Purpose: for the past decade, community-based programmes have been a popular strategy for health promotion regarding physical activity and dietary behaviour. The implementation of these programmes is a complex process, characterized by (a) objectives that vary locally, (b) adaptions to the programme over time in response to a community’s shifting needs, challenges and opportunities, (c) emergent outcomes, and (d) non-linear causality. This poses several challenges for evaluation, as commonly used evaluation designs mainly focus on predetermined programme components and outcomes. Such a traditional evaluation approach may overlook necessary but unanticipated programme developments or outcomes and provide limited opportunity to learn from these. The aim of this study was to develop a novel evaluation approach that considers the complexity perspective, in order to evaluate a large community-based programme for childhood obesity prevention in the Netherlands.

Methods and results: we reviewed theoretical and methodological literature regarding community-based health promotion, complexity theory and evaluation in order to develop an evaluation approach that considers complexity. The developed evaluation approach focusses on elements of the complex and adaptive implementation process of community-based health promotion. These include the local programme theory, implementation, adaption, the influence of context and feedback loops, and intended as well as emergent and unintended outcomes. By studying each of these elements in practice using innovative qualitative methods, including Ripple Effects Mapping and the Critical Event Card tool, we aim to learn about principles that guide effective obesity prevention across community contexts. Practice-based knowledge can subsequently be validated in other contexts. The results of the evaluation will provide insight in how community-based health promotion programmes impact communities, and which mechanisms underly success or failure.

Conclusions: the proposed evaluation approach aims to retrospectively take into account complexity of a programme that was implemented and developed in practice. Since considering complexity in evaluation is a relatively new challenge in public health, we believe it is essential to share and deliberate on innovative evaluation approaches and methods.

Purpose: Physical activity (PA) is associated with positive health outcomes over the entire life course. Many population-based interventions to promote PA focus on implementing incremental changes to existing facilities and improvements of existing infrastructure (e.g., improved bike lanes, renovated sidewalks, or complete streets). While prominent among existing interventions and less costly than building new facilities, rigorous assessment of their impact on PA outcomes is lacking. The purpose of this study was to determine if upgrades to existing PA facilities/infrastructure are associated with increases in children’s PA. 

Methods: Two randomly sampled cohorts of 3- to 15-year-old children (n=599) living in four low-income New Jersey cities were followed during 2- to 5-year periods from 2009 through 2017 using telephone surveys. Data were collected on children’s PA at two time points from each cohort; data on changes to existing PA facilities were collected yearly from 2009-2017 using Open Public Records Act requests, publicly available data sources, and interviews with key stakeholders. PA changes were categorized into six domains (PA facility, park, trail, complete street, sidewalk, or bike lane), and changes coded as new opportunity, renovated opportunity, or amenity. PA outcome was measured as change in the number of days per week in which the child engaged in at least 60 minutes of PA, trichotomized as: decrease, no change, or increase. Ordered logistic regression was used, controlling for child age, sex, race; parent’s nativity status (native-born vs foreign-born); household poverty level; and PA at time 1. 

Results: Response rates were 49% and 36% for time 1 and 2, respectively. Exposure to an additional new or renovated PA opportunity within a mile of a child’s home within 18 months prior to time 2 resulted in 14% greater odds (p=0.020) of a child increasing the number of days they accumulated at least 60 minutes of PA. Similarly, each upgrade to a street increased those odds by 74% (p=0.017). 

Conclusions: Incremental improvements to the PA environment near children’s homes increase children’s daily PA. Improving PA infrastructure in cities will improve children’s health and prevent childhood obesity.

Purpose: Cities globally have started to seriously invest in sustainable forms of transportation. Using routinely collected city-level data, we aimed to evaluate whether constructing cycling infrastructure in Paris and Lyon affected cycling activity along new routes. 

Methods: Routinely-collected daily cycle count data were acquired for the cities of Paris and Lyon, from which 18 newly-built cycling infrastructure improvement projects were identified with pre-post data. A comparison street was chosen if it shared a parallel pre-intervention trend, the same six-month pre-post monitoring periods as the intervention street, and if it was located > 2 km from the intervention street. For streets without a full year of data (n=3), all available data were used. Difference-in-difference (DiD) analysis was performed for all streets. For streets with at least one year of data, interrupted time series (ITS) analysis was conducted to corroborate DiD results. In addition, sensitivity analyses were conducted which examined whether the choice of control streets, follow-up period, and a potential intervention lag effect of one-month could impact results.

