Purpose: This systematic review and meta-analysis aimed to compare the effectiveness of positive (‘carrot’) strategies, negative (‘stick’) strategies, and a combination of the two on modifying travel behaviour.

Methods: Nine databases were searched for controlled before-and-after studies of population-level interventions and travel behaviour (e.g. driving, active travel, public transit, walking, and cycling) from adults in the general population. Interventions were categorized as carrots (e.g. new bike share programs), combined carrot and stick (e.g. traffic calming), or stick interventions (e.g. congestion charging) by whether gains or losses of functions could occur (how the intervention seeks to affect behaviour). Harvest plots were used to visually summarize the findings weighted by study quality as determined using the Effective Public Health Practice Project tool. Where possible, outcomes were converted into standardized mean differences (SMD) and random‐effects meta‐analyses were conducted.

Results/findings: We extracted data from 83 publications reporting 98 interventions.  From these, we identified 20 intervention types and 8 function categories. The majority of interventions were carrots (n=64), followed by carrot and stick (n=17) and stick (n=17). Most evaluations were conducted in North America and Europe on a city-wide or community-level scale. Harvest plots demonstrated that most evaluations, particularly those classified as of higher quality, found changes in favour of the intervention. Results for carrot interventions, however, were less consistent than for stick or combined interventions. This was consistent with findings from the meta-analysis, which were statistically nonsignificant but had point-estimates of greater magnitude for driving outcomes for sticks (SMD -0.21; 95%CI -0.43, 0.01) and combined carrot and stick interventions (-0.17; -0.65, 0.31) compared to carrots (-0.09; -0.21, 0.03). Likewise, for active travel outcomes, combined carrot and stick interventions had a higher SMD (0.60; -0.44, 1.63) compared to carrot interventions (0.10; -0.06, 0.25).

Conclusion: This is the first review to compare whether positive, negative, or combined strategies differ in effectiveness on changing travel behaviour, which can aid policymakers in designing sustainable transportation policies. Further research is needed for interventions with a stick component, which suggest greater effectiveness yet remain less well-studied, possibly because they are less conducive to experimental manipulation.

Purpose: Infrastructure for active travel (walking and cycling) is receiving increasing attention as an important way to promote physical activity and improve health. However, their design and implementation often brings about significant challenges. We aimed to synthesise stakeholders’ views and experiences of developing guidance for, designing, commissioning and implementing environmental interventions to promote active travel.

Methods: Eight electronic databases were searched, with no restrictions, complimented by hand searching to identify studies containing qualitative data analysed using a qualitative approach (e.g. interviews, focus groups) from stakeholders with experience of designing, commissioning or implementing environmental interventions to promote active travel or relevant guidance. Two reviewers independently assessed articles for eligibility. Risk of bias of individual studies and confidence in the review’s findings were assessed, with 25% checked by a second reviewer. Studies were synthesised using thematic analysis using a ‘solutions lens’.

Findings: Of the 22,239 articles identified, 37 studies met the inclusion criteria. Twenty studies focused on infrastructure promoting walking and cycling, fourteen on cycling and three on walking. Most were conducted in a limited number of high-income countries. Overarching themes were: 1) identifying the right actors to bring about change; 2) initiating and maintaining collaborations; 3) factors influencing choice of infrastructure; 4) securing and managing resources. Key actors were multi-sectoral, from across all levels of the decision-making process who had an interest in active travel and ability to influence change. Their collaboration was essential to gaining resources, sharing knowledge and meeting local needs. Effective communication was through political and administrative channels, advocacy and promotional activities, and co-design with stakeholders and communities. Actors should recognise and act on opportunities for upgrading or new infrastructure, should be sensitive to context (e.g. demographic, political, socio-cultural), and implemented with other complimentary behavioural interventions. Persuasive arguments included highlighting evidence for health and economic benefits, trialling of temporary infrastructure, using personal testimonies and evidence from other contexts.

