O bservational studies show that people who undertake

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1 924 RESEARCH REPORT Environmental ercetions and walking in English adults Charles Foster, Melvyn Hillsdon, Margaret Thorogood... See end of article for authors affiliations... Corresondence to: Mr C Foster, University of Oxford, Institute of Health Sciences, Oxford OX3 7LF, UK; charlie.foster@dhc. ox.ac.uk Acceted for ublication 26 January J Eidemiol Community Health 2004;58: doi: /jech Study objective: To examine the relation between adults ercetions of the social and hysical environment and their self reorted walking behaviour. Design: Cross sectional survey. Setting: England. Particiants: A national samle of 4265 adults aged years. Main outcome measures: Self reorted walking behaviour was categorised into two dichotomous variables: (a) any reorted walking in ast four s, (b) reorted walking >150 minutes er in the ast four s. Percetions of the social environment covered safety of walking alone and social suort for walking. Percetions of the hysical environment covered attractiveness of local area for walking, access to shos, leisure centres, arks, cycle aths, and traffic density. Main results: In women, erceived safety of walking during the day (OR = 0.53; 95% CI: 0.31 to 0.88), and no sho within walking distance (OR = 0.72; 95% CI: 0.52 to 0.99) were associated with any reorted walking occasions. Percetions of the environment were not related to women walking >150 min/. In men, having a ark within walking distance was associated with walking >150 min/ (OR = 2.22; 95% CI: 1.18 to 4.35). No other significant associations were found. Conclusions: Women seem to be more concerned about walking for utility and in safety. Men are more likely to walk >150 min/ if they have access to a local ark but their walking is not influenced by concerns about safety. Future research should focus on the relation between objective measures rather than ercetions of the environment and hysical activity. O bservational studies show that eole who undertake moderate to high levels of hysical activity, including walking, have a lower risk of chronic diseases, such as coronary heart disease, hyertension, and diabetes. 1 4 Although there is some debate about the recise amount of hysical activity needed for rotection against cardiovascular mortality, eole who are hysically active tyically exerience a 30% 50% reduction in relative risk of coronary heart disease comared with eole who are sedentary. 5 6 A number of international and national health bodies, including the UK s Deartment of Health, have roduced common recommendations for hysical activity advising that adults should undertake at least 30 minutes of moderate intensity hysical activity (an activity with an energy exenditure of >5 kcal/min but (7.5 kcal/min) on at least five days of the. 7 9 However, only 37% of men and 25% of women in England are active at this level. 10 UK adults reort only low levels of walking. 9 In resonse to low levels of adult hysical activity the Health Education Authority was commissioned by the Deartment of Health to run a three year health romotion camaign. The Active for Life camaign aimed to increase ublic knowledge of the moderate intensity hysical activity message and to increase adults levels of moderate intensity hysical activity, esecially walking. It was evaluated by three annual surveys of a reresentative samle of adults. The authors obtained ermission from the Health Develoment Agency (formally the Health Education Authority) to analyse these data. In this aer we reort on the relation between ercetions of the hysical and social environment and two measures of walking behaviour, as reorted in the second annual survey (wave 2) of the three surveys of the samle cohort. Our a riori hyothesis was that associations between ercetions of the social and hysical environments would be different for men and women for different atterns of walking. METHODS Samle The evaluation methods of the Active for Life camaign have been reorted reviously. 11 Briefly, a nationally reresentative cohort of adults, aged 16 74, was recruited and followed u over three years from 1995 to The articiants were selected using the small users ostcode address file (PAF) for England. A multi-stage cluster random robability design was used to identify addresses. 