Results/findings: There was some variation in effects between locations: significant net increases in cycling counts were observed in 9/18 streets (e.g. Boulevard Voltaire, 894 counts/day; 95% CI: 357, 1431). No significant effects were found for the other half of streets, particularly streets assessed for only one month post-intervention (3/18). In general, DiD outcomes did not differ between methods for choosing control groups. ITS results were consistent with DiD results in terms of direction of effect, but changes in level and trend change were found to be largely non-significant. Results from the sensitivity analyses did not substantially differ from those of the main analyses.

Conclusions: Infrastructural improvements were found to be effective for larger arterial streets and those with longer follow-up periods. Further research should investigate why improvements were more effective at increasing cycling levels in certain streets than others.

Purpose: This exploratory study aimed to assess how variations in intervention form (e.g., cycle infrastructure length, number of traffic lanes) and function (e.g., access, safety, space) can contribute to the effectiveness of new cycle infrastructure interventions on levels of cycling.

Methods: Data from a previous natural experimental study evaluating 15 new cycle infrastructure improvements in Paris and Lyon were used for this analysis. The outcome was the difference in daily cycle counts, measured using automatic cycle counters, between intervention streets and control streets. To assess form and function, we performed a virtual street audit using Google Street View to assess changes to 14 individual street features and derived a function score based on 7 components. We performed separate analyses using an induced smoothed least absolute shrinkage and selection operator (LASSO) regression to identify the most relevant form or function variables associated with changes in cycle counts. Analyses were adjusted by city, intervention location (i.e., central v. outer city), baseline levels of cycling, and follow-up period length.

Results/findings: For every 1 SD increase in cycle lane length, we observed an increase of 83 cycle counts per day (95% CI 32, 134). For features related to motorized vehicles, removing car parking was associated with an increase of 197 counts (108, 285), while removing traffic lanes was associated with an increase of 154 counts (58, 249). The only significant negative association was adding a public transport stop, with a change of -83 counts (-158, -8). Functions positively associated with a change in cycle counts were safety (75, 95% CI 8, 141) and space (72, 95% CI 10, 135). No other intervention features or functions were significantly associated with cycle counts.

Conclusions: Using routinely collected data, a novel virtual street audit to assess street-level changes, and LASSO regression, this study found that specific intervention features such as length and removing space for cars and functions such as increasing safety may be more important than others in influencing changes to cycling behaviour. There is a need to understand whether these findings may be generalizable to other contexts.

Purpose: There is a dearth of robust natural experimental studies of urban green space interventions on physical activity and wellbeing. The aim of this study was to examine the impact of new walking infrastructure and other green space improvements along an urban canal in Greater Manchester (UK) on canal usage, physical activity and other wellbeing-promoting behaviours.

Methods: Two comparison canal sites were matched to the intervention canal site using eight correlates of physical activity at the neighbourhood (e.g. population density) and site (e.g. lighting) levels. The outcome measures were the total number of adults using the canal, physical activity and two other wellbeing-promoting behaviours (social interactions and taking notice of the environment), assessed using a behaviour observation tool at baseline, 7, 12 (primary outcome) and 24 months. Canal sites were then compared using negative binomial regression models and Mann-Whitney U tests. A process evaluation assessed potential displacement of activity from an existing canal path using intercept surveys and observations.

Results: The total number of adults observed using the improved canal path increased more than the comparison sites at 12 months post-baseline (incidence rate ratio (IRR) 2.10). There were similar observed increases at 7 months (IRR 1.67) and 24 months (IRR 2.42). There were significant increases at the intervention path in walking behaviour at all three follow-ups, and vigorous physical activity at 7 and 24 months. There were also notable increases in social interactions at 12 months and 24 months at the intervention path, with over twice as many social interactions compared to baseline. The process evaluation suggested that there was some displacement of activity, but the intervention also encouraged existing users to use the canal more often.

Conclusions: Urban canals are promising settings for interventions to encourage green space usage and potentially increase physical activity and other wellbeing-promoting behaviours. Interventions that improve access to green corridors along canals and provide separate routes for different physical activities may be particularly effective. More robust natural experimental studies like this are now needed to better inform policy and practice recommendations on the effectiveness of a wider range of urban green space interventions.