Conclusions: Our findings will assist a wide range of stakeholders to successfully navigate the process of implementing infrastructure and inform policy. Further research is required to understand techniques, methods and processes that stakeholders used in a range of settings.

Purpose: Increasing physical activity in daily travel can contribute to the prevention of non-communicable diseases. Understanding how prevalent active and sedentary travel behaviours are and how they are distributed is critical in developing future strategies, but robust evidence does not seem to exist in Asian cities. We examined the prevalence and geographic variations of active and sedentary travel in greater Tokyo.

Methods: Data were provided by 412,253 working-age adults (aged 20–64 years) from the fifth Greater Tokyo Metropolitan Area Household Travel Survey. Participants reported their travel behaviours using a 24-hour travel diary. They were categorised into those engaged in active travel (≥30 min/d in active modes (walking and cycling) and 0 min/d of car use) or not and those engaged in sedentary travel (0 min/d in active modes and ≥60 min/d in cars) or not. Variations in travel behaviours were examined across four distinct geographic regions that varied by population density.

Results: The overall prevalence of active travel was 40% and that of sedentary travel was 11%. The prevalence of active and sedentary travel differed between regions: it was 50.2% and 4.4% in inner metropolitan (mean population density: 161 persons/ha); 45.3% and 8.2% in higher-density outer metropolitan (92 persons/ha); 35.4% and 13.4% in lower-density outer metropolitan (37 persons/ha), and 20.1% and 21.7% in peri-urban areas (6 persons/ha), respectively. Multilevel regression analysis found that each 10 persons/ha increment in population density was associated with 18% higher odds of engaging in active travel (95%CI: 1.16, 1.20) and 13% lower odds of engaging in sedentary travel (95%CI: 0.86, 0.88).

Conclusions: In the greater Tokyo metropolitan area, 40% of working-age adults met physical activity guidelines through active travel without any car use. However, there were gradients in the prevalence of active and sedentary travel according to population density, which are likely to be reflective of built-environment and transport-system variations. Our findings suggest that residents of peri-urban areas are at greater risk of non-communicable diseases. Such evidence can inform the public health, transport, and urban planning sectors to develop area-specific initiatives to promote physically active lifestyles for the prevention of non-communicable diseases.

Purpose: Mid-March 2020, Belgium went in lockdown to combat the COVID-19-pandemic, which resulted in drastic changes in people’s work- and lifestyle. Especially physical activity (PA) and sedentary behaviour (SB) may have been affected. As low PA and high SB levels are associated with overweight and obesity, which have an apparent link with COVID-19 illness, it is important to investigate the impact of this lockdown on people’s PA and SB.  

Methods: This prospective cohort study is part of a larger longitudinal study, assessing PA and SB levels of Flemish secondary school staff throughout the 2019-2020 school year. Fortunately, we were able to compare one of our measurements, conducted between March 23 and April 7, 2020 (ten days after the installation of the lockdown measures) with a pre-lockdown (baseline) measurement, conducted between January 27 and February 11, 2020. Validated questionnaires were used to assess participants’ PA and SB. Mixed modelling was applied in R to evaluate the impact of the lockdown on PA and SB.

Results: Six hundred seventy-five secondary school employees (76.1% females; 43.9±10.2years; BMI of 25.2±4.4kg/m²; 90.4% teachers, 7.5% principals, 2.1% other school staff) were included. Significant increases were found for total PA (+102min/week; p<0.05), household PA (+281min/week; p<0.001) and leisure time PA (+136min/week; p<0.001), whereas decreases were observed for work-related PA (-264min/week; p<0.001) and transport-related PA (-38min/week; p<0.001). In contrast to walking and vigorous PA (showing no differences over time), participants were more moderately physically active (+194min/week; p<0.05) during the lockdown period. Significant increases were found for total SB (+864min/week; p<0.001), work-related SB (+583min/week; p<0.001) and leisure time SB (+551min/week; p<0.001), whereas a decrease was observed for transport-related SB (-284min/week; p<0.001).

