Characterisation of the natural environment: quantitative indicators across Europe

BACKGROUND: The World Health Organization recognises the importance of natural environments for human health. Evidence for natural environment-health associations comes largely from single countries or regions, with varied approaches to measuring natural environment exposure. We present a standardised approach to measuring neighbourhood natural environment exposure in cities in different regions of Europe. METHODS: The Positive Health Effects of the Natural Outdoor environment in TYPical populations of different regions in Europe (PHENOTYPE) study aimed to explore the mechanisms linking natural environment exposure and health in four European cities (Barcelona, Spain; Doetinchem, the Netherlands; Kaunas, Lithuania; and Stoke-on-Trent, UK). Common GIS protocols were used to develop a hierarchy of natural environment measures, from simple measures (e.g., NDVI, Urban Atlas) using Europe-wide data sources, to detailed measures derived from local data that were specific to mechanisms thought to underpin natural environment-health associations (physical activity, social interaction, stress reduction/restoration). Indicators were created around residential addresses for a range of straight line and network buffers (100 m-1 km). RESULTS: For simple indicators derived from Europe-wide data, we observed differences between cities, which varied with different indicators (e.g., Kaunas and Doetinchem had equal highest mean NDVI within 100 m buffer, but mean distance to nearest natural environment in Kaunas was more twice that in Doetinchem). Mean distance to nearest natural environment for all cities suggested that most participants lived close to some kind of natural environments (64 +/- 58-363 +/- 281 m; mean 180 +/- 204 m). The detailed classification highlighted marked between-city differences in terms of prominent types of natural environment. Indicators specific to mechanisms derived from this classification also captured more variation than the simple indicators. Distance to nearest and count indicators showed clear differences between cities, and those specific to the mechanisms showed within-city differences for Barcelona and Doetinchem. CONCLUSIONS: This paper demonstrates the feasibility and challenges of creating comparable GIS-derived natural environment exposure indicators across diverse European cities. Mechanism-specific indicators showed within- and between-city variability that supports their utility for ecological studies, which could inform more specific policy recommendations than the traditional proxies for natural environment access

Small Area and Individual Level Predictors of Physical Activity in Urban Communities: A Multi-Level Study in Stoke on Trent, England

Reducing population physical inactivity has been declared a global public health priority. We report a detailed multi-level analysis of small area indices and individual factors as correlates of physical activity in deprived urban areas. Multi-level regression analysis was used to investigate environmental and individual correlates of physical activity. Nine individual factors were retained in the overall model, two related to individual intentions or beliefs, three to access to shops, work or fast food outlets and two to weather; age and gender being the other two. Four area level indices related to: traffic, road casualties, criminal damage and access to green space were important in explaining variation in physical activity

Does the Health Impact of Exposure to Neighbourhood Green Space Differ between Population Groups? An Explorative Study in Four European Cities

It has been suggested that certain residents, such as those with a low socioeconomic status, the elderly, and women, may benefit more from the presence of neighbourhood green space than others. We tested this hypothesis for age, gender, educational level, and employment status in four European cities. Data were collected in Barcelona (Spain; n = 1002), Kaunas (Lithuania; n = 989), Doetinchem (The Netherlands; n = 847), and Stoke-on-Trent (UK; n = 933) as part of the EU-funded PHENOTYPE project. Surveys were used to measure mental and general health, individual characteristics, and perceived neighbourhood green space. Additionally, we used audit data about neighbourhood green space. In Barcelona, there were positive associations between neighbourhood green space and general health among low-educated residents. In the other cities and for the other population groups, there was little evidence that the association between health and neighbourhood green space differed between population groups. Overall, our study does not support the assumption that the elderly, women, and residents who are not employed full-time benefit more from neighbourhood green space than others. Only in the highly urbanised city of Barcelona did the low-educated group benefit from neighbourhood green spaces. Perhaps neighbourhood green spaces are more important for the health of low-educated residents in particularly highly urbanised areas

Cardiovascular disease risk communication in NHS Health Checks using QRISK®2 and JBS3 risk calculators: the RICO qualitative and quantitative study

