Physical activity: walking and cycling

General

The PDG noted that encouraging people to walk or cycle for recreation purposes is different from encouraging them to walk or cycle as a mode of transport.

The PDG considered walking and cycling as two separate activities.

Most people should be able to fit these activities into their daily lives and both are relatively cheap or may save money.

The PDG is aware of the volume of work and guidance available that is relevant to walking and cycling. It is also aware of the range of examples of good practice, both in this country and abroad. This guidance is intended to support, rather than replace that information.

People with disabilities are less likely to be physically active and more likely to face barriers to being active than those without impairments. Many of this group can walk or cycle. However, they may require additional support, for example, involving specially adapted equipment or changes to the physical environment.

The PDG noted that local authority structures and roles vary across the country and that this will affect who has responsibility for specific actions. As a result, the recommendations tend to refer to general areas of responsibility, rather than to specific job titles. Similarly, as different administrative areas may produce plans on similar issues under a different title, the recommendations refer to generic plans.

Achieving change is likely to be a long-term task and will involve participation by many professionals. This includes those working in local authorities and the NHS, as well as those working in communities (such as voluntary and faith sector organisations). The actions needed include those recommended in this and related NICE guidance.

The PDG noted that in the 'Cycle cities and towns' where cycling and walking had increased, the level of spending to encourage walking and cycling for transport purposes had been in the region of £5–10 per head per year. This had been maintained for a prolonged period. The PDG noted that this level of funding could be achieved by changing investment priorities within existing budgets rather than requiring additional funds.

Evidence

Evidence related to walking and cycling comes from a number of different professional sectors, in particular, transport and health. Each sector has its own approach to research and evaluation which can lead to difficulties in identifying and interpreting the evidence.

Health sector evidence tends to involve controlling for as many factors as possible to help identify and explain any causal links between a given activity and health. While this provides greater certainty about cause and effect, it has tended to limit investigation to topics which lend themselves to this strict approach. Examples include promotional work with individuals to encourage them to walk or cycle, or within a limited setting, such as a school. Transport and other professional sectors are more likely to address population-level factors – and are more likely to have a range of outcomes or intentions in mind. For instance, both public health and transport professionals might have an interest in the benefits of cycling. However, the former might want to know how it impacts on levels of physical activity (and hence health), particularly among those who were previously inactive. Transport professionals, meanwhile, might want to know which particular journey would be cycled (and hence, the impact on motor traffic and congestion levels). They would tend to have less interest in who has changed their mode of transport. As a result, while both groups might have a legitimate interest in activities to increase cycling levels, the outcomes of evaluations might be different.

The PDG noted that different professionals have different reasons for wanting to encourage people to walk and cycle. For instance, transport professionals may aim to reduce the volume of motorised traffic (by identifying and influencing people who are most likely to move from motorised transport to cycling). From a public health point of view, the goal might be to encourage people who are currently inactive to take up walking or cycling in order to increase the amount of physical activity they do. While the 2 goals are very closely related (and can be complementary) they may focus on different groups and involve different approaches and outcomes.

The evidence identified was predominantly from an urban perspective, so rural issues are under-represented in the recommendations.

It is difficult to apply the findings of non-UK cycling studies to England because of the cultural and legal differences – and the fact that levels of cycling are considerably higher in many other countries. Equally, the value of findings from older literature may be of limited relevance because of the social and environmental changes that have since taken place.

There is evidence that interventions tailored to people's needs and aimed at either the most sedentary groups – or at those who are most motivated to change – can encourage people to walk more. Evidence showed that interventions could work if aimed at individuals, households or groups.

Evidence showed that community-wide promotional activities, combined with an improved infrastructure, had the potential to increase cycling rates by modest amounts. Studies of marketing activities aimed at individuals reported a consistent, positive effect on cycling behaviour. However, the PDG noted that more robust study designs were needed to generate more detailed evidence of the best way to achieve this improvement. (For instance, detail is needed on whether the increases are sustained over time or are limited to certain subgroups such as young men.)

Practical experience indicates that two particular factors play a key role in increasing walking and cycling rates: having a 'champion' who is committed to promoting walking or cycling, and effective local authority support.

Four interventions, including two multi-component interventions (Cycling Demonstration Towns and Sustainable Travel Towns) were included in the economic modelling. Using cost per quality-adjusted life year (QALY) gained, the interventions were highly cost effective, even when the effect disappeared after year 1. The PDG noted that the key factors influencing the outcome of the economic model were: threshold cost, level of effects, decay in effects and costs related to initial effects. Members also noted the importance of offering the most appropriate interventions for different local settings and needs.