12 At each address one eligible resondent was randomly selected from one household. At baseline, in 1995, trained interviewers from a social marketing comany interviewed articiants at home. The 30 minute interview collected data on reorted hysical activity, hysical health, knowledge of and attitudes towards hysical activity, and ercetions of barriers to hysical activity, lus sociodemograhic information. In wave 2 (1996) a series of questions were added to the interview asking about articiants ercetions of the hysical and social environment. The Health Education Authority aroved the original study. The variables used in this study all came from wave 2. Outcome measure Physical activity was assessed by asking articiants about the frequency, duration, intensity, and tye of hysical activity they had erformed in the revious four s. The tyes of hysical activities were occuational, walking, heavy housework/diy, gardening, and sort/recreation. Walking included any occasion of walking for at least 15 minutes, whatever the urose of the walk. Perceived environment Nine questions were asked about the articiant s ercetions of their hysical and social environment. A Likert scale was used to categorise some resonses, while others were simle yes/no resonses. 13 The statements related to the social

2 Environmental ercetions and walking 925 Table 1 Characteristics of 4157 articiants in the 1996 Active for Life survey (wave 2), demograhics, self reorted walking, and ercetions of the environment by gender Number of subjects or hysical asects of the environment. The assessment rocedure and statements are given in the aendix. Demograhic details The sociodemograhic data collected included age, gender, social status, educational qualifications, self reorted health status, and car ownershi. Health status was evaluated by a question asking whether articiants had any illness, disability, or health condition that limited their hysical activity. Car use was assessed by asking articiants whether they had access to a car or van. Men Women All Demograhics Age grou (%) Social status (%),0.01 AB C C DE Educational qualifications (%),0.01 A levels or higher Any qualifications No qualifications Self reorted health limitation (%),0.01 Yes Car use (%),0.01 Yes Home ownershi (%) 0.07 Owned/being bought Walking Walking for at least 15 min/ (%) 0.43 (15 min/ >15 min/ Walking for at least 150 min/ (%) 0.32 (150 min/ (%) >150 mins/ Percetions of environment Safe to walk in the day (%),0.01 High safety Low safety Safe to walk at night (%),0.01 High safety Low safety Park/oen sace convenience (%) 0.52 High convenience Low convenience Local shos convenience (%) 0.33 High convenience Low convenience Neighbourhood aesthetics (%),0.01 High aesthetics Low aesthetics Neighbourhood traffic (%),0.01 High traffic levels Low traffic levels Access to leisure centre (%) 0.04 High access Low access Comany (%) 0.19 Has comany No comany No comany (%) 0.51 Not refer comany Prefers comany Data analysis We created two categorical variables for self reorted walking: walking for at least 15 minutes er in the ast four s and walking > 150 minutes er in the ast four s. We felt that it was inaroriate to combine ercetions of the environment into summary variables as two tyes of measure were involved (resonses to statements using Likert scales or yes/no resonses). However, we collased resonses to the Likert items into agree (1 or 2) or disagree (4 or 5) categories. Resonses in the neither agree or disagree category were excluded from the analysis. Age

3 926 Foster, Hillsdon, Thorogood Table 2 Descrition of the 4157 articiants in the 1996 Active for Life survey (wave 2) ercetions of the environment by gender and self reorted levels of walking Percetions of environment Women Walking for at least 15 min/ was groued into six 10 year bands from 16 to 74. Social status data were categorised using the social grade system. 14 These categories range from Grou A rofessional occuational grous (doctors, lawyers, managers) to Grou E unskilled manual workers (general labourers). Educational qualifications were categorised into three grous, A level or higher qualifications, any qualifications, or none. Particiants reorting any condition that limited their hysical activity were excluded from the analysis (n = 108). A series of forced entry, logistic regression models were erformed to examine the relation between ercetions of the social and hysical environment and the two walking variables, using Stata Searate models were roduced for men and women and were adjusted for otential confounding factors: age, socioeconomic status (SES), education, self reorted health status, and car use. These factors are known to be associated with hysical activity. RESULTS Altogether 4268 interviews were conducted in wave 2, reresenting 64% of the 6711 resondents at baseline. A total of 4157 articiants (42.9% male) rovided comlete sets of environmental, sociodemograhic, and walking data. Table 1 shows the characteristics of this grou by gender. No significant differences between men and women, in rates of the two categories of walking were observed (walking for at least 15 min/ = 0.43; (150 min/ = 0.32). Women were more concerned than men about the safety of walking, articularly at night. More women also thought that their neighbourhood was leasant for walking and fewer of them thought there was a lot