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Economic, physical, built, cultural, learning, social and service environments have a profound effect on lifelong health. However, policy thinking about health research is dominated by the ‘biomedical model’ which promotes medicalisation and an emphasis on diagnosis and treatment at the expense of prevention. Prevention research has tended to focus on ‘downstream’ interventions that rely on individual behaviour change, frequently increasing inequalities. Preventive strategies often focus on isolated leverage points and are scattered across different settings. This paper describes a major new prevention research programme that aims to create City Collaboratory testbeds to support the identification, implementation and evaluation of upstream interventions within a whole system city setting. Prevention of physical and mental ill-health will come from the cumulative effect of multiple system-wide interventions. Rather than scatter these interventions across many settings and evaluate single outcomes, we will test their collective impact across multiple outcomes with the goal of achieving a tipping point for better health. Our focus is on early life (ActEarly) in recognition of childhood and adolescence being such critical periods for influencing lifelong health and wellbeing.

The food environment has taken on much of the impact of the COVID-19 pandemic. Evidence shows people's relationship and access to the food environment is a determinant of their health and wellbeing, and in relation to prevalence of chronic and non-communicable diseases. The spatial planning system forms part of a whole systems action in shaping the environment in a way that maximises population health gain. While these practices have had varying degrees of success, the sudden introduction and spread of COVID-19, and the responses to it, has forced us to re-examine the utility of current planning practice, particularly the impact on inequalities. In this commentary we aim to explore the post-pandemic role of spatial planning as a mechanism for improving public health by highlight a whole system perspective on the food environment, referring to experiences in Wales as a case study, and concluding with observation on future consumer trends around access to food.

Few natural experiments have assessed the effect of the built environment on physical activity. The 2012 London Olympic Games Athletes' Village (renamed East Village) will provide social, intermediate, and market-rent accommodation. This development offers a unique opportunity to assess the effect of a rapidly changing built environment designed to encourage health and active living on the physical activity patterns of residents. A 2-year controlled longitudinal study of 1200 families (each including at least one adult and one child) will be carried out to establish whether physical activity levels in families relocating into East Village show a sustained increase compared with families living outside East Village. Families applying to live in the social, affordable, and market-rent accommodation in East Village will be recruited at application. Participants will have assessments of objectively measured physical activity (with ActiGraph monitors, ActiGraph, FL, USA) and body composition in their present place of residence and will be reassessed 1 year later, either in East Village (intervention group) or in their original place of residence (control group). Multilevel models will assess differences in change in physical activity between intervention and control groups, allowing for individual and household level factors, and other sociodemographic confounding factors (ascertained by electronic questionnaire). We will assess whether differences in physical activity among intervention and control groups relate to use of the local environment, and (if so) which environmental components. The study is predicated on a 70% follow-up rate and is powered to detect a 5% increase in the number of daily steps (and other activity and adiposity outcomes); this represents the lower limit of potentially worthwhile increases in physical activity. To date, 1121 participants have been recruited from 386 social and 322 intermediate households; 69% (487/710) and 84% (346/411), respectively, have recorded at least 4 days (>540 min) of physical activity data. Baseline recruitment will be complete by early 2015. This study offers an important opportunity for a natural experiment. Behavioural theories, particularly social learning theory, which can underpin potential benefits of a changed built environment, will be explored. Although the opportunity is unique, the results might also be generalisable to other urban building projects and should inform future evidence-based urban planning. This research is being supported by project grants from the Medical Research Council National Prevention Research Initiative (MR/J000345/1) and National Institute for Health Research (12/211/69).

