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Moving Matters - Interventions To Increase Physical Activity

"The NIHR physical activity evidence review will be an invaluable tool to anyone working in practice or policy. Evidence should be one of the key building blocks for any decisions. It helps decision makers determine what works and what doesn’t, what should be commissioned and prioritised, and (equally important) what should be stopped. The beauty of this review is that it brings together a range of evidence in a concise way, and comes with clear prompts to consider how to practically apply the findings."

Sarah Ruane, Strategic Lead for Health, Sport England

Executive summary

Being active matters because it is an important way of staying healthy. We know that people can reduce their risk of many serious diseases by staying physically active. Activity is also important for mental well-being and keeping socially connected. Finding enjoyable ways to be active can benefit people in so many ways. But it is often hard for people to start and keep the habit of regular activity. Around a quarter of people are inactive and less than two thirds meet recommended activity levels. We need to know more about what works in getting people active and sustaining this, particularly for those who are least active now. This review focuses on National Institute for Health Research (NIHR)-funded research evaluating interventions to increase physical activity for individuals and populations. This features over 50 published and ongoing studies. Evaluations range from programmes in schools and communities to changes in transport and the environment, which are designed to promote greater activity.

Early years and young children of primary school age

From the few studies available, it appears that there is no single best way to help parents, nursery schools and others to encourage and promote healthy activity during the early years. Small changes everywhere are probably required to help to keep young children active throughout the day. Much attention has focused on primary school aged children. Two large trials of healthy lifestyle programmes in schools showed little effect on activity but some positive changes in other areas like unhealthy snacking. A review of evaluations of changes to playgrounds to encourage a range of activities showed mixed results.

Young people of secondary school age

There are different challenges to get teenagers and young people active once they enter secondary school. Research based on what we know about behaviour change emphasises the importance of young people having some control over lifestyle choices. Two large trials focused on girls, who often are least active at this age, but interventions from dance to whole school programmes showed little effect. Other studies looked at wider changes to the environment. Free bus passes in London increased use of buses and did not displace walking or cycling. One area which retained free access to swimming pools saw more people swimming, particularly children, including those from most deprived areas. Studies suggest that a range of changes are needed both to encourage deliberate exercise and to build activity into the everyday routines of young people.

Adults at home and at work

We know that getting people started from a base of very little or no activity is difficult. One trial of a walking scheme for inactive adults focused on small increases of steps which were sustained at three years. Research has tried to find out more about motivations and barriers to activity. Concerns about health can motivate people – as in the large trial of a walking programme for those at risk of diabetes, with increased activity levels seen for those with highest blood sugar levels at the start. Deprivation, difficult travel, and costs have been identified as barriers to activity, including those referred to fitness programmes by their general practitioner. Although one trial of subsidised activities showed no marked impact, another of free access and promotion of leisure facilities led to increase in use with greatest effect in most deprived areas. Some targeted approaches, like a weight loss programme for men through football clubs, showed sustained effects on activity and diet. In work, as well as neighbourhoods, changes to the environment can encourage less sedentary behaviour. A trial of standing desks showed they were well received, led to less sitting, and improved well-being.

Older adults

People tend to become less active as they age, and this is not evenly spread – the least active include women, those with longstanding illness, obesity and poor social networks. Existing research, including a recent trial of a weekly exercise class, suggests that older people are more likely to keep active through structured group activities than exercising on their own at home. The social aspect of exercise and activity are particularly important. Successful approaches include walking programmes tailored to older people showing sustained increases in a large trial.

Built and natural environments

Our neighbourhoods and transport links can affect how active we are. Evaluation a guided bus lane and path for walking and cycling increased active travel. Other studies have looked at new motorways and related increases in car use, and at regeneration around the Olympic Games sites in London which did not lead to expected increases in activity and well-being. Ongoing research is looking at traffic calming measures and how new towns can be designed to improve health and activity.

Conclusions

This review provides an emerging picture of what we know about increasing activity for populations and individuals. There are no single solutions. What may drive us to keep and stay active depends on who we are, where we live, and wider system issues. This body of research shows some real gains, producing robust and often objectively measured evidence. These range from tailored approaches such as football clubs for men to those focusing on small achievable changes, such as walking programmes using pedometers to measure and gradually increase daily steps. Other initiatives, from free access to leisure services, guided busways and standing desks at work, show the benefits of enhancing access and how redesigning the environment can help drive activity. Other promising initiatives - including some school-based activity programmes - which appeared effective in small studies, were not borne out in more robust research. These initiatives may have resulted in other benefits, from reducing loneliness and increased well-being, even if they did not deliver expected gains in physical activity. We shouldn’t think of physical activity in isolation, and need to be realistic about the impact of short term single interventions in changing longstanding habits and behaviour. We have identified some areas where more research is needed, from programmes targeting the least active to transitions to active retirement, and how best to tailor interventions to different contexts and groups of people. NIHR is enthusiastic to fund more high quality research in this area. Study designs need to be informed by what we know about behavioural science, the complexity of drivers to stay active and well, and the range of barriers that prevent particular groups from being more physically active.

Introduction

About this review

This report brings together recent evidence on ways to influence physical activity behaviours in individuals and populations. This report focuses on studies funded by NIHR. Its purpose is to bring together NIHR-funded research, raising awareness of the findings and relating them to a broader body of research, but it is not a comprehensive review of all available evidence.

The NIHR was set up in 2006 to provide a comprehensive health research system focused on the needs of patients and the public. Since then it has funded a number of programmes, projects, and research centres related to physical activity and public health. These different studies have not been brought together in this way before.

We have looked through the portfolio of NIHR-funded research and identified studies with a focus on increasing physical activity in everyday life, and whose findings are most relevant for those who support the health and well-being of communities. These decision makers may work across a range of roles and organisations, in healthcare, local authorities, community organisations, education, or private companies. Prompts for reflection after each chapter are intended to encourage you to consider how the research may be helpful to you and your local communities. In order to retain our focus, we have had to exclude a wider body of evidence from the NIHR and other funders which focuses on the health benefits of physical activity. Such evidence is well represented in guidelines on physical activity from the UK Chief Medical Officers (updated guidelines are expected in autumn 2019), and NICE quality standards for physical activity. Studies have been selected with help from an expert group of relevant stakeholders listed in the acknowledgements section.

Sport England Infographic

Figure 1: Physical activity levels of adults. Sport England Active Lives adult survey (xiv)

While many gaps in the evidence remain, we are pleased to share research that has identified useful components that can together help our communities to become more physically active. We hope this review will also help to identify areas for future research that will provide important understanding of how to increase physical activity for everyone.

Research included in this review

We have primarily included in this review NIHR-funded studies that assess ways to increase physical activity through individual, community, and environmental interventions. Studies that address physical activity as part of a larger suite of measures are included if they report changes in physical activity.

We have excluded many otherwise important studies that: did not involve interventions to try to change physical activity; that were exploratory or focused on research methods; that selected participants on the basis of their having defined clinical conditions; or that used exercise as therapy.

Although not included here, many funders other than the NIHR also support important work to develop the understanding of physical activity. Notable funders include the Medical Research Council, What Works Centres, the Big Lottery Fund, Sport England, and the Wellcome Trust.

Approach to physical activity

We have taken physical activity to mean any bodily movement produced by skeletal muscles that results in energy expenditure. Types of physical activity in daily life include occupational, transport, sports, conditioning, household, leisure, and other activities. This is broader than exercise, which refers to physical activity that is planned, structured, and repetitive and has as a final or an intermediate objective the improvement or maintenance of physical fitness(ii).

