Optimising methods for measuring effects of neighbourhood environments on diet, physical activity, smoking & alcohol intake in older people in the UK

Context and potential benefits of the research:
Smoking, poor diet, lack of physical activity and high alcohol consumption are well known risk factors for a variety of preventable chronic diseases. It has been estimated that over 30% of deaths from circulatory disease, including heart disease, could be avoided, mainly through a combination of stopping smoking, improving diet and increasing physical activity (WHO). While characteristics of individual people are important, there is growing recognition that the environments in which we live also affect our health behaviours. The shaping of neighbourhood environments that empower and encourage healthy behaviours is recognised as an essential approach to public health policy, and is increasingly relevant with the future relocation of local public health services into local authorities in England.

However, there is little consensus on what are the key aspects of the local neighbourhood environment that influence our health-related behaviours. It is still a relatively new and evolving field of research. Further development is needed to improve the technical quality of the research methods, understand the relevance of specific environmental factors to different population groups (ie children, working and non-working adults, old people) and their utility for enhancing our understanding of variations in diet, physical activity and other behaviours. This has implications for disease prevention and deciding where future health policy and interventions should be targeted.

This study is novel and important as it aims to conduct the most comprehensive assessment of characteristics of neighbourhood environments in the UK that influence four important behavioural risk factors for CVD, and focuses on the health behaviours and outcomes of older people (over 65 years), an age group for which these study approaches have rarely been applied. The health of older adults may be particularly vulnerable to the impacts of their local neighbourhood as they are likely to have reduced capacity and motivation to travel longer distances due to personal health and mobility factors.

Aims and Objectives:
The main aim of the proposed research is understanding how different neighbourhood-level environmental factors (e.g. built environment, crime levels, access to recreational space, access to shops and price of food, location of healthcare and other services) influence individual health behaviours and cardiovascular disease risk. This project will specifically investigate which local environmental level factors influence tobacco and alcohol use, nutrition, physical activity and risk of obesity in older men and women living in urban areas across the UK.

This study will use and compare a range of different research methods to investigate the effect of the neighbourhood environment on health. Data on the lifestyles, behaviours and health of over 4000 older people has already been collected by individual surveys as part of two ongoing national studies of older men and women in the 22 UK study towns. In addition, data on the local neighbourhood environment in the 22 towns where these older people live will be collected using 3 approaches (collecting routine local data, newly collected data from surveying the physical features of the neighbourhood at street level, and new data collected using remote imaging technology- such as google street view). This information will allow us to compare how different factors at individual, household or local community level impact on smoking, alcohol intake, diet, physical activity, and risk of overweight, and to identify which measures of the environment are the strongest determinants of these behaviours. The results should help design more effective public health policies to improve healthy liefstyles and prevent cardiovascular disease.

This study will conduct a comprehensive UK-wide study of older men and women (over 65 years) to (i) develop measurement methods for quantifying the extent to which local neighbourhood environments influence patterns of diet, physical activity, smoking and alcohol behaviours, and physiological CVD risk indicators (BMI and BP), in older people in UK urban settings; (ii) identify features of neighbourhood environments which are most important in influencing health behaviours in older people, and highlight factors potentially amenable to public health or policy interventions.

For the 22 study towns, we will obtain and compare three different sources of spatial data on local neighbourhood environment features potentially relevant to older people's behaviours; local environmental data from routine sources, from de novo primary environmental data collected by a robust 'street' survey tool (OPECR) developed specifically for this study, and environmental data from remote imaging (e.g google street view). Using the neighbourhood environment measures collected, we will conduct a cross-sectional analysis of the association of these measures with CVD risk factors (behaviours and physiological indicators) in older men and women across the UK. We can deliver this large, comprehensive nationwide study at a fraction of its total cost by utilising individual level data on behaviour and physiological risk indicators for 4000 women and men (over 65 years) in 22 towns already collected in 2010-2011 as part of the ongoing longitudinal studies - the British Women's Heart and Health study (BWHHS) and the British Heart Study in Men (BRHS).

In addition, we will conduct a pilot study of the use of wearable GPS/ accelerometer monitors of activity and mobility in older people to explore objectively how and why older men and women move around their local neighbourhood. This will inform the study analysis.

Whilst the methodological focus of the research is of greatest potential benefit to population health academics, the specific applications of this method and the results will be of wider societal relevance to policy makers, the third sector and the public, as well as experts working in various non-health academic fields including geography, urban planning and architecture.

Academic impact:
The primary aim of this proposed research project is to develop, validate and compare methods for assessing the influence of the environment on four risk factor behaviours in older people (diet, physical activity, smoking and alcohol intake). As such, the methods are targeted primarily at the academic community. However, a further strength of our approach is the intention that such environmental measurement methods can also be used, with very little modification, as an evaluative tool to assess the health impacts of local neighbourhood factors relevant to current and future UK public health policy and delivery, for example on improving environmental approaches for increasing physical activity.

Upon completion of the project it is the intention to ensure that the environmental dataset is made available for the benefit of future academic and other research. This project will complete a detailed characterisation of the environment of over 1000 areas in 22 towns across the UK and details on personal, social and environmental determinants of physical activity in over 4000 older men and women. At present no such resource exists at this scale.

Economic and Societal impact:
The third sector and members of the public may also benefit from outputs of this research. The principal investigator already has strong links, as a Trustee, with the National Heart Forum Charity which has over 65 member organisations which represent consumer groups, charities and voluntary organisations across the UK. This allows us to engage, through them, with a range of third sector partners and the wider public about the development and outputs of the research and its relation to cardiovascular disease and risk factor issues. The National Heart Forum are already interested in the impacts of the broader environment and recently published 'Building Health: Creating and enhancing places for healthy, active lives: What needs to be done?' which examines how the design of towns, cities and buildings might encourage physical activity. They have also helped to set up set up a Healthy Places website (http://www.healthyplaces.org.uk/). This website currently explains the operation of laws and policies that could enable, or place limits on, local government and community activity that affects how a place can influence health including diet and physical activity. The outputs of this proposed research will contribute to this, and other similar initiatives, providing 'evidence and information' for the third sector and the general public interested in the impact of local neighbourhoods on health, or those wishing to get involved in the increasing number of community development initiatives which focus on improving healthy behaviours.

The study findings will also be relevant to policymakers, not only in the Department of Health and wider NHS but also in UK local government with its role in local urban planning and enforcement of local laws relating to food, alcohol and smoking. This research will provide evidence to enable better judgments about whether CVD prevention policy should redirect resources to the problems people face because of where they live rather than continue with the current health policy focus on changing individuals lifestyles.