Background The NHS Health Check is a national cardiovascular disease prevention programme. There is a lack of evidence on how health checks are conducted, how cardiovascular disease risk is communicated to foster risk-reducing intentions or behaviour, and the impact on communication of using different cardiovascular disease risk calculators. Objectives RIsk COmmunication in Health Check (RICO) study aimed to explore practitioner and patient understanding of cardiovascular disease risk, the associated advice or treatment offered by the practitioner, and the response of the patients in health checks supported by either the QRISK®2 or the JBS3 lifetime risk calculator. Design This was a qualitative study with quantitative process evaluation. Setting Twelve general practices in the West Midlands of England, stratified on deprivation of the local area (bottom 50% vs. top 50%), and with matched pairs randomly allocated to use QRISK2 or JBS3 during health checks. Participants A total of 173 patients eligible for NHS Health Check and 15 practitioners. Interventions The health check was delivered using either the QRISK2 10-year risk calculator (usual practice) or the JBS3 lifetime risk calculator, with heart age, event-free survival age and risk score manipulation (intervention). Results Video-recorded health checks were analysed quantitatively (n = 173; JBS3, n = 100; QRISK2, n = 73) and qualitatively (n = 128; n = 64 per group), and video-stimulated recall interviews were undertaken with 40 patients and 15 practitioners, with 10 in-depth case studies. The duration of the health check varied (6.8–38 minutes), but most health checks were short (60% lasting < 20 minutes), with little cardiovascular disease risk discussion (average < 2 minutes). The use of JBS3 was associated with more cardiovascular disease risk discussion and fewer practitioner-dominated consultations than the use of QRISK2. Heart age and visual representations of risk, as used in JBS3, appeared to be better understood by patients than 10-year risk (QRISK2) and, as a result, the use of JBS3 was more likely to lead to discussion of risk factors and their management. Event-free survival age was not well understood by practitioners or patients. However, a lack of effective cardiovascular disease risk discussion in both groups increased the likelihood of a maladaptive coping response (i.e. no risk-reducing behaviour change). In both groups, practitioners often missed opportunities to check patient understanding and to tailor information on cardiovascular disease risk and its management during health checks, confirming apparent practitioner verbal dominance. Limitations The main limitations were under-recruitment in some general practices and the resulting imbalance between groups. Conclusions Communication of cardiovascular disease risk during health checks was brief, particularly when using QRISK2. Patient understanding of and responses to cardiovascular disease risk information were limited. Practitioners need to better engage patients in discussion of and action-planning for their cardiovascular disease risk to reduce misunderstandings. The use of heart age, visual representation of risk and risk score manipulation was generally seen to be a useful way of doing this. Future work could focus on more fundamental issues of practitioner training and time allocation within health check consultations. Trial registration Current Controlled Trials ISRCTN10443908. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 50. See the NIHR Journals Library website for further project information

A Qualitative Exploration of Two Risk Calculators Using Video-Recorded NHS Health Check Consultations

Background: The aim of the study was to explore practitioner-patient interactions and patient responses when using QRISK®2 or JBS3 cardiovascular disease (CVD) risk calculators. Data were from video-recorded NHS Health Check (NHSHC) consultations captured as part of the UK RIsk COmmunication (RICO) study; a qualitative study of video-recorded NHSHC consultations from 12 general practices in the West Midlands, UK. Participants were those eligible for NHSHC based on national criteria (40-74 years old, no existing diagnoses for cardiovascular-related conditions, not on statins), and practitioners, who delivered the NHSHC. Method: NHSHCs were video-recorded. 128 consultations were transcribed and analysed using deductive thematic analysis and coded using a template based around Protection Motivation Theory. Results: Key themes used to frame the analysis were Cognitive Appraisal (Threat Appraisal, and Coping Appraisal), and Coping Modes (Adaptive, and Maladaptive). Analysis showed little evidence of CVD risk communication, particularly in consultations using QRISK®2. Practitioners often missed opportunities to check patient understanding and encourage risk- reducing behaviour, regardless of the risk calculator used resulting in practitioner verbal dominance. JBS3 appeared to better promote opportunities to initiate risk-factor discussion, and Heart Age and visual representation of risk were more easily understood and impactful than 10-year percentage risk. However, a lack of effective CVD risk discussion in both risk calculator groups increased the likelihood of a maladaptive coping response. Conclusions: The analysis demonstrates the importance of effective, shared practitioner-patient discussion to enable adaptive coping responses to CVD risk information, and highlights a need for effective and evidence-based practitioner training