Data from a UK randomised control trial (RCT) were used to model the cost-effectiveness of led walks. The PDG raised concerns because the RCT showed no difference in effect between led walks and the provision of advice only. The results were not used for the recommendations. Using evidence from an evaluation of 'Get walking, keep walking', a large UK study, produced a cost per QALY of around £2700.

In addition to a cost–utility analysis, cost–benefit ratios were also calculated for environmental and traffic outcomes. These considered a range of benefits associated with increased walking or cycling and a consequent change in motor vehicle miles driven. The methodology was based on that used by the Department for Transport. However, health benefits (which account for most of the benefits calculated using the Department for Transport methodology) were not included, as these had been calculated in the cost–utility analysis.

The PDG recognised the importance of considering children. However the modelling did not consider under-18s due to a lack of direct evidence on children's behaviour in many of the studies.

Pedometers

Pedometers are cheap, effective and 'user-friendly'. The PDG noted that they may play an important role in helping people to walk more, provided they are used within a programme involving monitoring, support and goal setting. However, the PDG also noted that the use of set targets (such as 10,000 steps a day) was unlikely to be helpful if it did not take into account someone's current level of activity. In addition, some people may be put off if pedometers are used as part of a competition.

The PDG discussed the role of other technologies that might replicate pedometers, including mobile phone apps. While these may have a role to play in getting people to walk more, there is a lack of robust evidence to indicate whether or not they are effective.

Wider influences

A wide range of factors influence whether or not people walk or cycle. Many were outside the scope of this guidance. In particular, the PDG noted that environmental factors such as the quality, accessibility and availability of walking and cycling networks are likely to be important. Other issues, such as the relative costs and convenience, are also likely to be significant. As a result, it recommended that this guidance should be implemented in conjunction with other related NICE recommendations, in particular NICE's guideline on physical activity and the environment.

The scope for this guidance included an adapted logic model (Sallis et al. 2006) which sets out local factors and interventions which can impact on walking and cycling rates. It demonstrates the conceptual link between local interventions targeting the physical or social environment (or individuals) and intermediate outcomes in relation to walking and cycling. These outcomes, in turn, link to impacts on health, the environment and other areas (such as the economy). The model also highlights how local policy, resources and other factors influence the effectiveness of local interventions to improve rates if walking and cycling. For example, a decision to use cycling as a form of transport can be influenced by the level and speed of motor traffic, attitudes to safety, the ability to plan and execute a route, and the ability to carry baggage. (Please note: although national factors such as legislation and fuel duty also have an important impact, these are not included here as they fall outside the scope of the guidance.)

A number of legal issues differentiate England from parts of continental Europe, where levels of cycling are significantly higher. In parts of continental Europe, 'strict liability' means that pedestrians or cyclists injured in a collision involving a motor vehicle do not have to prove fault in seeking compensation. In addition, drivers have a civil responsibility to have insurance that will pay vulnerable victims independently of fault, while not changing criminal responsibility (see 'Expert paper 2'). Such legal requirements may act as an incentive for drivers to behave in a way that protects the most vulnerable road users.

The PDG noted that relatively few people in England cycle on a regular basis for transport purposes. This is not the case in other parts of Europe. For example, in Denmark and the Netherlands, it is considered the norm to use a bicycle for many journeys. Age is not necessarily a barrier. In the Netherlands, 26% of all journeys –and 19% of all the journeys made by people over 75 – are by bike (Ministry of Transport, Public Works and Water Management 2009). The PDG considered these examples as possible aspirational goals for England.

The PDG noted that moving towards the higher levels of cycle use seen in some Northern European countries is a process that will involve change over a prolonged period. It also noted that some of these changes are beyond the scope of this guidance. However, it felt that substantial public health benefits (such as increased levels of physical activity and reduced emissions of air pollutants) could be achieved as a result of such a process.

The PDG noted a range of issues which, if tackled in isolation, are unlikely to lead to a significant increase in walking or cycling. It also noted that tackling such issues could, nevertheless, provide a necessary foundation for interventions which will have a significant impact. For example, a key factor preventing people from walking and cycling is the danger as well as the perceived danger (including personal security fears) facing them on or near roads, paths or trails. The PDG discussed a range of measures that may help overcome this problem. These included:

Action to increase walking and cycling rates may reduce motor traffic volume and the PDG was concerned that the resulting benefits (of reduced congestion and reduced air pollution) should not be lost. For example, less traffic could lead to increases in vehicle speed, or may encourage some people to drive for journeys previously undertaken using other modes of transport. Members noted that action to ensure this does not happen could include a reallocation of road space or a reallocation of time at junctions to favour walkers or cyclists, or restricted motor vehicle access.