In considering physical activity, researchers often differentiate aerobic physical activity, strength and balance activity, and sedentary behaviour. All have important health effects, and guidelines usually recommend considering all three. Additionally, the ways in which people may be active or sedentary vary, as part of their leisure or work, through travel, and through sport or exercise.

PHE Infographic

Figure 2: Health benefits of physical activity for adults.(i) Public Health England.

This review takes a life-course approach, considering the changing needs and opportunities of different age groups from infancy onwards, as well as considering interventions in the workplace and in the built and natural environments. This reflects the fact that people’s physical activity behaviours depend on the characteristics and attitudes of individuals, as well as the wider contexts and environments in which they live. In order to influence a person’s physical activity behaviours effectively, it will help to tailor any intervention in light of the whole system of factors that influence their behaviour, and the aspects that can be most effectively influenced.

Much research aggregates results for large numbers of people, and understanding the commonalities of what makes an intervention work is important to developing a science of behaviour. However, it is important to keep in mind the diversity of people and circumstances involved, to consider reasons why what works for one person may not work for another, and to adapt interventions to particular contexts. Understanding and addressing inequalities is essential in order to generate the greatest health and well-being benefits from physical activity. These inequalities often relate to social and cultural norms, economic factors, gender, geography, ethnicity, and a person’s current health. A finegrained understanding of the specific barriers that groups and individuals face is essential for effective interventions to be made available to those who may benefit most.

"Move more, eat better, reduce alcohol, don’t smoke. Blah, drone, lecture… this isn’t nearly enough. We need to think not only about the things we can do for ourselves, but about how physical activity is affected by our whole ecology: the things we can do for each other, the things the worlds of work and school can do, and the things the system can do for its citizens."

Professor Jim McManus, Director of Public Health, Hertfordshire County Council

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NICE Quality Standard QS183

Physical activity: encouraging activity in the community

This NICE quality standard provides useful best-practice benchmarking for local authorities, healthcare commissioning groups, workplaces and schools. It covers how local strategy, policy and planning and improvements to the built or natural physical environment such as public open spaces, workplaces and schools can encourage and support people of all ages and all abilities to be physically active and move more.

  • Statement 1 Local authorities and healthcare commissioning groups have senior level physical activity champions who are responsible for developing and implementing local strategies, policies and plans.
  • Statement 2 Local authorities prioritise pedestrians, cyclists and people who use public transport when developing and maintaining connected travel routes.
  • Statement 3 Local authorities involve community members in designing and managing public open spaces.
  • Statement 4 Workplaces have a physical activity programme to encourage employees to move more and be more physically active.
  • Statement 5 Schools and early years settings have active travel plans that are monitored and updated annually.

Figure 3: NICE Quality Standard. Physical Activity: Encouraging activity in the community (2019).

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Work by the World Health Organisation (iii) has considered the complexity of factors that interact to shape a person’s physical activity behaviours.

Interventions that address any one part of this system in isolation are not likely to have substantial effects, but by carefully teasing out the important factors and how to influence them effectively, multifaceted interventions can be implemented that address a range of these factors and are able to increase the proportion of people who are achieving recommended levels of physical activity. Recent quality standards for physical activity from NICE (figure 3) support this view that many systems need to be addressed together to improve physical activity levels.

The evidence presented here is not comprehensive, but aims to present the story so far through selected high-quality research that the NIHR has funded into how to increase physical activity at different times in people’s lives, as well as through changes related to the workplace and the built and natural environments. We hope that this report increases awareness of the evidence to support different interventions, and can lead to more active and healthier communities across the UK.

A note about referencing

This review uses three forms of referencing: Summaries of featured studies use a number and can be found here. Ongoing and feasibility studies use a letter and can be found here. And where these or other publications are referred to in passing, the review uses roman numerals and can be found here.

Early Years

Introduction

Our early childhood years are essential for development and are considered to have important and long-reaching consequences throughout our lives. Even before birth, pregnant women benefit from physical activity and, with sensible adaptation, this does not cause any harm (iv). Physical activity in infants and young children has both immediate and longer-term benefits related to physical health and motor development, as well as sleep, cognitive development and quality of life. Evidence of the benefits of physical activity for young children is growing, and the Chief Medical Officers as well as World Health Organisation (v) have developed guidelines. Compelling links are being made that more active pre-school children are likely to become more active school age children and adults (vi).

This chapter considers: what can we do to encourage and support infants and young children to enjoy being active from birth up to age four?

Research Findings

There is relatively little evidence about how best to increase activity levels in young children. Although simple interventions around parental goal setting have been shown to be effective for some other behaviours, physical activity appears to be less readily influenced.

A large review of studies (Study 1) with children up to the age of six assessed the social factors associated with physical activity levels. It suggests that ways to encourage parental monitoring (where parents try to understand and supervise their children’s activities) are likely to be an important factor for increasing physical activity. The review also found that training providers, such as school teachers, could increase children’s levels of moderate-to-vigorous activity. Maternal role-modelling, where mothers are physically active with or without their child, showed promising results in the three studies that assessed it. Some other factors that might intuitively be expected to affect activity were not shown to make a clear difference, including the child’s gender, parental goal setting, social support, motor skill training, and increased time for physical activity. Although some important factors have been identified, there are likely to be others, and the interaction between combinations of factors may be crucial. This research has begun to unpick the influences on behaviours in young children, but additional work is needed to determine how best to modify these factors.

Child Swimming

The preliminary Empower study (vii) involving mothers and infants attempted to change family behaviours to prevent obesity. This noted that while goals that were set around diet and sedentary time were mostly achieved, most of the unsuccessful attempts at setting goals were related to increasing physical activity. This suggests that a much better understanding of the factors relating to physical activity is needed, not only to reduce the proportion of people who are obese, but to improve the health of all infants.

Ongoing research

The ongoing Startwell project in Birmingham (Study A) has developed a nutrition and physical activity training programme for staff in nurseries to help them make the nursery a healthier environment for young children. The study will assess changes in the food and drink offered, opportunities for active play, and how staff model healthy behaviours. If this proves to have been effective, it could inform other programmes to train people who work with young children.

"Evidence shows that being active as a child or young person can continue into being an active adult. Inequalities in activity can therefore become ingrained at a young age.”

Michael Brannan, National Lead for Physical Activity, Public Health England

The NAP SACC UK feasibility trial (Study B) in 12 nurseries is evaluating how effective and cost-effective changes to the nursery environment can be for nutrition and physical activity. The trial adapted the US Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) intervention, and implemented it in six of the nurseries, along with a home component for parents using digital media. The trial is looking at changes to nutrition, physical activity, sedentary behaviour, and oral health in nurseries, as well as goal setting and changes at home.

Conclusions

Research has not identified any single changes that in isolation have large overall effects for infants and young children. This is not surprising given the diversity and rapid development of children during these earliest years, and the competing pressures their parents experience. Many interrelated factors and activities contribute to children’s physical activity, and to their time spent being sedentary. To help infants and children be more active will require many small changes throughout the whole variety of places and activities that make up a child’s day. Even where young children attend nurseries, their family and physical and social environments are likely to be particularly important influences on the physical activity of infants and young children.

Prompts for reflection

  • How can parents and families be encouraged to increase physical activity during early years?
  • What support do we give nursery and pre-school providers to promote enjoyable, active play?
  • How are local green spaces designed and managed to meet the needs of infants, children, and families?