Agent based models are a computational methodology in which systems of simulated heterogeneous agents interact with one another and their environment; they are a research tool with the potential to provide greater understanding of the complex, interdependent, and systemic determinants of population health challenges, particularly when co-produced with the decision makers, practitioners, and public who understand and experience these challenges from a variety of perspectives. Although agent-based modelling is becoming more widely used in health research, this methodology is currently underutilised in non-communicable disease prevention. We aim to highlight the potential role of agent-based modelling in supporting policy and practice decision-making in non-communicable disease prevention, using an obesity example to show how an agent-based model can capture the social influences in diet. We identified agent-based models addressing non-communicable disease prevention from PubMed, ScienceDirect, Google Scholar, and Web of Science, using the search terms “agent-based model” and “public health” between Jan 1, 2000, and Dec 31, 2022. Case studies were selected that best illustrated the use of agent-based models for UK public health challenges. Selection criteria also included open access code documentation and models that reported core methodologies. We identified three key case studies that best exemplified the use of agent-based models for addressing non-communicable disease prevention. A further three core sociological agent-based model case studies that were seen as core to methodology were also identified. Although we did not find any agent-based models that had been used for policy implementation to date, we did identify a model of obesity spread in networked agents. This model simulated how individuals influence each other with respect to food consumption and physical activity. We deconstructed this model to find that it is a good didactic example of agent-based methodology and shows the potential for agent-based models to be used to inform policy and practice decision-making in the future. Well-designed agent-based models that are developed in collaboration with public health stakeholders have the potential to provide new insights into non-communicable disease prevention and provide an opportunity to test policy scenarios in silico before they are applied in the real world. Population health Agent-based Simulation nEtwork (PHASE).

BackgroundIn 2021, Bristol became the first city outside London to introduce a policy to restrict advertisements of high fat, salt and sugar (HFSS) products and other unhealthy commodities (alcohol, gambling and payday loans) on council-owned sites. This research explored how the policy was implemented and evaluated its impact on exposure, consumption/use of these products, and household purchasing of HFSS products.MethodsTwenty-two semi-structured interviews with council employees (n=12), stakeholders from third sector organisations (n=5), industry (n=3) and government organisations (n=2) were carried out.We collected advertisement exposure information through in-person auditing pre- and post-implementation (n= 348 sites).We further conducted a repeated cross-sectional survey of exposure and consumption of residents of Bristol (intervention) and South Gloucestershire (comparator) before (n=2543) and after (n=2076) implementation. We also analysed 2020–23 timeseries of purchased foods and drinks by Bristol households (n=217) and three control areas (Cardiff, Gloucestershire, and Sheffield; n=795) using Kantar’s Worldpanel Take Home data.ResultsWidespread cross-council support for the policy facilitated its implementation. Interviewees stated that this policy acted as a springboard for further restrictions influencing other local authorities to adopt a similar policy and that the policy is part of a systemwide approach to improve public health. Interviewees stated that the policy would benefit from stronger internal auditing processes to prevent policy violations and that it could be extended to restrict high carbon products and potentially include additional advertising spaces.Unhealthy commodities advertisement exposure reduced in Bristol (11% to 0.8%) but increased in the comparator (0.9% to 18%). There was no measurable impact of the policy on consumption/use of unhealthy commodities, although the overall direction of results suggested a potential reduction. There were also no significant differences in household weekly energy purchased from HFSS products compared to the counterfactual (+897.6 kcal, 95% CI-57.7, 1,853.0), nor for fat, sugar or salt specifically.ConclusionThere was no evidence of a measurable impact of the policy on purchasing or consumption of unhealthy products, which can be explained by the small change in exposure; only ~30% of outdoor advertising space is owned by the Council (with only 11% advertising unhealthy commodities pre-policy).Although the policy was always intended as part of a system change rather than a stand-alone policy, lessons for other local authorities intending to pursue similar policies include cross-department communication during conceptualisation and implementation, and incorporating continued learnings from other local authorities, as well as an improved internal auditing system.

In 2021, Bristol became the first city outside London to introduce a policy to restrict advertisements of high fat, salt and sugar (HFSS) products and other unhealthy commodities (alcohol, gambling and payday loans) on council sites. This research evaluates the impact of this advertising restriction policy (ARP) on exposure to adverts of unhealthy commodities, consumption/use of these products, and household purchasing of HFSS products. We conducted a controlled repeated cross-sectional study of residents of Bristol (intervention) and South Gloucestershire (comparator) before (n=2543) and after (n=2043) the ARP. Self-reported exposure and consumption/use of these products was collected. The intervention effect was analysed using a controlled before-after design. In addition, we analysed 2020–23 timeseries of purchased foods and drinks by 1012 households from Bristol (intervention; n=217) and three control areas (Cardiff, Gloucestershire, and Sheffield; n=795) using Kantar's Worldpanel Take Home data. A controlled interrupted time series design estimated weekly household purchases of energy and nutrients from HFSS products compared to the counterfactual. Ethical approval for this study was granted by the University of Bristol Faculty of Health Sciences Research Ethics Committee (FREC). Preliminary results do not indicate significant changes in exposure or consumption/use of unhealthy commodities post-intervention. However, overall direction of results suggested a potential reduction; ie, a –22·1 (95% CI –47·3, 16·2) percentage point decrease in reported consumption of fast-food in intervention versus comparator. Preliminary results also did not indicate significant differences in weekly energy purchased from HFSS products compared to counterfactuals (+915·1 kcal, 95% CI –31·7, 1861·9), nor for purchases of fat (+39·4 g, 95% CI –19·6, 98·3), saturated fat (+23·5 g, 95% CI –2·9, 49·8), sugar (+53·2 g, 95% CI –14·4, 120·8) or salt (–0·4 g, 95% CI –4·1, 3·2) from HFSS products. These results did not indicate a clear impact of Bristol's ARP on consumption of unhealthy commodities or exposure to their adverts, or purchasing of HFSS products. Bristol City Council only own ˜30% of the outdoor advertising space in Bristol which may explain the limited impact. This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research Programme (Award ID: NIHR152114) and supported by the NIHR Applied Research Collaboration West (ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust. The views expressed in this article are those of the authors and do not necessarily represent those of the NHS, the NIHR or the Department of Health and Social Care.

