Background to the ENABLE London study

Importance of physical inactivity

Physical inactivity is one of the leading causes of premature mortality, responsible for over 5 million deaths per year worldwide.1 Low levels of physical activity are associated with numerous adverse health outcomes in adulthood, including coronary heart disease, stroke, type 2 diabetes mellitus and cancers.2 The annual global health-care cost of physical inactivity has been estimated to be near $54B.3 In the UK, physical activity levels are undesirably low, with over one-third of men and 40% of women not meeting physical activity recommendations of at least 150 minutes of moderate activity per week.4 The important need to address this has resulted in initiatives to increase population levels of physical activity, which have become enshrined within public health policy.5,6 Evidence suggests that levels of physical activity are lowest among those who are socioeconomically disadvantaged7 and those who experience greater economic, access and health-related barriers to being physically active,8 which potentially drives social inequalities. Socioeconomic status is also associated with differences in the types of physical activity observed; in particular, higher socioeconomic status is associated with more vigorous leisure-time physical activity.9 Previous research has found variation in physical activity by day of the week, with studies showing lower levels of activity on Sundays than weekdays in young adults10 and parents and their children.11

Housing tenure

There is emerging evidence, from UK-based studies12,13 in particular, suggesting that housing tenure (owner vs. private renter vs. public sector renter) may be an important determinant of health. Among particular groups, including those who are economically inactive or unemployed, housing tenure might provide a better indication of socioeconomic status than measures based on occupation or income.14 Indeed, in several studies housing tenure remained associated with health outcomes following adjustment for conventional measures of socioeconomic status, such as income or education.12,15 A more nuanced approach is therefore required with respect to measures of socioeconomic status, and they should not be simply regarded as interchangeable.13,16 Despite this, there has been limited research examining the direct effect of housing tenure on physical activity, and existing evidence is equivocal. Harrison et al.17 found no association between housing tenure and meeting the recommended levels of physical activity among community-dwelling healthy adults in the north-east of England.17 Similarly, housing tenure was not associated with self-reported energetic physical activity among older Australians.18 Ogilvie et al.19 found overall levels of physical activity to be higher in individuals living in social housing than in owner-occupiers.19 The authors suggest that social housing tenure may capture occupational physical activity levels that are likely to be higher among those in social housing.19 By contrast, living in private-rented accommodation was associated with a greater likelihood of taking up exercise over a 9-year period among men aged 18–49 years at baseline than living in local authority accommodation.20

The residential built environment

Housing tenure may affect health and health behaviours in part through characteristics of the home or the neighbourhood itself,21,22 or through psychological factors such as self-efficacy or self-esteem.23 Social housing estates, which are common in the UK, may be associated with specific cultures and norms, which in turn shape residents’ behaviours.12 Subjective characteristics of the neighbourhood environment, such as higher perceived access to recreational facilities and shops in local proximity, have been shown to be associated with higher levels of physical activity.24,25 Residents who perceive their neighbourhood more positively have been shown to have better mental health and are less likely to relocate.26 Conversely, real and perceived crime has the potential to constrain residents’ physical activity.27 However, a recent systematic review suggested a lack of association between physical activity and perceptions of safety from crime; this highlights the need for high-quality evidence, including prospective studies and natural experiments,28 to examine this issue further. In particular, high-quality evidence is needed to understand the potentially multifactorial influence of residential location on health and health behaviours, with effects that are likely to extend beyond simple measures of socioeconomic status.28

Dose–response meta-analyses suggest that even small increases in physical activity would confer significant health benefits, particularly for cardiovascular and diabetes mellitus-related outcomes.2 Increasing physical activity levels, particularly among those living in more disadvantaged neighbourhoods, is an important public health priority. However, a wide range of community-wide interventions to increase population levels of physical activity, particularly those associated with change in the residential built environment, have failed to show consistently beneficial effects.29 Moreover, where modest effects have been shown, there is very little evidence and persistence of effects is not routinely assessed.29 Despite this, community-wide interventions related to the built environment remain attractive given their population reach.