Children of Primary School Age

Introduction

The greater children’s physical literacy (confidence, competence, understanding, knowledge, and - most importantly - enjoyment) the more active they are likely to be. However, many children begin to reduce their physical activity when they begin school, and girls and those from less affluent families are less likely to enjoy being active (viii). Schools are promising places to deliver interventions to increase physical activity, providing a means to deliver interventions to large numbers of individuals at once, as well as to shape the school environment and culture. But schools are also places where children are often encouraged to sit for long periods. How can we encourage children aged 5 to 11 to be more active travelling to school, in the classroom, during breaks, and outside school?

Research Findings

Research has explored how physical activity could be encouraged at school. One large trial (Study 2) found that that a school programme (including teacher training, lesson planning, homework tasks involving parents, and written materials for parents and newsletters) did not change overall physical activity or sedentary behaviour in the short term or a year later. The study, with 9-10 year olds in 60 schools in England, used accelerometers to accurately measure activity levels and provide more complete and objective measures of activity than diaries or recollections. The researchers speculate that the reason they did not see a change in activity may be that intervention ‘dose’ was not high enough, and it is possible that a more intensive version of the same set of interventions could be effective. The intervention did appear to improve other behavioural outcomes, reducing weekend screentime by 21 minutes per day, reducing snacking,and reducing consumption of high-energy drinks.

"Children and young people are not independent individuals so our approach must recognise the importance of their family, and their physical and social environments such as schools and neighbourhoods."

Michael Brannan, National Lead for Physical Activity, Public Health England

A systematic review of quantitative and qualitative studies looked at research and experience of implementing health promotion programmes in schools in the UK. (Study 3) It aimed to identify those characteristics of programmes, schools or communities which make health promotion programmes more feasibly or sustainably deliverable in both primary and secondary schools. The review found that when preparing for implementation, important factors were consulting with parents and teachers, particularly when the initiative and its benefits are not already well known within the school, engaging pupils’ interest and attention, and identifying potential shared benefits for teachers and pupils. There is weak evidence that it is important a programme has a good ‘fit’ with the school, complements the school ethos, and fits with other activities. The initial implementation stage was more successful where changes were actively supported by school governors and senior staff, where there was a named co-ordinator of the programme within the school who was able to influence others, and where those delivering the programme received support with personal and professional development. Little research was available for the authors to derive clear recommendations about how best to sustainably embed a programme into routine practice, or the factors that affect whether a programme is implemented as intended, and when and how programme adaptation is justified (for example without undermining effectiveness).

A trial of the novel Healthy Lifestyles Programme for 10-11 year olds in 32 schools (Study 4) found that a healthy lifestyles week with drama sessions and goal-setting activities over the summer, followed by reinforcement activities during term, successfully engaged pupils across the socioeconomic spectrum, families and teachers, but did not result in changes to accelerometer-measured physical activity, food intake, or measures of obesity at 18 or 24 months, although children did reduce their unhealthy snacking. There were high rates of follow-up and the intervention was delivered as intended (both in terms of content and quality of delivery) leading the authors to conclude that it is unlikely programmes targeting a single age group can ever be sufficiently intense to affect weight status, and call for approaches that affect the school, the family, and the wider environment.

A large review (Study 5) found three studies that evaluated playground improvements in UK primary schools, but some methodological concerns were identified, meaning that the evidence generated is not strong. One study improved structures and developed three playground zones for sports, for fitness and skills, and for quiet play. It showed improvement in some markers of accelerometer-measured physical activity at 6 months and 12 months, with greater benefits for younger children. The other two studies improved playground surface markings. One did not find any change in measures of physical activity, while the other found an immediate increase in markers of physical activity. The popularity of The Daily Mile initiative (where all pupils are encouraged to walk or run for an additional 15 minutes during the school day), indicates that even basic outdoor spaces can bring important opportunities for physical activity. Beyond schools, a study in Blackpool (Study 6) has found that continued subsidies for free swimming led to an additional 33 swimming sessions per 100 children, and six per 100 children swimming at least once per year with the greatest effect seen among children aged 10-14. This indicates that removing the cost of swimming for children is effective in a very deprived local authority area, and the data suggest the effect may be greatest for moderately deprived groups.

Ongoing Research

Beyond time spent being active, interventions to reduce sedentary time are also likely to bring health benefits. The ongoing CLASS PAL study (Study C) in 9-10 year olds is assessing a suite of measures that teachers are encouraged to use to adapt the way lessons are taught and how the school day is organised, with a view to breaking up sedentary time and incorporating more physical activity throughout the day.

The FRESH intervention (Study D) is a pilot family-based physical activity programme for children. The intervention is targeted at whole families, delivered at home with web-based tools. The study is predominantly recruiting from rural areas, where physical activity levels in children have been seen to be lower and to decline with age more rapidly than in urban areas. Noting research that youth physical activity promotion is largely school-based and of limited effectiveness, the FRESH intervention is attempting to involve family members who they consider likely to be crucial for long-term changes in physical activity.

Stand Out in Class (Study E) is a pilot trial to reduce sitting time in 9-10 year old children. It has set out to assess how effective height-adjustable desks are to reduce sitting time for children on an average school day, and how this may improve health, well-being and learning. A feasibility study found that sit-stand desks in a classroom for nine weeks reduced sitting time by 80 minutes/day. A pilot study is in now progress with Year 5, where the pupils use this type of desk in turn, for about one hour per day each.

Action 3:30 (Study F) is a feasibility evaluation of a programme to support teaching assistants to lead extracurricular physical activity sessions for 8 to 10 year olds. The intervention is based on self-determination theory, which suggests that teachers can develop pupils’ autonomy, belonging, competence, enjoyment and motivation in order to increase uptake of the sessions.

Conclusions

Evidence for how to increase physical activity among primary school-age children suggests that delivering health improvement interventions to children should be done both at school and at home. To increase physical activity further, research into acceptable ways to deliver higher ‘doses’ of interventions throughout pupils’ day, to make their school and home environments more conducive to physical activity, and to increase the involvement of families may be needed. Prompts for reflection What could you do to enhance school buildings and playgrounds to increase physical activity? How can we encourage walking and cycling to school, through changes to the environment, and support to parents, carers and schools? What opportunities are there for schools to work with pupils and parents to find ways to increase physical activity?

Young people of Secondary School Age

Introduction

For young people of secondary school age, physical activity improves physical function and bone strength, as well as mental wellbeing (ix). Muscle and bone strengthening and balance activities during adolescence are particularly important in order to maintain function and good musculoskeletal health in later life (x). The government recommends that physical activity should take place both within and outside school (xi). However, only 20% of UK teenagers meet physical activity guidelines. Relatively little is known about how to motivate teenagers to change and sustain these behaviours (xii), although physical activity literacy, and particularly enjoyment appears to be important (viii). This is also an important time for establishing patterns of behaviour that can sustain health through adulthood and old age. During secondary school, from age 11 to 16, people’s social circles expand and take on increasing importance, and much of the research addresses social influences on physical activity.

Kids walking to school

A review of 13 interventional studies (xiii) did not find that changing activity levels affects cognitive function, although the two were associated. Importantly, the review did not find that allocating school time to physical activity compromised academic achievement.

Research findings

Interventions for older children and young adults have demonstrated some ways to increase physical activity, and theories about which approaches are more effective have been developed and tested. Giving young people some responsibility to decide on and make changes to improve health may be one effective way forward.

A 2013 Cochrane systematic review of international research (not funded by the NIHR) (Study 7) noted that there is some evidence that for adolescents, school-based interventions can increase physical activity. The interventions increased time spent physically active by 5-45 minutes/day, reduced sedentary television time by 5-60 minutes/day, and increased VO2max (a marker of cardiorespiratory fitness). However, the review’s findings were limited by the quality of the included studies, and the reviewers noted that additional research on the long-term impact of these interventions is needed.