In 2021, Bristol became the first local authority outside London to introduce restrictions on advertisements for high fat, salt and sugar products and other unhealthy commodities (alcohol, gambling and payday loans) on local authority advertising sites (including bus shelters and some billboards). This research explored how the policy was implemented and what learnings may support other councils seeking to adopt a similar policy. Fourteen semi-structured interviews with key stakeholders, including policy-makers (n=5), other local authority employees (n=3), employees of government organisations (n=1), third-party organisations (n=3) and those from the advertising industry (n=2) were carried out online. Interviews explored: policy implementation, policy acceptability across different stakeholder groups, support of the wider policy context, impacts and unanticipated impacts on the system, barriers and facilitators to implementation, considerations for other councils and the future plans of the policy. Data were analysed using framework analysis which allowed for both inductive and deductive coding. Our preliminary analyses suggest that widespread cross-council support for the policy facilitated its implementation. Having clear assessment criteria in place to examine product adherence to the policy was also deemed important as well as learnings from other third-party organisations and other local authorities. Interviewees expressed that outcomes of the policy include: improving public health, delivering clear and consistent messaging to the public regarding public health issues, reducing health inequalities across the city, influencing other local authorities to implement similar polices and springboarding for further restrictions. To enhance the sustainability of the policy, interviewees noted that further communication across the council and with industry is needed. Lastly, interviewees stated that the policy would benefit from stronger internal auditing processes to prevent policy violations. Lessons for other local authorities intending to pursue similar policies primarily include: improved internal auditing system, communication across departments and continued learnings from other local authorities. This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research Programme (Award ID: NIHR152114) and supported by the NIHR Applied Research Collaboration West (ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust. The views expressed in this abstract are those of the authors and do not necessarily represent those of the funders.

  \"I saw lots of people's backyards on that train, more parts of the old weird America than I'd ever seen, because the railway goes through places that were important when the track was laid 120 years ago,\" [Billy Bragg] says. \"And on the second leg of the journey, from San Antonio to Los Angeles, the train follows the border with Mexico. It was possible to look out one side of the train and see El Paso, and on the other side Juarez. You could throw a rock from the train into Mexico. I think it was on all our minds that this was where [Donald Trump] was going to build his wall.\" \"That got me thinking about American train songs, and the railroad as a metaphor,\" says Bragg. \"You know, car songs tend to be about driving a car. But train songs are so much more abstract. Think about a song like Folsom Prison Blues by Johnny Cash - that's actually a train song. The train is the catalyst for the emotions that he's feeling. It's not the prison. It's that lonesome whistle blowing. There's something in our common pop culture about songs about the railroad, in which the railroad becomes a metaphor for aspiration, for heartbreak, for death. The railroad has an immediate and evocative sense of distance, hope and fear.\" When we speak, it is coming to the end of 2016, and we discuss the year in which we lost Bowie, Cohen and Prince. \"Unbelievable. Unbelievable,\" he says. \"My theory is that Bowie was holding reality together, and that his death has unhinged it all. I'm kind of hoping that on New Year's Day, at a performance of his musical Lazarus - get the reference - he's going to reappear and say that the whole thing was a dream and that, actually, Chelsea won the Premier League. That's my hope.\"