Promoting physical activity in community settings: A critical exploration of intervention development, evaluation and implementation

Evidence demonstrating the important and wide-ranging benefits of regular physical activity is well documented, however, one in four of the world’s population is insufficiently active. Efforts to develop and implement effective interventions that facilitate and promote physical activity are therefore urgently required. Through submission of six academic works, published between 2013 and 2019, alongside a critical commentary, this thesis seeks to meet the UWE Bristol requirements for the Doctor of Philosophy by publication (DPhil) award in demonstrating a significant contribution to new knowledge in the area of community-based physical activity intervention development, evaluation and implementation. While the publications submitted refer to research conducted in a range of settings, with different populations of interest and methodological approaches applied, they share a common focus: interventions that promote physical activity in community settings. In the critical commentary, each publication is critically examined, with reference to Medical Research Council guidance on developing and evaluating complex interventions. The critical commentary also provides additional insight into the importance of the research undertaken and its contribution to existing knowledge; it explores the methodological approaches utilised; it demonstrates the candidate’s intellectual contribution to submitted works; and, it charts the candidate’s development as a researcher and plans for future research. Overall, the thesis makes the case for the development, evaluation and implementation of effective and replicable physical activity interventions for the real world, that explicitly consider the socio-ecological factors influencing physical activity behaviours and that reduce inequalities in health. A number of recommendations are proposed to support public health researchers, practitioners and decision-makers in the future development, evaluation and implementation of interventions that promote physical activity in community settings

Pilot evaluation of a school-based health education intervention in the UK: Facts4Life

© The Author 2017. Background This study assessed short-term changes in children’s health and illness attitudes and health status following Facts4Life, a school-based health education intervention. Methods Children aged 7–11 years (School Years 3–6) recruited from 10 schools in the UK participated in this study. A quasi-experimental design was utilized with 187 children participating in the intervention, and 108 forming a control condition. Children in both conditions completed measures of health and illness attitudes and health status at baseline and at immediate follow-up. Intervention effects were examined using mixed between-within subjects analysis of variance. Results Analysis revealed significant baseline to follow-up improvements in intervention group responses to ‘When I feel unwell I need to take medicine to feel better’ (Years 3 and 4: P = 0.05, η2p = 0.02; Years 5 and 6: P = 0.004, η2p = 0.07). For intervention group children in Years 5 and 6 there was an improvement in response to ‘When I am ill, I always need to see a doctor’ (P = 0.01, η2p = 0.07). There was no evidence that Facts4Life had an impact upon health status. Conclusions This study identified some positive intervention effects and results suggest that Facts4Life has potential as a school-based health education intervention

General practice referral of ‘at risk’ populations to community leisure services: Applying the RE-AIM framework to evaluate the impact of a community-based physical activity programme for inactive adults with long-term conditions

Background: In the UK a high proportion of adults with long-term conditions do not engage in regular physical activity. General practice (GP) referral to community-based physical activity is one strategy that has gained traction in recent years. However, evidence for the real-world effectiveness and translation of such programmes is limited. This study aimed to evaluate the individual and organisational impacts of the ‘CLICK into Activity’ programme - GP referral of inactive adults living with (or at risk of) long-term conditions to community-based physical activity.Methods: A mixed methods evaluation using the RE-AIM framework was conducted with data obtained from a range of sources: follow-up questionnaires, qualitative interviews, and programme-related documentation, including programme cost data. Triangulation methods were used to analyse data, with findings synthesised across each dimension of the RE-AIM framework.Results: A total of 602 individuals were referred to CLICK into Activity physical activity sessions. Of those referred, 326 individuals participated in at least one session; the programme therefore reached 30.2% of the 1,080 recruitment target. A range of individual-, social-, and environmental-level factors contributed to initial physical activity participation. Positive changes over time in physical activity and other outcomes assessed were observed among participants. Programme adoption at GP surgeries was successful, but the GP referral process was not consistently implemented across sites. Physical activity sessions were successfully implemented, with programme deliverers and group-based delivery identified as having an influential effect on programme outcomes. Changes to physical activity session content were made in response to participant feedback. CLICK into Activity cost £175,000 over three years, with an average cost per person attending at least one programme session of £535.Conclusions: Despite not reaching its recruitment target, CLICK into Activity was successfully adopted. Positive outcomes were associated with participation, although low 6- and 12-month follow-up response rates limit understanding of longer-term programme effects. Contextual and individual factors, which may facilitate successful implementation with the target population, were identified. Findings highlight strategies to be explored in future development and implementation of GP referral to community-based physical activity programmes targeting inactive adults living with (or at risk of) long-term conditions