A large review (Study 5) of studies into improving health in schools in the UK and abroad found that empowering students to modify their environment was effective in increasing general health outcomes. Two of the studies assessed interventions in US middle schools (ages approximately 11-14 years) to change the school food and physical activity environment. These independent studies were well conducted though still at some risk of bias, involving 8 and 12 schools in the intervention arms. Both improved some measures of physical activity, but not of dietary quality. One found promising effects with regard to reductions in aggressive behaviour, and the other noted that pupils became more able to influence their schools to create environments supportive of physical activity. Altogether, there was non-definitive evidence for the effectiveness of interventions in the school environment to build communities and relationships, and to empower students in modifying food and physical activity environments.

This review also identified a number of particular theories which could be helpful for developing effective interventions, and assessed evidence for their effectiveness. It found that interventions based on three types of theory, all of which contain strong social aspects, were more likely to be effective. Key implications were: schools are more likely to encourage healthy behaviours if they provide opportunities to participate in school life, develop the skills necessary for this participation, and enable students to gain recognition for this; schools with stable student and staff bodies, good relationships between staff and students, and an ethos of shared norms, are likely to have better health outcomes; schools should develop practical reasoning about pupil’s own and others’ feelings, perspectives, and emotions, increasing the ability to form strong relationships

"It’s essential to see beyond organised, competitive sport so as to reach people who don’t see themselves as sporty. Physical activity needs to be built into all areas of children and young people’s lives."

Philip Insall, Public contributor

The Bristol Girls Dance Project (Study 8) was a project to increase physical activity in adolescent girls, a group at high risk of inactivity. The features of the intervention were carefully developed with stakeholders during formative work. The study delivered dance classes to girls in several schools twice a week for 20 weeks, and measured their activity levels throughout the day. It did not find that twice-weekly dance classes increased overall physical activity, and it may be useful to consider why. One important factor may have been that girls in the trial were recruited when they were new in their school, and so had not settled into a routine of particular activities. Many of the girls may have dropped out as part of the process of exploring alternative activities. The study found that the girls who opted to attend the classes were those who were already relatively active compared to those who did not opt in. The researcher team speculates that if the intervention had been implemented once the girls were better established in the schools, rather than when they first arrived in Year 7, it may have been possible to proactively recruit those who were less active, and ongoing attendance at the dance classes may have been higher.

The introduction of free bus passes for young people in London led to an increase in journeys by bus. This evaluation (Study 9) also found that travel-diary surveys did not demonstrate a change in overall numbers of journeys by walking or cycling. This suggests that improving public transport does not displace walking. The evaluation used surveys and was not able to assess the incidental physical activity associated with these increased bus journeys, such as walking to and from bus-stops, or the increased opportunities for active recreation the transport provided. As the bus passes did not reduce other walking journeys, they are likely to have a positive effect on physical activity overall. More detailed and objective evaluations of the effects of interventions to increase access to public transport would help to quantify these benefits.

The Girls Active study (Study 10) supported schools to improve their physical activity culture and practices. Teachers attended training, were provided with resource packages, and then developed action plans that considered girls’ motivations and ways to increase participation in sport and physical education. The teachers then selected and developed peer leaders from among 11-14 year old girls, who in turn encouraged others to be more active. Objectively measured activity after 14 months was assessed, but not found to have changed. The authors suggest several reasons for the lack of effect. It may have been due to the long time for schools to set up the programme, and a disconnect between the plans for activities and those actually undertaken. Peer leaders may not have had the maturity and skills to influence their peers, particularly where there were conflicts with other school commitments. They suggest that a school culture shift is necessary, with involvement of pupils, teachers, and senior leadership, and that this sort of change may take several years to develop.

Ongoing research

Engaging adolescents in changing behaviour (EACh-B) (Study G) will evaluate a three-component intervention including: LifeLab, a three week science module to motivate and support pupils to think about how lifestyle changes at an early age can affect their health and the health of their future children; encouragement from trained teachers to improve diets and exercise; and a smartphone app involving friends and using game features.

An ongoing study (Study H) is assessing how and why young people from a deprived town in Cornwall engage with a long-running dance group, the TR14ers. It will assess physical activity, diet, nutrition knowledge, emotional well-being, and other health-related behaviours. The research also seeks to understand how and why young people engage and sustain engagement with the group and the impact of participation on health and the wider determinants of health in the short, medium and long term. It will enable researchers and practitioners to understand how to create the conditions to engage and sustain participation in health promotion programmes in areas of high economic deprivation.

The GoActive intervention (Study I) for 13-14 year olds aims to increase daily physical activity. The intervention actively encourages pupils who may be shy or less active to participate. Each class chooses two activities each week from a range chosen to appeal to a wide variety of students, and are encouraged to try at least one by mentors and peer leaders. Key themes of GoActive are: choice and novelty of activity; mentorship from older pupils and peers; competition and reward with a points system for participation; and flexibility of times and locations to suit pupil preferences.

The trial of Peer-Led physical Activity iNterventions for Adolescent girls (PLAN-A) (Study J) will train 13-14 year old pupils over three days to be peer supporters. These peer supporters will informally diffuse health promotion messages to their peers in order to encourage physical activity. The intervention is based on two main theories: the Diffusion of Innovations theory (about how ideas, beliefs and behaviours are socially communicated), and Self-Determination Theory (about how to foster high-quality and sustainable motivation). Physical activity outcomes will be measured with accelerometers, and cost-effectiveness estimated from a public sector perspective.

Conclusions

Developing new skills, such as dance, could have short and long term benefits that are not necessarily captured by changes in total moderate-vigorous physical activity, or even with cardio-respiratory fitness. One-off interventions to increase organised physical activity may be effective for young people, but once the activity or programme finishes, there is too often little to prevent their reverting to previous patterns of physical behaviour. Ways to sustain changes in behaviour are needed.

To significantly increase the proportion of children and young people meeting guidelines for physical activity will require changes that not only encourage deliberate activities such as sport, but that build incidental physical activity into all areas of children and young people’s lives, while also breaking up sitting time. Small changes that build increased activity into many routine activities, and that carefully take account of the social environment appear to be promising approaches. These diverse opportunities can provide valuable activity in themselves and, if they can improve young people’s confidence in their physical abilities, may also make them more likely to engage in other activities.

Prompts for reflection:

  • When young people begin secondary school, are they supported to take part in a wide range of physical activity opportunities in and outside school?
  • How can we encourage more active travel for all young people?
  • Are there additional barriers for certain groups? What initiatives could encourage young people to avoid sitting for long periods?

Adults

This chapter considers adults, from leaving school up to their mid-60s. Some people continue to engage in structured exercise or sport throughout adulthood, while many are physically active only incidentally as part of their routine day, and over five million (xiv) feel unable to be physically active at all. Physical activity plays a key role in the maintenance of good health and reducing the development of many diseases. Systematic reviews have begun to identify and collate the active ingredients that make interventions likely to be effective for different groups. For example, one meta-analysis (xv) found that interventions for inactive adults are more likely to remain effective after at least six months where they used: action planning, instruction on how to perform the behaviour, prompts or cues, behaviour practice or rehearsal, graded tasks, and self-reward.

Man cycling

Ageing of adults is not uniform, with those in poor health or poverty having very different experiences. The greatest health gains are likely to come from modest increases for those who are least active, and from interventions designed to be sustained in the long term (xv). This suggests a significant role for adaptations to encourage activity as an inherent part of people’s day, whether through leisure, travel, work, or reducing time spent sitting. Despite nearly two-thirds of the adult population meeting the CMO physical activity guidelines (xvi), stubborn inequalities remain. Women, those from lower socio-economic groups, and black and South Asian communities are less likely to be active.

