UK Ministry of Housing, Communities and Local Government (MHCLG) 
Exploring the use of smart phone reward programmes as a method of reducing levels of air pollution in the Berkshire area, through encouraging increased physical activity and sustainable travel
In Bracknell Forest and surrounding local authorities, levels of exercise are comparatively better than the regional and national average. Despite this, there are two key Public Health Outcome Indicators which have been identified as areas requiring improvement; air pollution and the percentage of adults who are walking for travel at least three days a week3. These indicators are due to form a large part of work amongst Public Health teams in 2019/20, and the key outcome of the proposed discovery phase is to assess if a smart phone reward programme is a successful method of addressing these.
Air pollution is the leading environmental cause of premature death and contributes to an estimated 5% of global deaths.19 In the UK, this equates to between 28,000 and 36,000 deaths a year. There is strong evidence that air pollution causes the development of coronary heart disease, stroke, respiratory disease and lung cancer, and exacerbates asthma20. In the National Institute for Health and Care Excellence (NICE) air pollution guidance, it is acknowledged that air pollution is a national problem impacting a number of local authorities. The guidance urges local authorities to consider a range of effective interventions that encourage movement to low or zero emission areas21. Air pollution is a significant consideration in the project area as both the level of air pollution (fine particulate matter) and the fraction of mortality attributable to particulate air pollution is higher in the region than nationally3 and the expectation is the proposed project will help to lower the carbon footprint in Bracknell and the surrounding areas.
In Bracknell Forest and surrounding local authorities, levels of exercise are comparatively better than the regional and national average. Despite this, there are two key Public Health Outcome Indicators which have been identified as areas requiring improvement; air pollution and the percentage of adults who are walking for travel at least three days a week3. These indicators are due to form a large part of work amongst Public Health teams in 2019/20, and the key outcome of the proposed discovery phase is to assess if a smart phone reward programme is a successful method of addressing these.
Air pollution is the leading environmental cause of premature death and contributes to an estimated 5% of global deaths.19 In the UK, this equates to between 28,000 and 36,000 deaths a year. There is strong evidence that air pollution causes the development of coronary heart disease, stroke, respiratory disease and lung cancer, and exacerbates asthma20. In the National Institute for Health and Care Excellence (NICE) air pollution guidance, it is acknowledged that air pollution is a national problem impacting a number of local authorities. The guidance urges local authorities to consider a range of effective interventions that encourage movement to low or zero emission areas21. Air pollution is a significant consideration in the project area as both the level of air pollution (fine particulate matter) and the fraction of mortality attributable to particulate air pollution is higher in the region than nationally3 and the expectation is the proposed project will help to lower the carbon footprint in Bracknell and the surrounding areas.
Alongside reducing air pollution, it is important to further increase physical activity, as outlined in a UK government report published in July 2019 which outlined that regular activity can reduce risk of developing hip fractures by 68%, type 2 diabetes by 40%, heart disease by 35% and depression by 30%1. Despite this, low levels of physical activity levels remain a concern, with recent data suggesting 25.1% (11.3m individuals) nationally are failing to complete at least 30 minutes of moderate intensity exercise per week2. This data suggests that a lack of physical activity is also an issue which is found in multiple local authorities. The dependencies and stakeholders to this problem are wide ranging including, but not limited to, local authorities, the NHS, employers and the individuals themselves. The proposed project will be user centred to use an incentive scheme to encourage an individual to make sustainable choices to simultaneously improve their own health as well as the health of the surrounding environment.
The exact cause of why individuals are not currently choosing to be physically active is complex and far-reaching. However, evidence does suggest that there are significant disparities between activity levels in different socio-economic groups. Individuals who are in routine jobs, aged 75+, homeless, isolated, and/or from an ethnic minority are less likely to be physically active. As a result of this, the proposed project would also link to pathways to promote the use of physical activity as a tool for those with a lower socioeconomic status to achieve the outlined aims and improve their quality of life. For these groups, any financial incentive should hopefully represent a significant motivating factor to engage with the project, therefore providing the potential for innovation for local authorities as a way of capturing travel and physical activity patterns in all user groups of society.