of traffic. Overall the ercetions of the local environment for walking were ositive for both genders. N >15 min/ Walking for at least 150 min/ Men >150 min/ N Walking for at least 15 min/ >15 min/ Walking for at least 150 min/ For both men and women, there were no associations between any of the nine ercetions of the environment and the two walking categories in simle 262 tables (table 2). In logistic regression models only three of the nine erceived social and hysical environment variables were significantly associated with any tye of walking for men or women (table 3). In women two variables were significantly associated with walking for at least 15 minutes er. Women who reorted feeling unsafe to walk in their neighbourhood during the day were 47% less likely to reort walking for at least 15 minutes er in ast four s, than women who felt more safe (OR = 0.53; 95% CI: 0.31 to 0.88). Women who reorted not having a sho within walking distance were 28% less likely to reort walking for at least 15 minutes er in the ast four s (OR = 0.72; 95% CI: 0.52 to 0.99). No environmental variables were significantly associated with women walking more than 150 minutes er. Age, SES, educational qualifications, self reorted health, and car use were not significantly associated with walking for at least 15 minutes er or walking more than 150 minutes er for women. In men the only variable significantly associated with walking more than 150 min/ was having a ark/oen sace within walking distance (OR = 2.22; 95% CI: 1.18 to 4.35). No other significant associations were found. DISCUSSION Although both genders had ositive ercetions of their hysical and social environments their resonses differed. Women s walking was related to concerns about safety to walk during the day, and having shos within walking distance. Women seemed to be concerned about utility and >150 min/ Safe to walk in the day High safety Low safety Safe to walk at night High safety Low safety Park/oen sace convenience High convenience Low convenience Local shos convenience High convenience Low convenience Neighbourhood aesthetics High aesthetics Low aesthetics Neighbourhood traffic High traffic levels Low traffic levels Access to leisure centre High access Low access Comany Has comany No comany No comany Not refer comany Prefers comany

4 Environmental ercetions and walking 927 Table 3 Odds ratios and 95% confidence intervals for articiants in the 1996 Active for Life survey (wave 2) ercetions of the environment and the likelihood of any walking (>walking for at least 15 min/ the ast four s) and frequent walking (>150 min/ walking er in the ast four s) by gender Percetions of environment Women >walking for at least 15 min/* >150 min/ walking* safety. Men s walking more than 150 minutes er was related to access to a local ark, with no exressed concerns about safety. Searate regression models were constructed for men and women, as univariate analysis showed significant differences by gender and we hyothesised that the different asects of the hysical and social environment would influence men and women in a different way. Thus, our models allowed gender to act as a otential moderator of the erceived effect of the environment rather than as a confounding variable. 18 Our study found similar associations to environment items to those highlighted in a recent review. 19 However, our results showed gender differences that were not observed in revious studies where the association between walking and environmental variables were studied These other studies have not examined this otential effect of gender on such associations. The cross sectional nature of the data does not allow us to make causal links between ercetions of the social and hysical environment and walking behaviour. The study samle, a second year wave of a longitudinal evaluation study cohort, was a self selected samle of adults, suffering a Men >walking for at least 15 min/ * >150 min/ walking* OR 95% CI OR 95% CI OR 95% CI OR 95% CI Safe to walk in the day Low safety to to to to Safe to walk at night Low safety to to to to Park/oen sace convenience High convenience to to to to Local shos convenience Low convenience to to to to Neighbourhood aesthetics Low aesthetics to to to to Neighbourhood traffic High traffic levels to to to to Access to leisure centre High access to to to to Comany No comany to to to to No comany Prefers comany to to to *Adjusted for age, SES, educational qualifications, self reorted health limitation, and car ownershi. Key oints N Both genders reorted ositive ercetions of their hysical and social environments. N Women were more likely to reort not walking for at least 15 minutes er if they had concerns for their safety and did not have any local shos within their neighbourhood. N Men were more likely to reort walking more than 150 min/ if they had access to a local ark or oen sace in their neighbourhood. N Evidence of considerable differences in ercetions of the environment was found between genders for both low and high walking grous. 