Research findings

Some interventions have attempted to increase levels of incidental physical activity as adults go about their daily lives. The relative benefits of moderate to vigorous physical activity compared to light activities or even simply standing are not well explored. One review (xvii) noted that, while workplaces and many urban areas may not be suitable for vigorous physical activity, it may be relatively straightforward to replace sedentary behaviours such as sitting with standing or light activity. For example, many people could benefit if buildings are designed to encourage movement, people are encouraged to stand on public transport, and standing desks are available in offices. These changes would make few demands on individuals and could shift population activity patterns from being sedentary to including significant amounts of standing or light activity. This may bring its own health benefits, and may also make any later transition to moderate or vigorous physical activity more likely to be successful.

A study of factors from early adulthood that influence mid-life physical inactivity (Study 11) found that people who are obese in early adulthood, or who live in industrial or local authority housing areas are more likely to remain inactive or become more inactive, and less likely to become regularly active.

Interventions may need to be tailored carefully to these groups in order to be effective and reduce inequalities. Interventions to increase physical activity as part of reducing other health risks have been shown to be effective in the short term and sustainable in the long term. The Football Fans In Training programme (Study 12) was intended as a weight-loss programme for men. To address diet and physical activity it used behaviour change methods such as goal-setting, self-monitoring, and feedback. Coach-led physical activity training and encouragement of mutual support and learning were central. These behavioural changes were notably well sustained, and even three and half years later, participants continued to walk for an extra 90 minutes each week. Important features that may have contributed to the sustained effect of the intervention include the continued self-monitoring of diet and physical activity and the social support networks that were developed. It is also likely that using professional sports grounds to deliver the intervention may have increased participant buy-in and motivation.

The Walking Away from Type 2 Diabetes trial (Study 13) delivered a three-hour structured group education programme with pedometers to patients with high risk scores for developing diabetes. The intervention addressed self-efficacy (belief in one’s own ability to succeed at a task), identified barriers to walking, promoted self-regulatory skills through action planning and pedometer use, and encouraged individuals to increase their physical activity by 500 steps/day every fortnight, up an additional 3000 steps/day. The intervention was low resource, and found a moderate increase of 411 steps/ day at one year. However, the difference was not sustained in the longer term. Participants with more abnormal glucose measurements at baseline were more successful at changing their behaviour at one year. This suggests that the process of individuals plotting their glucose values on a risk chart may have increased these patients’ perception of the severity of their disease and so increased their intention to be physically active. In contrast, the 23% who did not attend the initial education session and refresher sessions had higher BMIs, larger waist circumferences, were more likely to smoke, and may have been more likely to come from deprived areas. This suggests that additional strategies and personalised approaches to support uptake and adherence to prevention programmes may be particularly useful for these groups.

An evaluation (Study 14) of exercise referral schemes, where doctors refer a patient to a fitness programme, found that referral uptake was lower for people without their own transport or from more deprived neighbourhoods. This suggests that good transport links to such programmes are important, and it may be that enhanced public transport could improve uptake from more deprived areas. Where people were referred because of cardiovascular risk factors, their uptake was greater, which may reflect increased motivation and strong belief that exercise is an effective way to reduce this health risk. This review did not explore the specific aspects of interventions that make them more effective. A separate economic assessment of exercise referral schemes (xviii) found that although no clear changes were seen in physical activity, the schemes may have improved quality of life. What evidence is available indicates such referral schemes are likely to provide reasonable value for money based on health outcomes, particularly in those who are obese, have high blood pressure, or have depression.

Use of graded tasks, where large tasks are broken down into smaller, more manageable ones, may be particularly effective. One primary care study (Study 15) provided a pedometer and 12-week walking programme based on behaviour change techniques to encourage building long-term habits, with advice to gradually add 3000 steps in 30 minutes. A year later, participants had significantly increased their daily step count by 10% and their moderate-to-vigorous physical activity by one third. These changes were sustained at three years. Whether this intervention was delivered by post or through practice nurse-led support groups made little difference, suggesting that significant professional support may not always be required. The postal intervention was also more cost-effective. By monitoring steps using pedometers built into smartphones, it is possible that the costs of the intervention could be reduced further.

A review of the barriers to physical activity participation in mid-life (Study 16) emphasised that consideration of these barriers is important for tailoring interventions to particular groups. Interventions that improve psychological factors of motivation, self-belief, and self-esteem may be important. The review also identified that people are deterred from opportunities for physical activity by cost. A trial (Study 17) offering subsidised activities to residents in Devon slightly increased residents’ time spent being physically active, but did not show an increase in numbers of people meeting physical activity guidelines. The authors noted that this lack of effect may have been because few residents had been aware of the interventions.

A different evaluation (Study 18) examined the impact of variations in local authority pricing policies on health inequalities. It found that offering universal free access to leisure facilities, alongside significant marketing and outreach activities, led to an additional 4% of the local population attending gym or swim sessions in a month and increased overall levels of self-reported physical activity levels by 2 percentage points. The effect was greatest for more deprived groups. Together, these studies indicate that reducing cost barriers and increasing community engagement may be important for making all residents more active, particularly those who received out of work welfare benefits, low wage households, working families with young children, and retired people.

Taking part in environmental and conservation activities is sometimes considered an effective way to encourage people to be physically active. However, a systematic review (Study 19) found that most of the research in this area was of low quality, and so could not draw definitive conclusions. Most of the studies did not find significant effects on health and well-being. Some studies did suggest benefits for self-reported health and physical activity, but an increased risk of anxiety. Participants enjoyed the social opportunities afforded by these programmes.

A review of UK guidelines (Study 20) found little specific guidance for how effectiveness of interventions varies between ethnic groups, nor how they can best be adapted. The development of a more fine-grained understanding of the factors affecting physical activity is important for effective interventions. The scarcity of ready-made advice about how to tailor interventions to particular groups increases the importance of undertaking detailed local assessment of barriers to physical activity for a wide range of groups, and the need for effective community engagement to shape interventions and raise awareness of opportunities.

Ongoing research

The Yoga Study (Study K) is working with people of South Asian descent, who have elevated risk of type 2 diabetes and cardiovascular disease. This group may be less likely to engage in physical activity, and the study has identified culturally appropriate forms of physical activity. They are testing whether yoga and light intensity walking are effective in reducing type 2 diabetes. A novel diabetes prevention programme (Study L), has found that people with existing type 2 diabetes could be recruited and trained in a range of techniques to become peer supporters for participants at high risk of themselves developing type 2 diabetes.

The NIHR Public Health Research Programme is commissioning further research into which interventions are effective to maintain or increase physical activity for people in mid-life, with particular attention to factors such as ethnicity, socioeconomic status, occupation or gender.

Conclusions

Physical activity in adults tends to reduce with age, but these studies have indicated there are effective ways to help adults to become more active. Many studies have found that a variety of techniques are suitable to help adults to maintain changes in their behaviour over several years. People are becoming increasingly aware of the benefits of physical activity, and the challenge is not only to provide opportunities for physical activity, but to further increase people’s motivation and capability. People for whom sport and other physical activity does not appeal are likely to have most to gain from appropriately tailored interventions, and surveys (xvi) have found that although the number of adults engaged in traditional sport are stable, people are increasingly taking up activities that can fit into a busy day, that are enjoyable, and where ability does not matter.

Prompts for reflection

  • Beyond sport, what can be done to achieve modest improvements in everyday activity?
  • What can we do that will appeal particularly to those who are least active?
  • What are the most important active ingredients you could consider including in order to make your interventions as successful as possible?