Local roads may act as a barrier to walking and cycling for children. Although it is not a panacea (addressing road conditions is vital), achieving 'Bikeability' level 3 would mean they could deal with all types of road conditions and more challenging traffic situations. This may be important, at least, for older children. The PDG noted that cycling off-road, where there is no exposure to motor vehicles may be appropriate for those who find road cycling too challenging.

Physical activity

Most people can walk, including groups such as older people and those with some functional difficulties. While the majority of adults (85.8%) in the UK say they can ride a bicycle (Department of Culture, Media and Sport 2011), cycling as a means of transport is a minority activity. It accounts for a small percentage of all journeys – and for a small part of overall physical activity in this country. Nevertheless, 43% of adults own a bicycle and 14% use it at least monthly (Department for Transport 2009b). Cycling remains popular among children and young people, with 41% of those aged 5–16 years cycling at least weekly (Department for Transport: unpublished data 2012).

In London, an estimated 4.3 million trips a day (around two thirds taken by car, the remainder mainly by bus) could be cycled. For this survey, trips were assessed according to a set of criteria designed to reflect trips currently made by bicycle (Transport for London, 2010).

Inequalities

Overall physical activity levels vary across the population (see section 2). This is also the case with specific activities, particularly cycling.

Most adult cyclists in most areas of England are male. The highest number of cyclists are among people who are middle-aged. Black and minority ethnic groups cycle the least. Cycling participation is roughly equal across income quintiles but the biggest growth has come among the more wealthy.

The variation in levels of walking among groups in terms of gender, race or socioeconomic status is probably the smallest for any type of physical activity.

People in households without a car walk, on average, 284 miles per year, compared to 176 miles per year walked by people in households with a car (Department for Transport 2010b). People who are most physically active do not necessarily walk or use a bicycle as a mode of transport. For some, the fact they have access to a car may have a positive influence on their physical activity levels.

The distance walked in Great Britain varies per person per year. In the quintile with the lowest household income, the distance walked is 223 miles, then it is 202, 182 and 177 miles respectively for people in the next 3 quintiles. In the quintile with the highest household income, people walk an average 201 miles per year. For cycling, the distance increases across the spectrum. Miles cycled per person per year is 32 in the lowest 2 quintiles, then 39, 49 and 77 miles respectively (Department for Transport 2010b).

One way of encouraging people to walk or cycle, as a form of transport, might be to apply greater levels of restraint on car usage in urban areas. This could be achieved, for instance, by introducing restricted parking and higher parking charges. However, there is a need to consider how this would impact on car owners living in areas where the environment is not conducive to walking or cycling, or where there is little real alternative to driving.

The guidance recommends an integrated package of measures which address a range of barriers to walking and cycling. It should be noted that reducing car use may have a beneficial influence on the environment by reducing traffic volume and air pollution and this may have a positive impact on the health of the whole population.

The PDG discussed the impacts that the recommendations may have on health inequalities. It acknowledged that those who are better off may have more opportunity to respond to the choices on offer. It also acknowledged that some transport interventions may deliberately target those most likely to change their mode of transport, rather than those who are least active. In addition, it noted that people with disabilities have specific needs. Taking these issues into account, the PDG emphasised that the recommendations should be accompanied by action to address factors such as a hostile and degraded environment, restricted access points, poor surfaces and the availability of disabled toilets. The Group also noted that some people with, for example, sensory or cognitive impairments, may need specially adapted equipment or information.

Interventions which reduce motor traffic will reduce air pollution and road danger (assuming the benefits of a reduction in motorised traffic are 'locked in' and not accompanied by, for instance, an increase in traffic speeds). Planners may be reluctant to apply traffic reduction measures in one locality for fear of 'gridlock' on other, neighbouring roads. However, in most cases, the overall level of motorised traffic will be reduced. This is likely to have a positive impact on health inequalities because people from deprived groups, who are exposed to the greatest risks from air pollution and traffic injuries, are most likely to benefit. The very old and the very young, as well as those with pre-existing respiratory or circulatory problems, will also benefit from a reduction in overall exposure to air pollutants.

Barriers and facilitators

When making transport choices, habit is important for most people, most of the time. Choosing to use a different mode of transport from usual is also likely to require more planning and thought. For instance, making a decision to start cycling might mean obtaining appropriate clothing, preparing the bike, route planning and allowing time for a trip of an unknown duration. The PDG noted that these factors are unlikely to remain as significant barriers once walking or cycling becomes the norm. For instance, both will usually involve reliable and more predictable journey times. Many journeys may be quicker, as well as being more healthy. There are also wider community benefits from reduced congestion and pollution.

