Movement For Growth

Increased physical activity

Through West Midlands on The Move, the WMCA has a vision to increase physical activity. Through the West Midlands Cycling Charter there is the aim to increase cycling to 5% of trips to work by 2023. An Action Plan outlines the delivery of schemes and programmes to achieve this goal.

One of the most convenient ways for people to get more physically active is to build it into their daily routine. This is usually through encouraging people to walk or cycle. Public transport also plays an important part in increasing physical activity when people walk or cycle as part of their journey.

The Chief Medical Officer’s (CMO) advice is that adults get 150 minutes of moderately intensive physical activity each week, or that 75 minutes of intensive activity can have the same effect.

There are an estimated 580,000 adults who are inactive and achieve less than 30 minutes of physical activity a week in the West Midlands. In the West Midlands it is estimated that 3 out of every 10 adults are not achieving that across all their activities for the whole week.26 This is lower than the England average, and if physical activity levels were increased to this average then 90,000 fewer people would be inactive.

There are inequalities in how likely people are to be physically inactive. Data from across England shows that:

1. 54 out of 100 people older than 75 years are physically inactive, compared with 15 out of 100 16-25 year olds
2. 27 women in every 100 are inactive compared with 24 out of every 100 men
3. 32 out of every 100 people in semi-routine or routine 33 out of every 100 people with a long term disability are physically inactive, compared with 21 out of every 100 with no impairments. The more impairments an individual has, the more likely they are to be physically inactive
4. 37 out of every 100 people in semi routine or routine occupations are inactive, compared with 17 out of every 100 people in managerial or professional jobs.

People with disabilities or long-term conditions are less likely to be physically active and less likely to cycle or walk the whole journey to work.

Increasing the range of opportunities to walk and cycle creates an accessible way to get physically active. People who cycle for transport purposes are 4 times more likely to meet physical activity guidelines. Walking and cycling to and from public transport is an important source of physical activity.

There are numerous health benefits that can be achieved from encouraging physical activity. Across the whole of the UK, if physical inactivity was eliminated then it would add an additional year to the national average life expectancy.

The more intensive or longer the physical activity is for, the greater the protective effect. The longer that people are physically active for, the lower their risk of premature death.

Even small increases in physical activity can have a significant impact. For someone who is inactive, doing around 25 minutes of walking per day can reduce the risk of premature death by about 9%. The same amount of time spent doing more intense cycling reduces the risk of premature death by 17%.

Physical activity has the greatest effect on health when people who would be otherwise inactive are enabled to become active. Whilst walking for around 25 minutes every day reduces the risk of death by 10%, reducing this risk by a further 10% requires five times the amount of walking. Transport schemes that reduce the number of people who are inactive are likely to have a bigger impact for each person than schemes aimed at people who are already physically active.

As cycling is usually more intensive exercise than walking, it can reduce the risk of death by a large amount, especially when done regularly. One study of people aged between forty and sixty nine found that regularly cycling reduced the risk of death by 40% during the research.

The benefits of physical activity can be gained even after someone has been physically inactive for a long time. In those over 60 year olds, 2 hours of walking every week translated as a 22% reduced likelihood of premature death. Greater benefits were seen with more activity.

Walking for transport in the West Midlands

Walking is the most likely way that most adults will meet the CMO recommended physical activity levels.

Currently around 1 in every 10 journeys to work in the West Midlands are entirely by foot, however, this disguises many more walking trips. Many people walk to and from public transport such as buses and train stations. Although these are relatively short distances, they are important ways to improve health and wellbeing, especially amongst people who would otherwise be inactive.

More people walk during the week than is suggested using commuting statistics. Counting walks of only 10 minutes or more, over 40% of adults walk five times a week and most walk at least once. These might be trips to destinations other than work, or for leisure.

There is a direct relationship between mental health and the built environment as a whole. People who rate the built environment in their neighbourhoods as poor can be around 30% to 60% more likely to report having depression in the last six months, with higher rates of lifetime depression.

Compared with physical health, there has been less discussion and research on street design and its relationship to mental health and wellbeing. This is an important area for research to understand how streets can meet the objectives of Thrive West Midlands.

There have been few studies on the relationship between how the design of streets encourages people to walk and mental health. Whilst the overall relationship between mental health and street design is unclear, some characteristics such as increased volumes of traffic have been shown to increase psychological distress.

Transport and social cohesion

Street design can increase social contact between residents. Social contact and supportive social networks strengthen mental resilience in children66 and improve community cohesion. People who are socially isolated are at greater risk of poor mental health,67 68 and isolation can have much wider impacts on early deaths, hospital admissions in the elderly and cardiovascular disease.69 Whilst isolation can occur at any age, the elderly are more at risk of being socially isolated.

If street design helps people to walk to places then it will directly impact on the strength of the local community. People who can walk to local services know more neighbours, are generally more trusting of people, and have more social contact.70 The ease of accessibility of local services such as shops, parks or other facilities also increases the number and strength of social connections that people have.

Streets with less traffic encourage larger social networks and places where people are more likely to stop and chat. People on streets with smaller traffic volumes are more likely to have more friends and acquaintances.