Workplace Changes

Introduction

It makes sense for organisations to encourage employees to keep active. The links between activity and health and well-being means that workplaces which support staff to stay active are likely to be rewarded by greater productivity and lower absence rates. Long periods of sitting still can lead to poorer health, from cardiovascular disease to diabetes and musculoskeletal problems, yet people may feel restricted to certain postures as they complete tasks. In this way, there is a clear business case for workplace interventions to support and maintain exercise and activity among employees. In research terms, there are also advantages to workplace activity studies. These involve well-defined populations where interventions can be tested and evaluated in more controlled settings. However, workplace interventions will do little for those who are not in work, and interventions for people in office-based jobs may need to be very different to those whose jobs are active or require significant standing. A diversity of interventions in different contexts will always be required to address inequalities in physical activity.

Many employers recognise that they have an obligation to the health and well-being of their workforce. Investing in the health of employees can also bring business benefits such as reduced sickness absence, increased loyalty and better staff retention. NICE Guideline PH13 (2008), Physical activity in the workplace.

Research findings

We know more now about the harmful effects of extended periods of sitting. A Cochrane review (Study 21) identified studies of different kinds looking at interventions to reduce sitting time at work. This included ten studies looking at sit-standing desks which reduced sitting time but evidence was low quality and effects were less marked when people were followed up for longer. Other low quality research found mixed results from changes in workplace policy (such as introducing structured breaks) or practice (such as computer prompts to walk about the room, activity trackers, and treadmill desks). Most studies in this review were small with a high chance of bias, and the findings may not apply to non-office workers. A subsequent trial in hospital office staff (Study 22) tested a multi-component intervention involving group education, sit-stand workstations, behavioural feedback, goal setting and action planning, brief one-to-one coaching as well as a self-monitoring and prompt device. This intervention aimed to reduce sitting time at work. The intervention group reduced their sitting time at 12 months, with a difference of 83 minutes per work day seen between the intervention and control group. Sitting time was mainly replaced by standing time, and so stepping time did not change. Additional benefits in work-related and psychological health were seen. Although the NHS is a large employer, it is not certain how generalizable these results will be for non-NHS settings, nor how best to encourage more stepping as opposed only to standing. Many outcomes of interest related to health or workplace absenteeism will be assessed in a large follow-on trial on council workers with outcomes measured over two years.

A loyalty card scheme to improve maintenance of physical activity changes in office-based employees was evaluated in Northern Ireland (Study 23). It used key fobs that could be tapped on sensors placed within 2 km of workplaces to earn points that could be redeemed at local retailers. Motivational emails, tailored feedback, and information about walking routes were also supplied, and participants were encouraged to set their own goals, monitor their activity, and develop prompts. Unfortunately, the workplaces underwent significant restructuring during the evaluation, which may explain why the intervention group decreased their physical activity compared to the control group. Other possible reasons for this unexpected decrease in physical activity are that the incentives were not sufficient (only 39% were redeemed), and that early technological difficulties left participants feeling frustrated. The authors also consider whether the use of financial rewards to change health behaviours may have ‘crowded out’ intrinsic motivation (a person’s interest or enjoyment in the activity itself) to be active, but conclude that this was not the case.

Ongoing research

A collaboration between public health, built environment and computer science researchers (Study M) is examining how the indoor layout of UK office buildings affects physical activity and sitting time.

Initiatives to reduce sitting time in offices include a small feasibility study (Study N) which assessed the impact of sit-stand desks at work on energy expenditure, sitting time, and cardio-metabolic markers over 3 months. It found that most workplaces could accommodate sit-stand desks, and these were well received by most participants, and sitting time was reduced by an estimated hour and a half per day. The study did assess the most common reasons people reported switching from sitting to standing (back ache and stiffness, returning to the desk after being away, and feeling guilty), and for switching from standing to sitting (tiredness, leaving desk, and type of activity).

The UP FOR 5 study (Study O) is investigating whether an intervention to reduce total sitting time and to increase movement breaks throughout the day can improve health markers in people who are a high risk of developing type 2 diabetes.

Stand Up For Health (Study P) is a feasibility trial of an intervention for contact centre staff. The intervention is co-produced with employees, offering tailored activities. Outcomes of interest will be mental well-being, musculoskeletal disorders, productivity and job satisfaction.

And a large trial of the SMART Work and Life intervention (Study Q) follows on from study 31. It will be the largest trial of its sort, with the longest follow up. Council office workers will be followed for two years to see how effective standing desks and a programme of behavioural change interventions are at reducing sitting time, physical activity outside working hours, and a variety of biochemical and psychosocial measures.

Another trial (Study R) is examining the effectiveness of providing booklets, pedometers, walking routes, and goal setting support to employees in order to increase walking during their commute.

Beyond office workplaces, the SHIFT Study (Study S) is evaluating a structured health intervention for long distance truckers to change physical activity, sitting, and diet behaviours. An education session, physical-activity tracker, and simple exercise equipment for a ‘cab workout’ will be provided. Outcomes will include measures of physical activity, sitting time, sleep duration, and health markers relevant to cardiovascular risk.

Conclusions

The majority of working age adults spend much of their waking time at work. There is an opportunity for employers and workplaces to support staff to be more active. This is important given the links between activity and health, well-being, and productivity that are well established for those in sedentary jobs. Recent NIHR research has looked at different approaches taken in the workplace. A trial of standing desks in a hospital showed sustained reductions in sitting time, which supported evidence from a previous review. But types and patterns of work vary widely, and effective interventions will need to be developed and tailored to account for this. Carefully designed and evaluated interventions helps us to understand more about the complex interplay and drivers which encourage people to keep active over time. Qualitative feedback from study participants has suggested that efforts to develop more healthy habits in one area of life, such as reducing sedentary time, are likely to prompt efforts to improve other areas, such as diet and physical activity.

Prompts for reflection

  • Could we introduce adjustable desks or other ways to reduce long periods of sitting?
  • Does your workplace have the necessary facilities and systems to encourage active commuting?
  • How can the case be made effectively to employers that they should support more physical activity?

Older Adults

Introduction

We know from good evidence that physical activity can help people to maintain their functionality, independence, and quality of life, preventing and delaying some of the diseases which affect people as they age. These range from osteoporosis to cardiovascular disease and cognitive decline, as well as the syndromes which together can be described as frailty. Improving strength and balance is particularly important to reduce falls, which are a common injury for older people and may lead to people no longer living independently at home. And yet older people tend to be less active – with 47% of people aged 75-84 being inactive, and 70% of those over 85 years. Over half of all inactive people in England are aged 55 and over (xiv). As well as the benefits of improved strength, balance and overall fitness, activity can also be an important way of reducing isolation and increasing well-being for older people.

Sport England Infographics

Figure 4: There is a sharp increase in the number of people becoming inactive from age 75. Sport England (xiv)

Research findings

There appear to be very few research studies looking particularly at transitions to retirement, according to one review (Study 24). This may be an important time of transition in which to intervene, and could benefit from further research. However, a number of attempts have been made using different approaches to get older people to be more active at home and in the community. NIHR research has looked at some of these interventions to identify lessons for individuals and decision-makers.