Mirror neuron brain regions contribute to identifying actions, but not intentions

Previous studies have struggled to determine the relationship between mirror neuron brain regions and two distinct “action understanding” processes: identifying actions and identifying the intentions underlying those actions. This may be because the identification of intentions from others' actions requires an initial action identification process. Disruptive transcranial magnetic stimulation was administered to left inferior frontal gyrus (lIFG) during a novel cognitive task to determine which of these “action understanding” processes is subserved by mirror neuron brain regions. Participants identified either the actions performed by observed hand actions or the intentions underlying those actions. The extent to which intention identification was disrupted by lIFG (vs. control site) stimulation was dependent on the level of disruption to action identification. We subsequently performed functional magnetic resonance imaging during the same task. During action identification, responses were widespread within mirror neuron areas including lIFG and inferior parietal lobule. However, no independent responses were found in mirror neuron brain regions during intention identification. Instead, responses occurred in brain regions associated with two distinct mentalizing localizer tasks. This supports an account in which mirror neuron brain regions are involved in an initial action identification process, but the subsequent identification of intentions requires additional processing in mentalizing brain regions

The Bristol Twenty Miles Per Hour Limit Evaluation (BRITE) Study

This study aimed to evaluate the impact of the roll-out of 20mph speed limits across the city of Bristol. The research took a holistic, public health approach to evaluation, using a variety of data sources to examine changes in vehicle speeds, road traffic casualties, levels of walking and cycling, public perceptions and attitudes, and reported levels of health and wellbeing across the city. The study found statistically significant reductions in average traffic speeds of 2.7mph across the city of Bristol, following the introduction of 20mph speed limits. This is a larger reduction than seen in previous evaluations in other cities. The study employed a more sophisticated analysis than previous studies of 20mph limits, including using individual speed data from over 36 million vehicle observations and controlling for other factors that might affect changes in traffic speeds. There has been a reduction in the number of fatal, serious and slight injuries from road traffic collisions, equating to estimated cost savings of over £15 million per year. Although there is still majority support for 20mph speed limits in Bristol, there remains concern about compliance and behaviour of other drivers. Walking and cycling across Bristol has increased, both among children travelling to school and adults travelling to work. The introduction of 20mph speed limits in Bristol offers a model for other towns and cities across the UK, who are seeking to reduce traffic speeds, cut road traffic casualties, and promote community health and wellbeing through road danger reduction. In order to assess effectiveness of 20mph speed limits, it is vital that other towns and cities follow Bristol’s example, and prioritise the ongoing collection and analysis of appropriate data on vehicle speeds, road traffic casualties and wider public health impacts

Facts4Life: Phase II evaluation of the school-based resource. Final evaluation report

In April 2015 members of UWE's Centre for Public Health and Wellbeing were commissioned to undertake an evaluation of a school-based intervention, known as ‘Facts4Life'. The broad aim of the evaluation was to better understand the impact of Facts4Life on Gloucestershire-based pupils and their teachers, and to determine the costs associated with Facts4Life implementation in a school setting. This final evaluation report presents the findings from the research

Functional adaptation of internal bone structure in the wrist of extant hominids and fossil hominins