1 [Online] https://www.gov.uk/government/consultations/advancing-our-health-prevention-in-the-2020s
2 [Online]
https://www.sportengland.org/research/active-lives-survey/
3 [Online]
https://fingertips.phe.org.uk/search/exercise#page/0/gid/1/pat/6/par/E12000008/ati/102/are/E06000036
19 [Online]
https://www.gov.uk/government/publications/health-matters-air-pollution/health-matters-air-pollution
20 [Online]
https://www.gov.uk/government/news/public-health-england-publishes-air-pollution-evidence-review
21 [Online]
The assumption made relating to this project is that individuals are not choosing to use sustainable, active travel as it is easier and more convenient to use a car and they are not sufficiently motivated to use an alternative. In conjunction with this, individuals feel that the associated health benefits from an increase in physical activity are not tangible as they are too far in the future. This assumption is based on behaviour change theory which suggests individuals are more highly motivated by benefits that take place immediately, rather than those which happen later4. The main hypothesis of this project is that the use of an incentive-based behaviour change programme will result in individuals increasing their levels of physical activity and choosing to use more sustainable travel. Another hypothesis is that incentivising individuals to complete more sustainable journeys will improve air quality and consequently help improve respiratory health.
There are many tools and projects in place which are currently aimed at tackling physical inactivity. National initiatives from the NHS such as Change4Life5, couch to 5km6 and Strength and Flex7 have been promoted in recent years. Additionally, Sport England released a sports strategy covering 2016-21 with the aim of focussing on inactive and underrepresented groups to become more active8. At a local level in Bracknell Forest, the current tools in place to try and address the problem are community-based exercise classes which are part-funded by the Public Health team, as well as promotion of 152 community groups and activities on an online community map9.
The research methods used during the project will mainly be based on ecological momentary assessment which is an innovative data collection process that enables participants to provide data on their current behaviours in real time. This will be captured via an app which tracks journeys made and asks a user questions at the time of capture (e.g. “what was the purpose of this journey?” or “did this journey replace a normal trip which would be made in a car/private vehicle?”). The app will be able to then provide data on metrics such as the number of journeys made by each method, calories expended, volume of sustainable journeys made, and amount of CO2 emissions saved. The app could also be customised to ask a survey on baseline physical activity levels and personal health both at the start and the end of the defined period to enable comparisons to be made. Some specific examples of how this may indicate a return on investment and cost saving for local authorities is through data on the number of GP appointments attended or hospital admissions linked to physical activity such as a fall or air pollution such as respiratory related conditions. The application will use GPS data on smart phones so will be able to collect and report on this data per geographical region, on a cross council basis.
4 Zauberman, G., Kim, B. K., Malkoc, S. A. & Bettman, J. R. (2009). Discounting time and time discounting: Subjective time perception and intertemporal preferences. Journal of Marketing Research 46(4), 543-556
5 [Online] https://www.nhs.uk/change4life/activities
6 [Online] https://www.nhs.uk/live-well/exercise/couch-to-5k-week-by-week/
7 [Online] https://www.nhs.uk/live-well/exercise/strength-and-flex-exercise-plan/
8 [Online] https://www.sportengland.org/media/10629/sport-england-towards-an-active-nation.pdf
9 Bracknell Forest Council Public Health Community Map [Online]
http://health.bracknell-forest.gov.uk/online-services/community-map/
In the UK, air pollution is responsible for 28,000-36,000 deaths a year. There is strong evidence that air pollution causes the development of coronary heart disease, stroke, respiratory disease and lung cancer, and exacerbates asthma20. The cost of air pollution to the NHS and social care in England is estimated to be £157 million per year and there could be around 2.5 million new cases of coronary heart disease, stroke, lung cancer, childhood asthma, chronic obstructive pulmonary disease, diabetes, low birth weight, and dementia by 2035 if current air pollution levels persist. An increase in sustainable travel in the proposed area is likely to have a direct impact on reducing pollution levels and consequently improving respiratory health, as evidence shows that even a small reduction in pollution levels of 1µg/m3 can avoid 28 new cases of disease per 100,000 people and offer a saving of £15,000 per 100,000 people in NHS and social care costs15.