The PDG noted that changing travel mode might require stopping old habits, such as using the car for short trips. Or it might involve an even more fundamental lifestyle choice, such as deciding to give up having a car altogether.

The PDG felt it was important that, where possible, health professionals (and others) set a positive example through their own behaviour in relation to walking and cycling.

The PDG noted that the times when someone has to reconsider their transport choices (such as when changing job or school, retiring or moving house) may offer important opportunities to influence their behaviour.

Despite walking and cycling being different activities, sometimes they are grouped together. The PDG felt this was often unhelpful, as barriers and facilitators to walking and cycling vary – and, in turn, they differ according to whether the activity is chosen for transport or recreational purposes. They can also be specific to the purpose and location of the trip – and to the person undertaking it. Successful interventions to increase cycling and walking need to take into account this wide range of factors.

Walking and cycling, like any form of transport, involve exposure to a certain level of risk. This includes the risk of injury from falls or from collisions and exposure to air pollution. These risks are not unique to transport involving physical activity. However, evidence shows that the health benefits of being more physically active outweigh these disbenefits.

The whole population benefits from less exposure to polluted air and congested streets when there is a general shift away from motorised vehicles.

Risk of injury or collision is a key consideration when walking and cycling in places where there are other people. As well as the actual level of risk, perception of risk is important. The PDG noted that cyclists and pedestrians are more vulnerable in the event of a collision than those in a motor vehicle. At the same time, they are much less likely to cause injury in the event of a collision, due to their lower mass and lower speed of travel.

There is evidence to support the hypothesis (usually called 'safety in numbers') that areas where there are higher numbers of cyclists have better safety records than others. One of the reasons for this may be increased driver awareness of the likelihood of encountering a cyclist – and the fact that they modify their driving as a result.

The PDG concurred that transport planning could be a way to reduce road dangers for all users. These dangers relate to motorised traffic volumes and speeds. They are also caused by a lack of driver awareness of the risks of poor driving and the need to fully consider pedestrians and cyclists, including those with restricted mobility.

Attitudes to walking and cycling are generally positive or neutral, with walking generally regarded more favourably. However, a combination of factors discourages people from taking up either if it is a question of choice, rather than necessity. These include:

Wider impacts

Traffic volume and speed act as barriers to walking and cycling (for recreation, as well as for transport purposes). The PDG noted that the level of motor traffic creates congestion which, in turn, imposes costs on the economy, through loss of productive time. Motor vehicles are also major contributors to air and noise pollution, as well as to carbon dioxide emissions.

Increasing the amount people walk or cycle, particularly in urban areas, results in a change in exposure to air pollution. Moving journeys from motorised transport to walking or cycling may alter individual exposure to air pollution, while reducing the total emissions of pollutants. Modelling by De Hartog et al. (2010) suggests that an individual's risk from increased exposure to air pollutants is modest in comparison with the benefits of them being more physically active. In addition, the overall decrease in air pollutant emissions benefits the health of the whole population. The PDG noted that a range of other potential benefits might accrue from a shift to physically active travel. These include reductions in road danger, noise, congestion and emissions of carbon dioxide. Walking and cycling can also benefit local communities by encouraging more people of all ages to be out on the streets, so making streets appear less threatening.

Personal exposure to air pollution is influenced by route choice. Routes which avoid busy roads may have much lower levels of air pollutants. This can be a much more significant influence on personal exposure than the mode of transport used.

Cost–utility calculations were based on the increased longevity associated with walking and cycling. They incorporate the effects of deaths from collisions. In addition, the economic modelling included an assessment of the cost–benefit ratios associated with environmental pollution and congestion. In most cases, interventions to promote walking and cycling led to greater benefits than costs, when considering their impact on congestion, infrastructure, collisions, local air quality, noise, greenhouse gases and indirect taxation. Costs associated with collisions were included, based on the expected reduction in car kilometres. Changes in levels of injury, based on changes in walking and cycling behaviour, are difficult to predict, partly because the relationship is not linear (see 3.50). Large increases in cycling and walking, especially if accompanied by interventions to increase safety, could reduce the absolute number of related accidents. As a result, the model did not include an additional modelled effect on injuries. Only for Cycling Demonstration Town interventions were the costs greater than the benefits. However, the modelling did not include the substantial benefits (likely to be in excess of 80% of the total) to be gained from reducing the range of health conditions associated with not being physically active enough. (These were calculated separately.)

The PDG agreed that both walking and cycling provide a wide range of health, social, environmental and economic benefits. Members also agreed that there is significant scope to increase the levels of walking and cycling in England – and that this would result in gains across society.