the final three utilised longer time horizons of 3.5–5 years from which findings suggest that long-term exercise-based CR results in lower costs, reduced hospitalisations and a longer cumulative patient lifetime. None of the 15 articles met all the CHEERS quality criteria, with the majority either fully or partially meeting a selection of the assessed variables. Conclusion Evidence exists supporting the cost-effectiveness of exercise-based CR for cardiovascular disease patients. However, variability in CR program delivery and weak consistency between study perspective and design limits study comparability and therefore the accumulation of evidence in support of a particular exercise regime. The generalisability of study findings was limited due to the exclusion of patients with comorbidities as would typically be found in a real-world setting. The use of longer time-horizons would be more comparable with a chronic condition and enable economic assessments of the long-term effects of CR. As none of the articles met recent reporting standards for the economic assessment of healthcare interventions, it is recommended that future studies adhere to such guidelines.

Abstract Background There has been rapid increase in time spent using Internet as a platform for entertainment, socialising and information sourcing. This study aimed to evaluate the relationship between duration of time spent using Internet for leisure, depressive symptoms, and psychological distress among Australian adolescents. Methods Depressive symptoms were indicated by the youth self-report module from the Diagnostic and Statistical Manual of Mental Disorders Version IV criteria, and psychological distress was measured by Kessler Psychological Distress scale. Internet use was self-reported based on use on an average weekday, and an average weekend day. Multivariate logistic regression models were used to examine the relationship between Internet use and mental health outcomes. Models were adjusted for potential confounders: age; relative level of socio-economic disadvantage, and body mass index. Results Adolescents were aged 11–17 years (M = 14.5 years, SD = 2.04 years). Greatest time spent using internet (≥7 h a day) was significantly associated with experiencing depressive symptoms among females (OR = 2.09, 95% CI = 1.16, 3.76, p

Monforte, J. et al. (2019): “Infografía sobre actividad física para personas adultas con discapacidad”. Revista Española de Discapacidad, 7 (I): 257-265.

English physical activity guidance now recognises a double weighting of vigorous over moderate activity; 1 min of vigorous activity is the same as two ‘equivalent’ minutes of moderate activity. In addition, concerns of over-estimation of occupational PA led to newly applied measurement methods for this domain. Vigorous activity is associated with higher socio-economic position and occupational PA has the opposite association, so these changes may increase inequalities. We profiled adults' total and domain-specific ‘equivalent minutes’ of weekly PA in England 2012, and investigated inequalities in PA participation, accounting for the new weighting of vigorous PA, and new measurements of occupational PA.Nationally representative cross-sectional survey data on the self-reported PA of 8158 adults was used to produce a profile of the domain and duration of weekly ‘equivalent minutes’ of PA. Vigorous PA was double-weighted compared to moderate PA, and the percentage contribution from each PA domain quantified, stratified by gender and activity status and split by socio-demographic variables.Women, older adults, and adults without qualifications, from deprived areas, with worse employment conditions, or living in the North of England were significantly less likely to meet MVPA guidance. Type of activity was also socially patterned, particularly sport participation, which contributed a higher percentage of PA in adults of higher socioeconomic status. For active men, sporting activity was the most prevalent domain, and sports and walking for active women.In England, there are important socio-demographic differences in how adults participate in PA, and in percentage meeting public health guidance. Keywords: Epidemiology, Socio-economic position, Health survey

Non-communicable diseases (NCDs) disproportionately affect low- and lower-middle income countries (LLMICs) where 80% of global NCD related deaths occur. LLMICs are the primary focus of interventions to address development and poverty indicators. We aimed to synthesise the evidence of these interventions' impact on the four primary NCDs (cardiovascular disease, diabetes, chronic respiratory disease and cancer) and their common behavioural risk factors (unhealthy diets, physical inactivity, tobacco and alcohol use).We systematically searched four online databases (Medline, Embase, Web of Science and Global Health) for primary research conducted in LLMICS, published between January 1st 1990 and February 15th 2016. Studies involved development or poverty interventions which reported on outcomes relating to NCDs. We extracted summary level data on study design, population, health outcomes and potential confounders.From 6383 search results, 29 studies from 24 LLMICs published between 1999 and 2015 met our inclusion criteria. The quality of included studies was limited and heterogeneity of outcome measures required narrative synthesis. One study measured impact on NCD prevalence, one physical activity and 27 dietary components. The majority of papers (23), involved agricultural interventions. Primary outcome measures tended to focus on undernutrition. Intensive agricultural interventions were associated with improved calorie, vitamin, fruit and vegetable intake. However, positive impacts were reliant on participant's land ownership, infection status and limited in generalisability. Just three studies measured adult obesity; two indicated increased income and consequential food affordability had the potential to increase obesity. Overall, there was poor alignment between included studies outcome measures and the key policy options and objectives of the Global Action Plan on NCDs.Though many interventions addressing poverty and development have great potential to impact on NCD prevalence and risk, most fail to measure or report these outcomes. Current evidence is limited to behavioural risk factors, namely diet and suggests a positive impact of agricultural-based food security programmes on dietary indicators. However, studies investigating the impact of improved income on obesity tend to show an increased risk. Embedding NCD impact evaluation into development programmes is crucial in the context of the Sustainable Development Goals and the rapid epidemiological transitions facing LLMICs.

