A mixed methods investigation of factors influencing decision-making for new active living infrastructure in different contexts

Physical inactivity increases the risk of many non-communicable diseases. The built environment is an important determinant of physical activity and the ways in which places are designed and built may lock in, or out, opportunities for greater physical activity and improved health outcomes. Policies and guidelines support the creation of active living infrastructure (walking and cycling infrastructure and open spaces); however, local social, environmental and political context may influence what is built in practice. The aim of this mixed methods thesis is to investigate what influences the creation of new active living infrastructure across different contexts. It also explores the value of different methods to demonstrate impacts of new walking and cycling infrastructure. The first two studies are qualitative investigations exploring decision-making for active living infrastructure across three areas of England and in Jamaica. These involve semi-structured interviews with public health practitioners, urban and transport planners, environmental and civil society stakeholders and councillors. I then synthesise the findings from these studies to gain additional insights from across different country contexts. Building on the qualitative study findings, I investigate quantitatively the association of context with use, users and benefit-cost ratios of new walking and cycling infrastructure, using repeat cross-sectional data from 84 new walking and cycling schemes in the United Kingdom (Sustrans’ Connect2 programme). I also explore the association between use and physical activity using pragmatic monitoring data from Connect2 alongside more scientifically rigorous longitudinal cohort data from three of those schemes (the iConnect study). My final qualitative study follows on to investigate issues about perceptions of contextual relevance of case study examples. This involves semi-structured interviews with a sub-sample of participants from the first England qualitative study, using Connect2 walking and cycling route examples and results from my quantitative analysis as discussion prompts. I identified three themes in this thesis: how to bridge the gap between policy and practice for creating active living infrastructure; issues of inequality; and synthesising evaluations across contexts. I find that the benefits of active living infrastructure can be under-valued and suggest that formal and informal roles can facilitate sharing of believable stories, including case studies, to influence decision-makers. Whilst new walking and cycling infrastructure is associated with large relative increases in pedestrians and cyclists, and increases in physical activity, lack of monitoring and evaluation, reliance on market forces, and views on individual agency may be detrimental to tackling inequality. Greater collaboration between public health practitioners and non-health sectors could emphasise multi-sectoral outcomes of active living infrastructure, including wider economic impacts.