BACKGROUND. The benefits of physical activity for physical and mental health and well-being are well evidenced. Despite this, a substantial proportion of the adult population in England do not meet current recommended guidelines for physical activity leading to a significant burden on individuals, health services and the economy. Strategies are needed which lead to sustainable increases in physical activity at the population level. Walking is a free and accessible behaviour which is acceptable to most people and can be incorporated into everyday activities. Walking for transport is a type of walking which is undertaken specifically to travel from one point to another to reach a destination. Gaining an understanding of behavioural and contextual influences on walking for transport is important to facilitate specificity in designing effective interventions. Evaluating both the implementation and effectiveness of interventions to promote walking for transport in real-world settings may help to improve interventions and determine how they can be implemented at scale to impact population levels of physical activity. The research in this thesis aimed to contribute to the evidence base relating to understanding the factors influencing and the promotion of walking for transport in adults to address the problem of how to increase population levels of physical activity to improve health and well-being. Eight research articles are presented which used data collected as part of three research projects: Impact of Constructing Non-motorised Networks and Evaluating Changes in Travel (iConnect), Walking Works and Fitter for Walking. RESULTS. The Transport and Physical Activity Questionnaire (TPAQ) was developed and its measurement properties for assessing different domains of physical activity were tested. It was found to be suitable for use in comprehensively assessing transport and physical activity behaviour with comparable reliability and validity to other similar measures. A new 13-item scale was developed to assess adults perceptions of the environment in the neighbourhood (PENS) in the UK context. This was found to have comparable reliability to other similar scales. Using PENS and TPAQ, walking for transport was found to be positively associated with perceptions of supportive infrastructure, availability of local amenities, and general environment quality in the residential neighbourhood. Walking to and from work was found to be positively associated with the perceived presence of convenient walking routes, suitable pavements, maintained pavements or convenient public transport in the workplace neighbourhood. Walking to and from work was also positively associated with employees who were aged < 30 years, did not have a car, had no free car parking at work, were confident of including some walking or intended to walk to or from work on a regular basis, and had support from colleagues for walking. It was negatively associated with employees perceptions that they lived too far away from work to walk, walking was less convenient than using a car for commuting, they did not have time to walk, they needed a car for work, or they had always travelled the same way. In a community-based intervention to promote walking for transport, a wide variety of small-scale environmental changes were made which were led by local authorities (e.g. removal of encroaching vegetation, new/improved pedestrian signage, new dropped kerbs/kerb improvements, and new, repaired or improved footpaths) or by communities (e.g. planting bulbs, shrubs or bedding plants, clean-up days and litter pick-ups). Additional activities were undertaken to help increase awareness of the benefits of walking and promote the newly improved routes (e.g. led walks, themed walks, development of maps/resources and community events). After 12 months, there was a decrease in pedestrian route use overall and in four out of the five case studies where data collection took place. However, after 14-20 months there was an increase in pedestrian route use overall and in all case studies. Participants in the intervention perceived the main impacts to be improved physical and social environments. Implementing the intervention was found to be complex and required considerable resource and time. Processes required for implementation of the intervention were identified which included planning, preparation and delivery phases. Adaptability of the intervention to fit the local context was highlighted as being critical for successful programme delivery. In a whole-workplace walking to work intervention, no changes in walking behaviour were observed which may have resulted from barriers in using volunteer employee walking champions to deliver activities, the programme components not being delivered as originally intended, the types of activities which were delivered, and lack of awareness and participation by employees. CONCLUSIONS. A range of factors operating at different levels which influence walking for transport behaviour in adults were identified, confirming the need for specificity in studying both the behaviour and the contexts in which the behaviour is undertaken. Evidence is provided of the barriers and facilitators for implementing community-based and workplace interventions which aim to promote the behaviour. These should be addressed to maximise the effectiveness of interventions. Researchers, practitioners and policy-makers should take these research findings into consideration in the future design, planning and implementation of co-produced, multi-level interventions which aim to promote walking for transport. Future research should identify causal factors influencing walking for transport, improve intervention content and optimise intervention implementation. Researchers should address methodological limitations of work in this area, including the application of more rigorous study designs and the use of more reliable and valid measures of walking for transport and overall physical activity. Together this will maximise the potential impact of walking for transport interventions for promoting physical activity and improving health and well-being at the population level.

Yes / Background: Interpreting evaluations of complex interventions can be difficult without sufficient description of key intervention content. We aimed to develop an implementation package for primary care which could be delivered using typically available resources and could be adapted to target determinants of behaviour for each of four quality indicators: diabetes control, blood pressure control, anticoagulation for atrial fibrillation and risky prescribing. We describe the development and prospective verification of behaviour change techniques (BCTs) embedded within the adaptable implementation packages. Methods: We used an over-lapping multi-staged process. We identified evidence-based, candidate delivery mechanisms—mainly audit and feedback, educational outreach and computerised prompts and reminders. We drew upon interviews with primary care professionals using the Theoretical Domains Framework to explore likely determinants of adherence to quality indicators. We linked determinants to candidate BCTs. With input from stakeholder panels, we prioritised likely determinants and intervention content prior to piloting the implementation packages. Our content analysis assessed the extent to which embedded BCTs could be identified within the packages and compared them across the delivery mechanisms and four quality indicators. Results: Each implementation package included at least 27 out of 30 potentially applicable BCTs representing 15 of 16 BCT categories. Whilst 23 BCTs were shared across all four implementation packages (e.g. BCTs relating to feedback and comparing behaviour), some BCTs were unique to certain delivery mechanisms (e.g. ‘graded tasks’ and ‘problem solving’ for educational outreach). BCTs addressing the determinants ‘environmental context’ and ‘social and professional roles’ (e.g. ‘restructuring the social and ‘physical environment’ and ‘adding objects to the environment’) were indicator specific. We found it challenging to operationalise BCTs targeting ‘environmental context’, ‘social influences’ and ‘social and professional roles’ within our chosen delivery mechanisms. Conclusion: We have demonstrated a transparent process for selecting, operationalising and verifying the BCT content in implementation packages adapted to target four quality indicators in primary care. There was considerable overlap in BCTs identified across the four indicators suggesting core BCTs can be embedded and verified within delivery mechanisms commonly available to primary care. Whilst feedback reports can include a wide range of BCTs, computerised prompts can deliver BCTs at the time of decision making, and educational outreach can allow for flexibility and individual tailoring in delivery / UK National Institute for Health Research (NIHR) under its Programme Grants for Applied Research scheme (Grant Reference Number RP-PG-1209-10040).