Characterisation of the natural environment: quantitative indicators across Europe

Background: The World Health Organization recognises the importance of natural environments for human health. Evidence for natural environment-health associations comes largely from single countries or regions, with varied approaches to measuring natural environment exposure. We present a standardised approach to measuring neighbourhood natural environment exposure in cities in different regions of Europe. Methods: The Positive health effects on the natural outdoor environment in typical populations of different regions in Europe (PHENOTYPE) study aimed to explore the mechanisms linking natural environment exposure and health in four European cities (Barcelona, Spain; Doetinchem, the Netherlands; Kaunas, Lithuania; and Stoke-on-Trent, UK). Common GIS protocols were used to develop a hierarchy of natural environment measures, from simple measures (e.g., NDVI, Urban Atlas) using Europe-wide data sources, to detailed measures derived from local data that were specific to mechanisms thought to underpin natural environment-health associations (physical activity, social interaction, stress reduction/restoration). Indicators were created around residential addresses for a range of straight line and network buffers (100m to 1km). Results: For simple indicators derived from Europe-wide data, we observed differences between cities, which varied with different indicators (e.g., Kaunas and Doetinchem had equal highest mean NDVI within 100m buffer, but mean distance to nearest natural environment in Kaunas was more twice that in Doetinchem). Mean distance to nearest natural environment for all cities suggested that most participants lived close to some kind of natural environments (64±58 to 363±281m; mean 180±204m). The detailed classification highlighted marked between-city differences in terms of prominent types of natural environment. Indicators specific to mechanisms derived from this classification also captured more variation than the simple indicators. Distance to nearest and count indicators showed clear differences between cities, and the those specific to the mechanisms showed within-city differences for Barcelona and Doetinchem. Conclusions: This paper demonstrates the feasibility and challenges of creating comparable GIS-derived natural environment exposure indicators across diverse European cities. Mechanism-specific indicators showed within- and between-city variability that suggests their utility for ecological studies, which could inform more specific policy recommendations than the traditional proxies for natural environment access

Clinical Study The Effect of Park and Urban Environments on Coronary Artery Disease Patients: A Randomized Trial

Aim. To test the hypothesis that walking in a park has a greater positive effect on coronary artery disease (CAD) patients&apos; hemodynamic parameters than walking in an urban environment. Methods. Twenty stable CAD patients were randomized into two groups: 30-minute walk on 7 consecutive days in either a city park or busy urban street. Wilcoxon signed-rank test was employed to study short-term (30 min) and cumulative changes (following 7 consecutive days of exposure) in resting hemodynamic parameters in different environments. Results. There were no statistically significant differences in the baseline and peak exercise systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), exercise duration, or HR recovery in urban versus park exposure groups. Seven days of walking slightly improved all hemodynamic parameters in both groups. Compared to baseline, the city park group exhibited statistically significantly greater reductions in HR and DBP and increases in exercise duration and HR recovery. The SBP and DBP changes in the urban exposed group were lower than in the park exposed group. Conclusions. Walking in a park had a greater positive effect on CAD patients&apos; cardiac function than walking in an urban environment, suggesting that rehabilitation through walking in green environments after coronary events should be encouraged

Neighbourhood green space, social environment and mental health: an examination in four European cities