Background: In October 2012, the WHO Eastern Mediterranean Region (EMR) developed a Regional Framework for Action to implement multisectoral action plans (MAPs) for the prevention and control of noncommunicable diseases (NCDs). Objectives: The aim of this project was to draw on the experiences of four EMR countries that had made good progress in developing these MAPs, to identify best practice and barriers in the development of them. Methods: Structured interviews were held with key stakeholders in the development of the MAPs from the four focal EMR countries: Lebanon, Morocco, Sudan, and Yemen. These interviews comprised two stages: first we conducted face-to-face interviews in September 2014; we then carried out follow-up teleconference interviews during October 2014. Thematic analysis of transcripts was used to identify several themes, including examples of best practices and challenges that were common to all four focal countries and are likely to be also relevant to many other countries in the development of MAPs. Results: Best practice in the development of MAPs includes methods to identify and recruit key sectors, ways to foster collaboration between sectors in the development and implementation of the action plan and means through which to encourage public support. Challenges identified included measuring outcomes in evaluating MAP success, current pressures and competing priorities for sectors and the perception of health issues as the responsibility of the health sector. Cultural and bureaucratic challenges were also discussed along with multisectoral fatigue, through the promotion of multisectoral approaches for a number of national issues. Conclusions: Although the development of multisectoral action plans to tackle NCDs is recommended, the process is a challenging one. Reflections from those countries which have experience in developing such action plans is important in identifying common challenges as well as recommending best practice, such that other countries may learn from their experiences.

Background: The central plank of the global strategy to combat non-communicable diseases (NCDs) is a cluster of highly cost-effective interventions that WHO has dubbed “best buys”. These 24 interventions promoted by WHO include tobacco taxation, salt reduction, cervical screening, and aspirin. Although the greatest burden of NCDs is in low-income and lower-middle income countries, evidence for most of the best buys comes from high-income countries. We did a systematic review to assess evidence for the effectiveness of best buys in low-income and lower-middle-income countries (LLMICs), where the need for effective NCD interventions is greatest. Methods: Using a registered protocol (PROSPERO: 42016039051) and following PRISMA guidelines, we searched 13 major databases for studies that quantified the effectiveness of the 24 interventions as defined in the 2013–20 Global Action Plan on NCDs. We included studies that were undertaken in 83 countries defined by the World Bank as LLMICs, published between Jan 1, 1990, and Feb 5, 2015. We accepted interrupted time-series designs as well as trials that compared interventions with usual health care. Two reviewers independently screened papers using a piloted form. We used study-specific Newcastle-Ottawa and Cochrane tools to assess risk of bias and adopted a narrative approach to data synthesis. Primary outcomes were NCD-related mortality, morbidity, and risk-factor prevalence. Findings: Our search returned 2672 records after duplicate removal and we included 36 studies in the final review, of which 26 had been done in India. 19 of the 36 studies reported on tobacco-related best buys, two pertained to diet and physical activity, four were on cardiovascular medication, and 11 on cancer interventions. Only four “best buys” had two or more studies that showed that the intervention was effective: group smoking reduction programmes, smoking bans in public places, cervical cancer screening, and hepatitis B immunisation. There was no evidence for the effectiveness of any best-buy interventions in 74 of the 83 LLMICs (89%). Interpretation: There is an urgent need to evaluate whether established NCD-prevention policies from high-income countries are effective in low-income settings. Our exact following of the wording of the WHO best buy definitions might have excluded some relevant studies; however, our review was comprehensive in scope and had a very robust search strategy. Funding: World Health Organization.

Summary: Background: Non-communicable diseases are the leading global cause of death and disproportionately afflict those living in low-income and lower-middle-income countries (LLMICs). The association between socioeconomic status and non-communicable disease behavioural risk factors is well established in high-income countries, but it is not clear how behavioural risk factors are distributed within LLMICs. We aimed to systematically review evidence on the association between socioeconomic status and harmful use of alcohol, tobacco use, unhealthy diets, and physical inactivity within LLMICs. Methods: We searched 13 electronic databases, including Embase and MEDLINE, grey literature, and reference lists for primary research published between Jan 1, 1990, and June 30, 2015. We included studies from LLMICs presenting data on multiple measures of socioeconomic status and tobacco use, alcohol use, diet, and physical activity. No age or language restrictions were applied. We excluded studies that did not allow comparison between more or less advantaged groups. We used a piloted version of the Cochrane Effective Practice and Organisation of Care Group data collection checklist to extract relevant data at the household and individual level from the included full text studies including study type, methods, outcomes, and results. Due to high heterogeneity, we used a narrative approach for data synthesis. We used descriptive statistics to assess whether the prevalence of each risk factor varied significantly between members of different socioeconomic groups. The study protocol is registered with PROSPERO, number CRD42015026604. Findings: After reviewing 4242 records, 75 studies met our inclusion criteria, representing 2 135 314 individuals older than 10 years from 39 LLMICs. Low socioeconomic groups were found to have a significantly higher prevalence of tobacco and alcohol use than did high socioeconomic groups. These groups also consumed less fruit, vegetables, fish, and fibre than those of high socioeconomic status. High socioeconomic groups were found to be less physically active and consume more fats, salt, and processed food than individuals of low socioeconomic status. While the included studies presented clear patterns for tobacco use and physical activity, heterogeneity between dietary outcome measures and a paucity of evidence around harmful alcohol use limit the certainty of these findings. Interpretation: Despite significant heterogeneity in exposure and outcome measures, clear evidence shows that the burden of behavioural risk factors is affected by socioeconomic position within LLMICs. Governments seeking to meet Sustainable Development Goal (SDG) 3.4—reducing premature non-communicable disease mortality by a third by 2030—should leverage their development budgets to address the poverty-health nexus in these settings. Our findings also have significance for health workers serving these populations and policy makers tasked with preventing and controlling the rise of non-communicable diseases. Funding: WHO.