Evidence suggests that a range of approaches may be effective in promoting exercise in older people, including both supervised exercise, from walking groups to dance classes, and behavioural approaches such as motivational counselling and tailored activity plans. A review of reviews, (Study 25) looked at a number of questions relating to physical activity in older people, including what works in increasing activity levels and reducing barriers to participation. Evidence was mixed on the duration needed and the added benefit of input from activity professionals. Available evidence suggested that older people were more likely to keep exercising with group classes in a centre than through homebased activity. Although research often didn’t follow up older people for any length of time, evidence in this review suggested the need for interventions to combine supervised exercise opportunities with theoretical understanding of behaviour change to sustain increased activity over time. Another part of the review looked at nine qualitative reviews to understand barriers to exercise. These included previous exercise habits and health status as well as personal and cultural preferences. These findings have contributed to advice (xix) from Public Health England about how to improve the uptake and maintenance of healthy behaviours in older adults to promote cognitive health.

Similar messages came from another review of ways to get older people more active. Evidence supported use of interventions, from walking groups to pedometers and motivating people to exercise more.

Walking appeared an important activity for this age group. Qualitative research on attitudes to exercise highlighted issues of identity in relation to exercise, fears of hurting oneself or falling and the importance of social aspects of activity. A synthesis of qualitative studies also showed the added social benefits of exercise, but few interventions were designed with this in mind. (Study 24)

Evidence from one large trial found that attending a weekly exercise class led to more people reaching recommended government activity levels of at least 150 minutes a week, but no difference in those doing exercise at home. The exercise class resulted in significantly fewer falls, a frequent cause of injury and loss of independence, although it did not find other direct changes in health and well-being. The trial involved over 1200 older people from 43 general practices. For six months, people took part in weekly exercise classes, home-based activity or normal care with no particular exercise plan. Their activity levels were measured a year after the intervention ended. Researchers noted that groups who were least active at baseline were also the most likely to drop out of the study. (Studies 26 and 27)

Older people doing chair exercises

A further study as part of this trial looked more closely at the characteristics of those who had maintained and improved activity levels. They found lowest rates among the oldest in this age group and women. Perhaps not surprisingly, the people most likely to achieve recommended activity targets were those who were already physically active and more fit and had wider social networks. This suggests the need to actively target approaches at certain groups in future interventions.

This is reinforced by important trend data from the ELSA project (xx) (part-supported by NIHR) which looks in detail at populations of older people over time. This showed that a greater proportion of older people are inactive now compared to ten years ago. It also found that this was more true for certain people, including women, smokers and those with a longstanding illness, depressive symptoms, arthritis and who were obese. This suggests the need for more tailored approaches to get these people active.

A successful example of a tailored approach is the PACE-UP study (Study 15), a pedometer intervention based on the older person’s own baseline step-count, which increased both frequency and intensity of walking in a graded manner in primary care patients aged up to 75 years. It demonstrated significant safe and sustained increases in both step-counts and time in moderate-to-vigorous physical activity levels at 3 years.

"...by encouraging, facilitating and supporting people to take part in enjoyable physical activity throughout the lifespan and health-span they can be helped to feel better, delay the onset of disability, frailty and dementia and can achieve what most people want to achieve: mainly to have a social life, and to stay in their own homes."

Professor Sir Muir Gray, Consultant in Public Health Oxford University Hospitals (xxi)

Ongoing research The REtirement in ACTion study (REACT) (Study T) is assessing the effectiveness and cost effectiveness of a community-based physical activity programme to help high-risk people over 65 to remain mobile. It uses a 12 month programme, with initial individual assessment and twice-weekly hour-long sessions to for six months, followed by ongoing exercise sessions, signposting to local activity opportunities, and the option to become ambassadors for the programme.

The Walk with Me Study (Study U) is a feasibility and pilot study of a peer-led walking programme for inactive 60-70 year olds. Initial findings were that the intervention was acceptable to participants and appeared to increase physical activity at 12 weeks and 6 months. The authors noted the need to tailor recruitment for very inactive, less healthy participants, and males.

Chair based exercise programmes may be beneficial for older people who find usual exercise programmes too strenuous. An ongoing feasibility study (Study V) in day centres, care homes, and community groups is assessing how feasible, acceptable, and tolerable chair based exercises are in these settings.

Developing the idea that social aspects of interventions are important, Project ACE (Study W) is assessing the use of peer volunteers to promote active ageing in order to identify the best bet physical activity promotion strategies for older adults.

Conclusions

Our population is ageing, and people tend to be less active as they age. Research shows that interventions such as walking groups to encourage activity are effective, with the most impact from classes and group activities, and more moderate effects seen with home-based individual approaches. To sustain benefits, interventions appear to need components that are based on theories of behaviour change, such as motivational counselling and goal setting. We don’t know enough from the research about the kind and intensity of intervention which works best, but qualitative evidence suggest the importance of social aspects of exercise, and reassurance around safety and health beliefs. More effort needs to be directed at certain groups most likely to benefit and least likely to take part in initiatives, including those with lower starting fitness and health problems or with weaker social networks.

Prompts for reflection

  • What are the most important life changes that influence physical activity in older people?
  • Can local physical activity programmes be adapted for people who are less able because of injury or health conditions?
  • Are physically active social and group-based opportunities available for older people?

Changes to the Built and Natural Environments

Introduction

Changing our environment and the cues it provides can be a powerful way to shape behaviour and increase physical activity. For example, transport policy interventions can bring both advantages and disadvantages for physical activity. They may promote active travel or improve access to opportunities for recreation and exercise. Measures to increase motor traffic capacity can effectively dissuade walking and cycling, as well as worsening air quality. Large roads can also act as barriers to non-vehicle travel, cutting communities off from each other as well changing the flow of traffic and potentially discouraging walking or cycling. Although many interventions have focussed on active transport, environmental approaches often benefit many groups on other ways: changes such as leisure opportunities, good paths, benches, and public toilets make towns and countryside easier and more accessible for everyone, older and younger alike. Interventions can generate a wide range of co-benefits, improving many aspects of our environment and health.

Research findings

Chapter four established that characteristics of neighbourhoods where people live in early adulthood can have strong and persistent influences on physical activity. In Chapter three, we saw that providing free bus travel to adolescents increased their use of buses without displacing walking or cycling. However, that study did not assess the physical activity associated with bus journeys. Several studies have looked more closely at the effects of transport interventions and the built environment on physical activity.

"Almost any intervention to make the environment more conducive to active travel will mean increased physical activity – but also better air quality, fewer road casualties, improved social cohesion, lower climate emissions, and less noise."

Philip Insall, Public contributor

Following introduction of a 22 km bus lane with an off-road path for walking and cycling, an evaluation (Study 28) found that residents near to the busway increased the time spent actively commuting, were more likely to commute by bicycle, and reduced the number of trips by car. This increase in physical activity on the journey to work appeared to be greatest for those people who were least active at baseline.

In contrast to the busway, new urban motorways may have the opposite effect if they do not sufficiently consider walking, cycling, and public transport. An evaluation (Study 29) of a new motorway in Glasgow found that people living near to the motorway increased their car use, but did not increase their active travel and may have reduced their overall physical activity. Some people felt cut off from other local people and places, and health outcomes for local communities may have been harmed.

These studies indicate the importance of well-designed transport systems and built environment layout. Large infrastructure projects bring significant opportunities to improve physical activity and well-being of those living nearby. Although changing road systems is expensive, where roads are being built or changed for other reasons, the inclusion of additional facilities to encourage active commuting may carry relatively low costs.

Transport infrastructure should be able to adapt to changing patterns of use over time, and by different groups of people.