The shape of wrist bones (carpals) in living hominids are thought to be adapted to the primary function of the hand, which in Homo sapiens is for manipulation, and in non-human hominids, locomotion. However, the hominid hand is inherently versatile in its use, and parsimony would suggest that the hominid last common ancestor was capable of manipulating and using simple tools. Therefore, key questions in palaeoanthropology ask when, why, and how tool use moved from facultative, as it is in other hominids, to obligate, as it is in H. sapiens. Inferring this transition within the fossil record is challenging as habitual behaviours are not always reflected in the external morphology of the skeleton. As the internal microstructure of bone is known to adapt to load dynamically, bone functional adaptation analyses provide an avenue to investigate how a joint has actually been loaded over an individual’s lifetime. The central question asked by this thesis was: ‘How and why does the internal structure of wrist bones differ among extant and extinct hominids?’. To achieve this aim, I investigated 1) whether functionally meaningful differences exist in the microarchitecture of extant hominid carpals; 2) how to detect signals of functional adaptation within the complex biomechanical environment of the wrist; 3) what can be inferred about hand use from the proximal capitate bone of fossil hominins? This thesis undertook three research projects, which all use ‘whole-bone’ methodologies for investigating functional signals of hand use. Using micro-computed tomography, I quantified and compared trabecular and cortical bone microarchitecture in 264 individual carpal bones across four extant hominids (Pongo, Gorilla, Pan, and H. sapiens) and four extinct hominins (Australopithecus sediba, Homo naledi, Homo floresiensis and Neanderthals). In the first project, I used inter- and intraspecific analyses to compare the trabecular and cortical microstructure of the proximal and distal capitate in extant hominids. Unique combinations of microarchitecture across the two segments of the bone differentiated the extant taxa. Notably, non-human hominids exhibited a distinctive pattern of extremely thick cortical bone in the distal capitate. This result suggested that highly localised functional adaptation responses were occurring across the capitate, and studying biomechanically distinct subregions of the carpus may be required to detect signals of functional adaptation. I then conducted intraspecific analyses on the scaphoid, lunate and triquetrum's trabecular and cortical bone microstructure across extant hominids. Results identified that microarchitectural differences across the three bones could be linked to the known or assumed biomechanics of the proximal row. Relative differences in the three bones differentiated locomotor mode between the genera: Gorilla and Pan expressed the same relative patterns of architecture, with Pongo and H. sapiens showing unique patterns. This project demonstrated that establishing relative patterns across a biomechanically distinct subregion of the wrist can differentiate hand use among extant hominids. Using a novel canonical holistic morphometric analysis, my final research project indicated that extant hominids have statistically distinct distributions of relative bone volume in the proximal capitate. Neanderthals and fossil H. sapiens exhibited the same pattern of relative bone distribution in the proximal capitate as modern H. sapiens suggesting a functional commitment to tool use leaves a distinct distribution of bone in the proximal capitate. Despite being the geologically oldest fossil, A. sediba was the only other species to exhibit a human-like distribution of bone, with evidence of a highly strained capitolunate and capitoscaphoid joint. Although H. naledi has human-like carpal morphology, it showed no evidence for human-like force transfer and loading at the midcarpal joint suggesting its hand use was not similar to a typical modern H. sapiens. The distribution of bone in H. floresiensis suggested that Oldowan-type tools were made and used with high ulnar-side loading of the hand and relatively lower loading of the thumb. This thesis demonstrated that a hand used primarily for manipulation has distinctive and statistically differentiated microarchitecture in the carpal bones. Unique microarchitectural features within the hominin species support a model of adaptive radiations of hand and tool behaviours among hominins. The similarity in microarchitecture at the midcarpal joint of H. sapiens and Neanderthals suggests it may be a strong signal of human-like commitment to tool use but is unlikely to capture variation in tool behaviour. Further analyses are needed to better understand how manipulation and arboreality are reflected in bone architecture. In particular, this thesis discussed how both climbing and transverse grips might be biomechanically compatible behaviours, as both emphasise high loading at the ulnar side of the hand and wrist and deemphasise the use of the thumb. Thus the use of transverse-type grips may have provided fossil hominins with an opportunity to improve the functional efficiency of tool behaviours without highly compromising climbing ability. Future analyses are likely to be most informative when numerous bones across biomechanically meaningful subregions of the wrist are analysed together. Analyses at the ulnar side of the wrist may be informative for identifying signals of climbing and grip preference differences in H. sapiens and Neanderthals