In conjunction with air pollution, physical inactivity has a significant contributing impact on premature death and is responsible for one in six UK deaths (equal to smoking). Despite this fact, a staggering 34% of men and 42% of women are not classed as being active enough for maintaining good health10. Physical inactivity costs the NHS in the UK around £1 billion per year11 and when including costs to wider society, this cost rises to £7.4 billion per year12. At a more local level, the estimated cost of physical inactivity to NHS clinical commissioning groups per person, per year is estimated to be £8.17 per person13. The cumulative population of the project partners is 448,182 which gives an estimated total financial cost of physical inactivity to project partners of £3.6 million per year.
The MOVES tool developed by Sport England was used when estimating the potential return on investment brought about by an effective physical activity programme14. Assuming that 5% of previously inactive residents in the target area were able to use the intended programme to complete 2 hours of low intensity walking per week over a consistent basis (defined as 2 years), the tool suggests that the potential return on investment in terms of NHS expenditure avoidance per year is £14.51 for individuals aged over 60, £4.48 for 46-60, £1.23 for those aged 31-45 and £0.85 for individuals aged 16-30. These figures also allow for a 30% drop off in those sustaining the outlined level of physical activity. These figures incorporate NHS and social care expenditure for physical inactivity related disease such as cardiovascular or metabolic conditions as well as conditions such as falls.
Although the resource cost to project partners relating to staff costs will vary, both air pollution and physical inactivity are an area of focus for all local authorities. Using Bracknell Forest council as a model, the estimated resource cost to design programmes to reduce physical inactivity amongst adults and children is equivalent to 25% of two staff members salary equating to around £16-20k per year. This cost sits alongside that incurred from transport and planning teams who also dedicate similar levels of staff resource towards traffic management and reducing levels of air pollution.
11 [Online] https://www.ncbi.nlm.nih.gov/pubmed/21562029
14 [Online]
https://www.sportengland.org/our-work/health-and-inactivity/what-is-moves/moves-tool/
15 [Online]
https://www.gov.uk/government/publications/air-pollution-a-tool-to-estimate-healthcare-costs
The Public Health arrangement within Berkshire is already set-up to enable collaborative working and is something which happens on a routine basis with examples such as joint commissioning and communication strategies. As well as Public Health teams within each local authority, there is a shared Public Health Berkshire team which is based in the same office as the lead authority who have the role of data analysis/insight, creating and supporting joined up working between the 6 local authorities in Berkshire. There is a consultant in Public Health and a Director of Public Health for Berkshire within this team, both of whom are supportive of the potential of the outlined project and will ensure buy-in and accountability for all partners. Part of the funding will be allocated to enable the project to have some dedicated time from the shared Public Health team to ensure that there is high-level oversight of the work.
Aside from this, digital tools such as conference calls and online platforms similar to google docs will be utilised to help maintain collaborative working on documents. All of the project partners involved in the bid are based no more than 45 minutes’ drive from each other and attend a monthly face to face meeting as well as fortnightly conference calls.
Additional support may be required in the initial stage to ensure that the best supplier is selected initially in order to provide the optimal product that meets the demands of the project. Once the funding is secured the project should require minimal further support to run. Part of the procurement process will explore the data outputs which could potentially be measured through the app to ensure that the best outcomes can be obtained. This process will be supported by the shared Public Health team for Berkshire.