Safer streets are essential in helping people move around the West Midlands without perceived or genuine risk of injury. Reducing the danger that people are exposed to decreases the risk of injury, but also encourages people to walk or cycle.

Human error is often cited as the major cause of traffic collisions. One perspective is that errors are a result of a set of circumstances and they can be prevented rather than being random events.79 Roads can also be designed so that errors do not result in deaths.

Addressing these underlying causes and ensuring that common errors do not lead to deaths can also reduce road danger and improve perceptions of safety. In this way, action to improve road safety can have a much wider influence on health beyond preventing injuries.

The World Health Organisation has promoted a ‘safe systems’ approach to road safety based on the Vision Zero approach in Sweden and Sustainable Safety in the Netherlands. Under these approaches, it is considered unethical to design roads where an error could lead to deaths.

Based on the understanding of how likely people were to die in a typical collision on different road types, speed limits were set to reduce the chances of this happening and segregated facilities provided for cyclists and walkers on roads that required higher speed limits. Over half of all deaths could be prevented by adopting a safe systems approach.

Part of a safe systems approach is 20mph limits in areas where pedestrians are at risk. If hit at 20mph, 3 out of every 200 pedestrians will be killed. At speeds of 30mph, the risk of death is around 1 in every 10. A recent analysis has shown that across England, around 85% of serious and fatal child pedestrian injuries occur on roads with 30mph limits, showing the wide potential of reducing vehicle speeds.

Children who live in deprived areas are more likely to be killed on the roads as pedestrians and cyclists. This is because of the more unsafe road environment, and the larger amount of walking that children do.85 Within the WMCA area there are typically higher rates of child serious and fatal injuries than the England average.

Across England, children aged 5-9 who live in the most deprived 20% of households are nine times more likely to be killed or seriously injured as a pedestrian than children who live in the 20% most affluent areas. Among 10-14 year olds the rate was just under four times as high. A similar picture is seen for child cyclists.

Traffic injuries have longer term impacts including psychological distress or other mental health issues for up to three years following the crash.87, 88 More severe physical injuries seem to lead to higher levels of psychological distress.

Transport is a source of noise. This noise comes from a variety of sources such as vehicle engines, the interaction between tyres and the ground, and wind resistance.

Sound can affect people in different ways, depending on the situation and the environment as well as sensitivity to the noise and attitudes about it. If people do not feel in control over a sound or that it is unfair that they should hear it, they are more likely to notice it and react negatively.

Quiet or calming sounds, particularly from natural sources, can have a positive effect on people. Quieter places indicate safety and put people at ease.

Alternatively, louder pleasant sounds from a bustling public space can create a lively and exciting place that people enjoy.

Positive effects can be lost, particularly when sound is unwanted or when it masks quieter reassuring sounds. Loud noises produced at a distance can then have a negative impact.

Although excessive exposure to loud noise can damage hearing, there are also health implications at lower volumes. Even at low volumes, transport noise can be perceived as negative and act as a cause of stress or disturbed sleep. This is how it has a direct impact on health as well as quality of life.

Night time noise is usually measured as an annual average and between 11pm and 7am. During this period, exposure to average noise levels of around 55db and above are considered by WHO as increasingly dangerous to public health.91 This is slightly quieter than many fridges. Over 200,000 people in the Birmingham and Black Country urban conurbation are exposed to average road traffic noise above this level at night.

Sleep disturbance and waking can occur at much lower volumes. People in groups who typically sleep longer or have fragmented sleep patterns are considered more at risk of the effects of night time noise. Groups with these sleeping patterns include children, the elderly, pregnant women, people with ill health, and shift workers.

The highest burden from noise on health and wellbeing is predominantly through sleep disturbance and annoyance. Noise annoyance can effect wellbeing by causing negative responses, such as anger, disappointment, dissatisfaction, withdrawal, helplessness, depression, anxiety, distraction, agitation or exhaustion. Noise also increases the risk of heart disease due to increased stress, which can have physical symptoms such as tiredness and stomach-discomfort, and raised blood pressure.

The evidence is developing about a range of other plausible health impacts such as increased risk of diabetes and low-birth weight births. There is a potential relationship with diagnosed mental health and people with depression are being more likely to report noise as a problem in urban areas.

Children are less able to deal with the stress caused by noise as they have not developed the same coping mechanisms as adults. In children there is evidence that noise is linked to emotional symptoms, conduct problems and hyperactivity.

Some studies have shown that road and rail noise also has a negative impact on mental health in primary school children, and predominantly in children who were born preterm, with a low birth weight.

Noise also has an impact of school performance and learning outcomes. Higher levels of noise exposure worsens memory, performance in tests and can cause a delay in reading age. WHO recommend that background noise should not exceed 35dB during teaching sessions.

Across the West Midlands there are variations in the number of people exposed to road, rail and air traffic noise.

