i) Behavioural Study
Walking behaviour was assessed using two methods. The primary outcome measure was pedometer step counts (Omron HJ-109E Step-O-Meter). The secondary outcome measure was 7-day recall of physical activity using the International Physical Activity Questionnaire (IPAQ), (long version, self-report) [
23]. The behavioural impact of the intervention was assessed over a 12 month period. This enabled evaluation of the short term, immediate effect of the intervention and also whether the intervention resulted in a longer term, sustainable change in behaviour. In Group 1 walking behaviour was assessed at baseline, 12 weeks, 24 weeks and 48 weeks. In Group 2 walking behaviour was assessed at baseline, 12 weeks, 24 weeks, 36 weeks and 60 weeks.
ii) Transtheoretical Model
The Transtheoretical Model was used as a theoretical framework to investigate the relationship between participants'
psychological constructs and behaviour change. Specifically, the study examined whether any of the four constructs of the Transtheoretical Model (stages of change, processes of change, self efficacy, and decisional balance [
24]), along with mood (Positive and Negative Affect Schedule (PANAS) [
25]) and quality of life (Euroqol EQ-5D [
26]) predicted behaviour change, and if behaviour change had a consequential effect on these variables. In Group 1 these questionnaires were completed at baseline, 12 weeks, 24 weeks and 48 weeks. In Group 2 the questionnaires were completed at baseline, 12 weeks, 24 weeks, 36 weeks and 60 weeks.
iii) Physiological Study
The WWW study investigated the
physiological response to the intervention in terms of body composition, blood pressure, heart rate, total cholesterol, high density lipoprotein (HDL)-cholesterol, insulin and glucose, and also investigated the impact of increased walking on circulating levels of inflammatory markers. In recent years clear evidence has emerged of the involvement of inflammatory mechanisms in several diseases including cardiovascular disease [
27], colorectal cancer [
28], stroke [
29], obesity [
30] and type 2 diabetes [
30]. With 65% of men and 60% of women in Scotland categorised as overweight [
6], 3% diagnosed with type 2 diabetes [
31], and death rates from coronary heart disease the second highest in Western Europe [
32], a greater understanding of possible interventions is a key public health goal. Chronic low grade inflammation can be defined as 2–4 fold elevations in both pro- and anti-inflammatory cytokines at rest [
33] and regular exercise has been shown to decrease resting levels of key inflammatory markers [
34]. WWW therefore investigated whether regular walking can decrease resting levels of three key inflammatory cytokines (interleukin-6 (IL6), C-reactive protein (CRP) and tumour necrosis factor α (TNF-α)) and their receptors (sIL-6R, TNFα, TNFαR1 and TNFαR2).
In Group 1 all physiological measures were taken at baseline and 12 weeks. At 24 weeks body mass, BMI, waist-to-hip ratio, percentage body fat, blood pressure and heart rate were assessed. In Group 2 all physiological measures were assessed at baseline, 12 week and 24 weeks. At 36 weeks body mass, BMI, waist-to-hip ratio, percentage body fat, blood pressure and heart rate were assessed. Full details of how these measures were obtained are in a separate paper (Baker et al., submitted for publication).
iv) Environmental Study
The physical
environment can facilitate or inhibit physical activity across populations. Within neighbourhoods, factors such as aesthetics, convenience of facilities, accessibility of destinations and perceptions of traffic safety have been shown to be associated with levels of walking [
35]. Psychosocial variables may also influence this relationship [
36]. The WWW study investigated the relationships between physical activity levels, in particular walking, and perceived (subjective) environmental barriers or facilitators to activity, and also any changes in physical activity levels and environmental perceptions over the course of the study. Self-reported perceptions of the physical environment can change over a relatively short period of time and this may be associated with a change in the level of moderate-intensity physical activity [
37]. The change may not always occur in a positive direction but evidence suggests that those who are already active report the most positive perceptions of the environment [
38]. The Neighbourhood Quality of Life Study (1
st Survey) (NQLS) was used to subjectively assess the participants' perceptions of their local environment in relation to physical activity. The NQLS incorporates 7 subscales of the Neighbourhood Walking Scale (NEWS) and 5 subscales that assess psychosocial variables related to the neighbourhood environment and physical activity behaviour. The NQLS psychosocial subscales are:
1. Enjoyment of physical activity (developed by the NQLS group)
2. Benefits of exercise (adapted from Hovell
et al [
39] and Calfas
et al [
40])
3. Social support for physical activity: Acceptable test-retest and internal consistency reliabilities and evidence of concurrent criterion-related validity [
41]
4. Barriers to regular physical activity (adapted from Hovell
et al [
39] and Calfas
et al [
40])
5. Social cohesion of neighbourhood: The social cohesion subscale is a 5 item measure of collective efficacy that has been shown to yield high between-neighbourhood reliability [
42].
The NEWS survey items have been adapted for use in a Scottish population (for example, replacing the word condominiums with the word tenements and removing references to canyons in the neighbourhood). This adapted form of the NEWS has previously been used with Glaswegian adolescents (Hamilton, L., unpublished undergraduate thesis). Two additional sections were added to the questionnaire to consider the effects of other barriers (i.e. weather) and also to investigate respondents' perception of distance.
In Group 1 these questionnaires were completed at baseline, 12 weeks, 24 weeks and 48 weeks. In Group 2 the questionnaires were completed at baseline, 12 weeks, 24 weeks, 36 weeks and 60 weeks.
An environmental audit tool has been developed and used to objectively assess the WWW study area, based on the SPACES audit tool developed by Pikora
et al [
43]. The survey items were adapted in this WWW project for use in a Scottish urban context. Surveying the study area using the audit tool enabled the walkability of an area around each participant's home that can be accessed within approximately 30 minutes' total walking time (radius of 1.6 km, as used by Giles-Corti
et al [
44]) to be assessed, as well as assessment of particular local walking routes described by the participants. The audit tool included aspects of the physical environment that have been demonstrated to be correlated with physical activity and particularly walking, for example path quality [
45], access to destinations such as shops, recreational facilities, parks and public transport stops [
45‐
47], aesthetics [
46‐
48] and safety [
48,
49], as well as additional aspects that seem likely to be influential in the UK context, e.g. pavement width. Residential density, land use mix and street connectivity have also been correlated with physical activity [
50] and these have been calculated using GIS to complement the findings of the environmental audit.
v) Qualitative Study
To understand the social context of the WWW study, qualitative research was undertaken alongside the randomised trial. This provided an insight into awareness of the project in the local community (through semi-structured interviews with general practitioners, shop-keepers and library staff), an insight into levels of interest among the target population (through observation carried out at key locations) and an insight into participants' experiences of and attitudes towards the walking intervention (through a series of focus groups). In the focus group discussions, an attempt was made to identify both the barriers and aids to adherence to the walking programme and to highlight any differing experiences for men and women. In addition, semi-structured interviews with members of the research team captured their experiences of the study and their thoughts on the feasibility of implementing the intervention.