Physical activity and the built environment

There is growing literature that investigates the influence of the built environment on physical activity levels.30 It seems highly plausible that improved walkability and improved access to green space, public transport and recreational facilities would encourage increased physical activity.31 However, evidence is heavily reliant on cross-sectional studies,32 which are prone to selection bias, in which people who are living in less walkable neighbourhoods are often intrinsically different from those who are not. Such studies make it difficult to establish temporality or to infer causal effects.33 Moreover, evidence has been mixed showing built environment-related associations with adiposity, but not with physical activity, which suggests that other health behaviours might be affected.34,35 Longitudinal studies have sought to establish causal associations of physical activity and the built environment, but the number of studies are few and the systematic reviews of studies, to date, have found this evidence less convincing.29,33,36 Specific methodological weaknesses have included (1) comparing movers with non-movers, who may be inherently different and have different reasons for moving or staying that govern their physical activity patterns,33 and (2) often relying on self-reported physical activity, which is prone to measurement error and reporting bias,37 and which could have an appreciable impact on the reporting of health outcomes at a population level.38 There have been increasing calls for high-quality evidence, particularly natural experiments, to evaluate the effect of the built environment on health behaviours, specifically physical activity levels, in which the population effects of sizeable change in the built environment can be examined.39–41 However, there have been limited opportunities to carry out such studies.

The ENABLE London study

The Examining Neighbourhood Activities in Built Living Environments in London (ENABLE London) study takes advantage of the natural experiment provided by the rapid change of brown-field land in the London Borough of Newham, UK, to create a novel built environment for public use and occupancy (namely ‘East Village’ E20, formerly the London 2012 Olympic and Paralympic Games Athletes’ Village). The extensive features of East Village, which make this sizeable change in the built environment suitable for evaluation as an intervention, are outlined below.

The East Village ‘intervention’

The planned intervention was the mixed-use development of the East Village residential neighbourhood incorporating commercial, retail, educational and transportation resources.

Specific activity-permissive features designed to encourage physical activity include improved access to open land and parkland, unrivalled transport links, and active travel options (including extensive walking and cycling paths), design features of the local environment (such as street furniture, provision and arrangement of pedestrianised space, public space aesthetics, secure bicycle parking) and the provision of new formal cycling and walking facilities in the Queen Elizabeth Olympic Park, such as the VeloPark, and cycle paths that extend into the Lee Valley and connect to the London Cycle Network.42,43 A local school, Chobham Academy, is within walking distance and provides schooling for all 3- to 19-year-olds. Retail outlets were planned within easy walking distance for everyday use (creating plazas at ground level within dedicated areas of East Village).42,43 Moreover, East Village is in close proximity to Westfield Stratford City – Europe’s largest urban shopping centre. Restriction of resident car parking (where fewer than one-sixth of homes have a designated parking space) combined with improved public transport links is designed to encourage local residents to adopt active modes of transport.42,43

Accommodation and housing tenures in East Village

East Village consists of 2818 units of accommodation, of which 1379 are social and intermediate accommodation (including shared ownership, shared equity and affordable market-rent), and 1439 are for market rent (private rent). The housing development includes a mixture of one- to four-bedroom town houses and apartments designed for single occupancy through to family-sized accommodation. Details of the different housing types are given below:

1. Social housing – approximately 675 units were available to those on the social housing register. The social housing sector is managed by East Thames Group and Triathlon Homes housing associations.
2. Intermediate accommodation – owned by Triathlon Homes (in association with the East Thames Group) with a total of 704 units (a mix of 79 shared ownership units, 269 shared equity units and 356 affordable market-rent units).
3. Market-rent accommodation – 1439 units owned by Get Living London for private rent.

Main research questions

The ENABLE London study sought to address the following primary research question: do those living in social, intermediate and market-rent accommodation in East Village show a sustained change in their physical activity levels, compared with their levels before moving into the Village, and compared with physical activity change among those who did not move into East Village?

Specific objectives of the study were to examine:

1. Whether or not any increase in physical activity observed among those living in East Village is directly attributable to the use of their local built environment and, if so, which facilities (e.g. open spaces, cycle paths, pedestrian walkways, recreational or green space, sporting venues) are important.
2. Whether or not changes in physical activity patterns in those living in East Village are modified by other factors, including age, sex, ethnicity, proximity to facilities, associated with living in East Village, housing tenure (as a marker of socioeconomic status) and employment status.
3. Whether or not adiposity levels among those living in East Village show a change from levels before moving into East Village, compared with any changes observed among those who did not move to East Village over the same period.
4. If changes in adiposity levels were observed, whether or not, and to what extent, changes in adiposity over the study period reflect changes in physical activity.

Secondary research questions included:

1. Does moving to East Village improve levels of mental health (depression and anxiety) and well-being, compared with those who did not move?
2. Does moving to East Village improve measures of the built environment and neighbourhood perceptions before and after moving, compared with those who remained outside East Village throughout?

This report

This report presents an original detailed description and summary of a large body of research, some of which has been published, submitted, or is being prepared for publication in other open-access academic journals. Further details of methods and findings presented in this report can be found in these publications, which are (1) cited in the report, (2) listed in Publications and (3) available on the study website (www.enable.sgul.ac.uk). We will continue to keep the study website updated with further publications emanating from the study.