The Olympic Games in London in 2012 offered an opportunity to assess (Study 30) whether regeneration of a large urban area, with increased green spaces, more sports infrastructure, and improved travel networks could be effective. This survey of young people and their parents found that although the regeneration from the Olympic Games did result in cleaner and safer environments, 18 months after the games well-being was not improved and there was no change in reported physical activity or sedentary behaviour between boroughs. It is likely that although the opportunity and infrastructure for sports and incidental physical activity were improved, other barriers to their use were not effectively addressed. Infrastructure is important, but further interventions to improve people’s motivation and capability to use the infrastructure may be important additional steps. Because this study relies on self-report about physical activity, it may not have captured important changes in the incidental physical activity generated through increases in walking in the improved urban environment or green spaces.

Ongoing research

Features of urban design that influence physical activity are being assessed by two ongoing projects. The ten Healthy New Towns across England are being evaluated for their success in improving the health of individuals and communities by applying healthy design principles to housing, transport, green spaces, waterways and community spaces. Identification of principles of healthy design, particularly as they encourage active leisure and transport, may guide urban development more widely (Study X). The ENABLE London (Study Y) project is examining how rapid changes to the local built environment following the Olympics can impact on health. In particular, the researchers are examining how the design of housing, roads, pavements, and outdoor spaces affect physical activity. A separate part of the project is also assessing whether the design of cities can reduce the risk of type 2 diabetes.

"Active travel needs to be considered from a community point of view not a driver’s point of view. As the UK builds new housing communities, we need to think beyond connecting them with roads suitable only for cars."

Allison Coles, Research, Insight and Projects Manager, British Cycling

Adoption of 20 mph speed limits for traffic in residential areas is often justified in terms of improving perceived safety, and encouraging more walking and cycling. Such speed limits may also lead to more pleasant environments to live, work and play in. The ‘Is 20 plenty for health?’ study (Study Z) is assessing how effective these speed limits are, and exploring the differential impact on groups such as older people, parents, people with mobility difficulties, shift workers, and people from disadvantaged backgrounds.

The NIHR Public Health Research Programme is commissioning further research to understand the potential of place to have an impact on health and health inequalities, and research into choice architecture to assess how the presentation of everyday choices can influence people’s decision making and shape behaviours such as being more physically active.

Conclusions

This research has shown how, by redesigning our communities and environments to make physical activity an easy and attractive option, we can begin to move from a situation where inactivity is the default for many. Environments could be created that encourage a range of more active behaviours, particularly for people who are not already active. Reform of our transport systems, for example by providing free or cheaper public transport to reduce reliance on cars, may lead to a virtuous cycle of increasing people’s inclination to be active. Such reforms may reduce barriers such as traffic density which can frighten and discourage many from considering forms of active transport like walking or cycling, or from accessing opportunities for leisure. Policy-makers, strategists and planners are encouraged to set objectives in line with the NICE guidelines on physical activity and the environment (xxii) for the creation of physical activity friendly buildings, schools, streets and public spaces, so that even those who are least fit can confidently and safely use them for active travel and leisure.

Prompts for reflection

  • What specific changes could improve the quality and appeal of local open spaces for those with low mobility, poor health, socioeconomic disadvantage, or specific cultural requirements?
  • How are you able to increase physical activity through national and local coordination of changes to transport, planning, leisure, and health?
  • What can you do to ensure the natural and built environment in ten or twenty years supports everyone to be physically active?

Discussion

This report highlights more than 50 published and ongoing studies funded by NIHR in the last few years to assess ways of getting people more active. This research addresses some important questions about what works best in getting particular groups of people active and helping them to stay active in the long term.

What can we learn from what worked?

Several initiatives to improve physical activity demonstrated real benefits. Many of these were designed using what we know of behavioural science and how people start and sustain good habits, as well as insight from participants. This included the programme delivered in football clubs for overweight men using peer support, coaching and goal-setting to achieve diet and activity changes, with participants staying active over time. Another study showed that breaking down activity goals into small, achievable changes and using pedometers, worked in getting adults and older people active and in maintaining their increased physical activity levels over the long-term. Other interventions, from standing desks at work to free bus travel, guided busways to increase walking and cycling to free access to leisure services, show the potential for real gains.

We know that there are no single solutions to the general problem of inactivity. How active we are depends on a number of complex and interconnected factors. This includes personal beliefs and habits and the wider demands and environment which shape how we live. This body of evidence shows the need for interventions to take account of what we know from the theory and practice of behaviour change. For example, as well as providing the right opportunities for physical activity, it is important to develop people’s motivations and capabilities to become more active. We also need to be realistic about the impact of short term single initiatives to improve activity levels, set against wider contexts and pressures.

Why do some promising interventions not work?

This research shows a mixed picture. Many promising evaluations of pilot initiatives did not result in increased activity when scaled up and tested in robust trials. This is true for a number of projects here, from dance classes for teenage girls to whole-school activity programmes in primary school. These high quality studies can give us more insights into why some of these plausible interventions may not have delivered the expected benefits. These include how children were approached to take part and the time and resources for teachers to deliver the intervention as planned. The large trial of a walking programme for those at high risk of diabetes did not show sustained activity levels in real-world settings, despite earlier positive findings. The reasons are complex but include poor attendance by those with poorest health status at start. Changes to the built environment in the Olympic park regeneration scheme did not deliver expected benefits. Improving the infrastructure is important but may not be enough on its own to change activity habits. On the other hand, the current state of the built environment and transport systems is generally so dissuasive of physical activity that it may effectively rule out positive results from physical activity interventions.

Some studies which did not show impact in terms of activity did deliver improvements in other ways, from reported well-being to reducing social isolation. We should not forget co-benefits of interventions. For instance, active transport schemes can help to reduce road traffic accidents, improve air or noise quality, and moderate climate change pressures, as well as potentially keeping people active. Policy makers are increasingly thinking now in terms of whole systems and joined-up planning, so that physical activity is not seen as an isolated goal, but an important aspect of many policies.

What do we still need to know?

Researchers are developing a better understanding of different types of intervention and how effective they can be, but many other opportunities to evaluate many projects and interventions are not taken. There are differences in general physical activity programmes for all and those which are targeted at particular groups of people. Factors such as income, employment, geography, gender, and ethnicity can all affect the chances of certain groups of people being active. Not everyone will have equal chances to take part in activities and many activities may just encourage those already active to do more, thus increasing inequalities. It is important that future research targets those with chronic levels of low activity and that we can evaluate tailored interventions to reach those who may benefit most. Learning from previous work, including the large-scale studies funded by Sport England provides useful insights, including the need to avoid using terms like ’sport’ and to re-frame activity in terms of social contact. There is a need for more research on activity which addresses the pressing inequalities agenda.

The studies here show how we can use opportunities which arise to measure impact and learn from new approaches. Several NIHR funded studies have used natural experiments to assess innovations as they occur, from Olympic Park regeneration to subsidised leisure to active transport measures, and have developed substantial expertise in these complex evaluations. To encourage more widespread evaluations of programmes, NIHR has launched phinder (xxiii) to match local innovations to research teams who can carry out evaluations as they happen. We want to hear about new initiatives which deserve robust evaluation so that others can learn from them.

NIHR and other research funders want to support more high quality research in this area, combining different disciplines ranging from physiology, public health, sports science to behavioural science. This is an exciting field bringing together different skills in a new way. There are opportunities for greater collaboration and consistency in approaches to physical activity research. These include how change is measured and how interventions are described. This should help to build up the knowledge base and capture learning more systematically, so that it can inform future implementation. Decision-makers need better understanding of quality evidence which is synthesised in a way which is clear but true to the science.

Given the declining levels of physical activity due to cultural, social and economic changes, and the capacity for physical activity to increase wellbeing and prevent many long term conditions, there is no room for complacency. To keep as well as possible, we need good evidence on getting more people active throughout their lives.

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