36% loss to follow u from the original wave 1 random samle. Wave 2 articiants were older, had higher SES, and greater access to a car but had the same activity levels. This would suggest that this grou are likely to be more affluent than the general oulation samle in wave 1. Therefore they may live in more desirable environments, which led them to reort their local environments so ositively. This selection bias may account for the weak associations seen in table 3 and the lack of association between other demograhic factors and walking. The self reorted measure of walking has not been assessed for validity or reliability but it was develoed from other national surveys, including the Health Survey for England. 10 This may have led to some misclassification of walking which is exected to be non-differential, leading to an attenuation of the true relation between ercetions of the environment and walking. As far as we are aware this survey s list of environmental statements was not based on other ublished work. However, the choice of statements and use of Likert and categorical resonses were similar to question develoment found in other studies. Our results have imlications for the romotion of moderate intensity hysical activity in the UK. The New Oortunities Fund and artner bodies have contributed just over 12 million ounds to the Walking the way to Health Initiative. 25 The roject offers eole the chance to articiate in grou walks, led by trained volunteers, and such an aroach may hel to deal with the fear of walking alone in Policy imlications N Policies and interventions that imrove the safety of street and ublic saces, and maintain green saces may also contribute to increasing levels of walking. N Design of ublic saces should reflect the needs of edestrians over other modes of transort. N Providing oortunities for walking with others in grous may tackle concerns for safety, articularly among female walkers.

5 928 Foster, Hillsdon, Thorogood the day for women. The UK government has recognised the imact of fear for ersonal safety on walking in women and older eole and that an unsafe environment inhibits walking. Encouraging adults to walk instead of using the car for short journeys may rove difficult if they have concerns for their ersonal safety and have few local facilities or destinations within walking distance. Our results suggest that the hysical environment, articularly convenience and erceived safety, influences walking behaviour in English adults. However, the study is based solely on self reorted walking and ercetions of the environment. More objective measures of hysical activity behaviour and the environment should be included in future research. ACKNOWLEDGEMENTS The Active for Life data were used with the ermission of the Health Develoment Agency.... Authors affiliations C Foster, BHF Health Promotion Research Grou, Deartment of Public Health, Institute of Health Sciences, University of Oxford, UK M Hillsdon, Health Promotion Research Unit, Deartment of Public Health and Policy, London School of Hygiene and Troical Medicine, UK M Thorogood, Division of Health in the Community, Warwick Medical School, University of Warwick, UK Funding: this research was funded by the British Heart Foundation. Conflicts of interest: none declared. APPENDIX Percetions of safety, convenience, and aesthetics of the environment were assessed by asking articiants about their resonses to a list of five statements. The list was receded with the statement, I am going to read out some statements that eole have made about their local neighbourhood. For each one lease tell me how much you agree or disagree with them referring to your neighbourhood. Particiants scored their answers using a Likert scale ranging from strongly agree (1), through neither agree or disagree (3), to strongly disagree (5). Percetions of safety to walk alone during the day or at night, was assessed using two items, It is safe to go out walking during the day on your own, and It is safe to go out walking during the night on your own. Percetions of the convenience of walking in the local neighbourhood was assessed using two items, A ark/oen sace is within walking distance, and Shos are within walking distance. Aesthetics of walking in the neighbourhood was assessed using one item, It is leasant to go walking in my neighbourhood. Particiants were asked to resond to statements about their ercetions of the traffic, access to sorts facilities and social suort in relation to walking in their local environment, using dichotomous yes/no resonses. Percetions of local levels of traffic used There is a lot of traffic in my neighbourhood. 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