Objectives This study examines the relationship between neighbourhood green space, the neighbourhood social environment (social cohesion, neighbourhood attachment, social contacts), and mental health in four European cities. Methods The PHENOTYPE study was carried out in 2013 in Barcelona (Spain), Stoke-on-Trent (United Kingdom), Doetinchem (The Netherlands), and Kaunas (Lithuania). 3771 adults living in 124 neighbourhoods answered questions on mental health, neighbourhood social environment, and amount and quality of green space. Additionally, audit data on neighbourhood green space were collected. Multilevel regression analyses examined the relation between neighbourhood green space and individual mental health and the influence of neighbourhood social environment. Results Mental health was only related to green (audit) in Barcelona. The amount and quality of neighbourhood green space (audit and perceived) were related to social cohesion in Doetinchem and Stoke-on-Trent and to neighbourhood attachment in Doetinchem. In all four cities, mental health was associated with social contacts. Conclusions Neighbourhood green was related to mental health only in Barcelona. Though neighbourhood green was related to social cohesion and attachment, the neighbourhood social environment seems not the underlying mechanism for this relationship

Improving uptake of Fracture Prevention drug treatments: a protocol for Development of a consultation intervention (iFraP-D).

Funder: Wellcome TrustINTRODUCTION: Prevention of fragility fractures, a source of significant economic and personal burden, is hindered by poor uptake of fracture prevention medicines. Enhancing communication of scientific evidence and elicitation of patient medication-related beliefs has the potential to increase patient commitment to treatment. The Improving uptake of Fracture Prevention drug treatments (iFraP) programme aims to develop and evaluate a theoretically informed, complex intervention consisting of a computerised web-based decision support tool, training package and information resources, to facilitate informed decision-making about fracture prevention treatment, with a long-term aim of improving informed treatment adherence. This protocol focuses on the iFraP Development (iFraP-D) work. METHODS AND ANALYSIS: The approach to iFraP-D is informed by the Medical Research Council complex intervention development and evaluation framework and the three-step implementation of change model. The context for the study is UK fracture liaison services (FLS), which enact secondary fracture prevention. An evidence synthesis of clinical guidelines and Delphi exercise will be conducted to identify content for the intervention. Focus groups with patients, FLS clinicians and general practitioners and a usual care survey will facilitate understanding of current practice, and investigate barriers and facilitators to change. Design of the iFraP intervention will be informed by decision aid development standards and theories of implementation, behaviour change, acceptability and medicines adherence. The principles of co-design will underpin all elements of the study through a dedicated iFraP community of practice including key stakeholders and patient advisory groups. In-practice testing of the prototype intervention will inform revisions ready for further testing in a subsequent pilot and feasibility randomised trial. ETHICS AND DISSEMINATION: Ethical approval was obtained from North West-Greater Manchester West Research Ethics Committee (19/NW/0559). Dissemination and knowledge mobilisation will be facilitated through national bodies and networks, publications and presentations. TRIAL REGISTRATION NUMBER: researchregistry5041

The relationship between natural outdoor environments and cognitive functioning and its mediators

Background Urban residents may experience cognitive fatigue and little opportunity for mental restoration due to a lack of access to nature. Natural outdoor environments (NOE) are thought to be beneficial for cognitive functioning, but underlying mechanisms are not clear. Objectives To investigate the long-term association between NOE and cognitive function, and its potential mediators. Methods This cross-sectional study was based on adult participants of the Positive Health Effects of the Natural Outdoor Environment in Typical Populations in Different Regions in Europe (PHENOTYPE) project. Data were collected in Barcelona, Spain; Doetinchem, the Netherlands; and Stoke-on-Trent, United Kingdom. We assessed residential distance to NOE, residential surrounding greenness, perceived amount of neighborhood NOE, and engagement with NOE. Cognitive function was assessed with the Color Trails Test (CTT). Mediation analysis was undertaken following Baron and Kenny. Results Each 100 m increase in residential distance to NOE was associated with a longer CTT completion time of 1.50% (95% CI 0.13, 2.89). No associations were found for other NOE indicators and cognitive function. Neighborhood social cohesion was (marginally) significantly associated with both residential distance to NOE and CTT completion time, but no evidence for mediation was found. Nor were there indications for mediation by physical activity, social interaction with neighbors, loneliness, mental health, air pollution worries, or noise annoyance. Conclusions Our findings provide some indication that proximity to nature may benefit cognitive function. We could not establish which mechanisms may explain this relationship