Benefits can also be maximised when street modifications or improvements are carried out to consider the wider health and wellbeing needs of residents or people who use the street. By doing this, the same intervention can often help to improve health and wellbeing in a wide range of ways, even when primarily targeted at one issue. Unintended negative impacts can also be identified and prevented by taking this approach.

Our approach to improving health through transport

There are actions that we can take to maximise the positive impacts that transport has on health and wellbeing. This can be done by embedding health and wellbeing considerations in to our approach to transport. By doing this opportunities and implications of schemes can be identified and acted upon. A set of actions has been developed to embed health into our approach.

To consider the breadth of health and wellbeing issues, a range of public health data and evidence is available. There is expertise in interpreting this data in the public health teams in constituent members. Often this evidence can be used to develop the business cases of schemes that improve health and wellbeing.

There are connections between different health and transport issues that might be missed if there is only a focus on single issues. Attention needs to focus on groups who might have the greatest health and wellbeing benefit and to protect groups most at risk. This report has identified children, the elderly and people living in deprived areas as these groups.

The design of streets and public places is an example of a transport intervention that can impact on multiple health issues. This report has identified many urban design interventions that can improve health and wellbeing by encouraging more walking.

ACTION ONE: We will use data on population health to help prioritise and target interventions

There is data and information that describes the health of local authorities and smaller geographies within them that can be used to assess health needs and how much benefit can be gained. That data will be included in the strategic outline cases for transport schemes that will improve health and wellbeing.

Across local authorities, the Public Health Outcomes Framework contains a set of indicators that explain the relative health and wellbeing of an area. This draws on a wide range of sources of data and is regularly updated when new data becomes available. To make best use of it, we will identify indicators that relate to transport and health and publish and update profiles for each local authority.

To make best use of health data for smaller areas within local authorities, we will develop health and transport dashboards that will show the health of people around transport schemes and corridors. Local authorities can communicate their health priorities to TfWM through their Joint Strategic Needs Assessment. These should reference health and transport. We will work with the public health departments of our WMCA members to make sure that they have access to relevant data sets to help identify priorities.

ACTION TWO: Through our Equality Impact Assessment process we will assess the equity of health impacts.

No-one should be disadvantaged from achieving their potential to be healthy and everyone should have a fair opportunity to be in good health. Some areas and groups within the West Midlands have poorer health. By identifying and understanding the needs of disadvantaged groups at an early stage we can make sure that schemes help everyone to achieve good health and wellbeing.

We will consider how transport schemes impact on health inequalities through the existing WMCA Equality Impact Assessment process.

ACTION THREE: We will understand the social impact of transport schemes.

There are many benefits from investing in health. These might be directly to the health service or local authorities because of reduced need for health and social care or the value that people put on preventing early deaths or lost productivity and informal care costs. By calculating this value we will include health in the business cases and the benefit-cost ratio that is used to understand the value of the scheme.

We will use The World Health Organisation ‘Health Economic Assessment Tool’ to calculate the benefits of increased physical activity from cycling, walking and public transport schemes. This is in line with Department for Transport guidance.

The Department for Transport also approve the use of the Sickness Absence Reduction Tool. This gives a financial value on reduced sickness absence from increased physical activity.

There are other opportunities to describe NHS and local authority savings, but which are not approved for use in business cases by the Department for Transport’s appraisal. We will explore the use of these tools internally to understand the size of benefits that might be currently missed.

Some significant transport schemes will benefit from a health impact assessment to identify opportunities to mitigate any health impact of the scheme on health, or capitalise on the opportunities to improve health. These can help to complete TfWM objectives to prevent the exacerbation of air quality problems. We will identify opportunities to conduct health impact assessments of transport interventions.

In some constituent member local authorities these are being built into the planning process and highlighted in the local plan, and these should also refer to the opportunity to conduct health impact assessments on transport schemes. We will work with local authorities to conduct health impact assessments, as part of broader sustainability and environmental impact assessments, whether lead by the local authority or TfWM.

The health and wellbeing issues identified in this report will be used to structure and assess any health impacts and should be considered by transport consultancies who have been commissioned to carry out Health Impact Assessments, alongside issues such as access to health care.

ACTION FOUR: We will set out an evidence based statement of what makes a healthy and active street and trial the approach

Streets can be an asset to improve the health of people who live and work close to them. This is a role beyond protecting people from the risk of injury or poor air quality. Streets that increase social contact or walking, cycling are health promoting environments. This helps to address transport challenges of people walking or cycling short distances.

There is now a large and continually growing evidence base that sets out how people use places such as streets and how to encourage more walking and cycling for travel. This has a wider impact on wellbeing as greater amounts of walking for transport improve the sense of community or community cohesion..

The WMCA has approved cycle design guidance for the West Midlands to achieve high standards for key cycling routes. The Guidance can be used to develop spaces that encourage physical activity and social contact and reduce conflict between pedestrians and cyclists.

We will set out the evidence base for a healthy and active street environment that create better conditions for walking and improve community cohesion. This will provide a benchmark that streets can be evaluated against and set principles to enhance the public realm and local conditions for active travel.

We will work with constituent members to trial and evaluate a series of healthy and active streets projects over the next 2 years.