Conclusion: Despite health beneficial increases in PA during the lockdown period, our findings equally show unhealthy increases in SB. Promoting a physically active and non-sedentary lifestyle is highly important during the current COVID-19-pandemic as, besides their association with overweight and obesity and its related co-morbidities, increased PA and decreased SB may positively affect the immune system.

Purpose: To tackle population health challenges, we must address the fundamental determinants of diet and activity patterns. Systematic reviews frequently conclude that the available evidence about the effects of environmental and policy interventions is too diverse, flawed or inconclusive to support a more general conclusion about what should be done. However, merely increasing the supply of intervention studies is not enough. The pivotal link between research and policy or practice should be the cumulation of insight from multiple studies. In spite of all the developments in quantitative methods for evidence synthesis, however, we struggle to derive meaningful generalisable inferences to guide and support public health action.  

Methods: We review theoretical, methodological and case study material from a variety of disciplines and propose a more eclectic, flexible and reflexive approach to building and interpreting the evidence.  

Findings: If conventional evidence synthesis can be thought of as analogous to building a wall, then we can increase the supply of bricks (the number of studies), their similarity (statistical commensurability) or the strength of the mortar (the statistical methods for holding them together). However, many public health challenges seem akin to herding sheep in mountainous terrain, where ordinary walls are of limited use and a more flexible way of combining dissimilar stones (pieces of evidence) may be required. This would entail shifting towards generalising the functions of interventions, rather than their effects; towards inference to the best explanation, rather than relying on binary hypothesis-testing; and towards embracing divergent findings, to be resolved by testing theories across a cumulated body of work.  

Conclusions: We should look beyond simple notions of ‘interventions’, search for patterns and embrace the mess in evidence synthesis in order to better understand what makes for an effective public health strategy. In this way we might channel a spirit of pragmatic pluralism into making sense of complex sets of evidence, robust enough to support more plausible causal inference to guide action, while accepting and adapting to the reality of the public health landscape. The traditional art of dry stone walling can serve as a metaphor for the more ‘holistic sense-making’ we propose. 

Purpose: Excessive and inadequate gestational weight gain is associated with adverse pregnancy outcomes and migrant women is an especially vulnerable group. In Sweden, approximately 20% of pregnant women are foreign born and the majority are Arabic- or Somali speaking. Further, most pregnant women regularly visit maternity healthcare, which makes it an important arena to promote a healthy lifestyle. We have previously shown that a Swedish smartphone app can improve dietary habits and reduce weight gain during pregnancy (HealthyMoms). To also reach migrant women, the app needs to be translated and adapted. Therefore, the aim of this study was to explore maternity healthcare staffs´ working routines and views on how the HealthyMoms app could be modified to best reach Arabic- and Somali speaking pregnant women (i.e. The HealthyMigrantMoms app).

Methods: We recruited healthcare staff (midwives, medical doctors, and a dietician) within maternity healthcare in Linköping, Sweden. Twelve semi-structured interviews were conducted (June-November 2020) and were then analysed using thematic analysis.  

Preliminary results: Healthcare staff expressed difficulties communicating healthy habits to migrant women due to language barriers and time constraints. An Arabic and Somali version of the HealthyMoms app was perceived to potentially overcome these barriers and aid in their work as a supportive tool for healthy habits in these women. The app was also highlighted as a tool with great potential to support women with gestational diabetes. The app should have a large focus on physical activity, include information about how the Swedish maternity care works and finally be culturally adapted (e.g., include information about fasting during pregnancy and culturally adjusted recipes). Regarding the app design, the information needs to be easy to understand and the app should include visual content (i.e., pictures, videos, and audio-files) to make it accessible to all women irrespectively of literacy level.

Conclusion: Maternity healthcare staff experience difficulties reaching and promoting healthy habits in pregnant migrant women due to communication problems. By translating the app to Arabic and Somali, including visual content and culturally adapting it, the HealthyMoms app could aid healthcare workers in their work to support healthy habits during pregnancy in migrant women.