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Journal of Public Health Advance Access originally published online on June 29, 2007
Journal of Public Health 2007 29(3):236-245; doi:10.1093/pubmed/fdm041
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© The Author 2007, Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved

Community-based lifestyle interventions: changing behaviour and improving health



Lindsay Blank, Research Associate1,

Mike Grimsley, Principal Lecturer in Applied Statistics2

Elizabeth Goyder, Director of the Section of Public Health and Reader in Public Health Medicine1

Elizabeth Ellis, Research Associate3

Jean Peters, Senior Lecturer1
1 School of Health and Related Research, Public Health, The University of Sheffield, Regent Court, 30 Regent Street, Sheffield S1 4DA, UK
2 Sheffield Hallam University, Sheffield, UK
3 London School of Hygiene and Tropical Medicine, London, UK

Address correspondence to Lindsay Blank, E-mail: l.blank{at}sheffield.ac.uk

Objective To explore the association between change in physical activity levels and fruit and vegetable consumption and changes in self-reported overall health and mental health, of residents living in deprived English communities.

Design Household survey conducted in 2002 and repeated in 2004.

Setting Thirty-nine deprived UK communities in areas participating in the New Deal for Communities (NDCs), a major government funded community development initiative.

Participants Ten thousand four hundred and nineteen residents in NDC areas and neighbouring comparator areas.

Main results Overall levels of physical activity and fruit and vegetable consumption are low but a large positive change in diet or levels of physical activity is associated with a significant change in mental health (2.86 and 2.71, respectively: P < 0.01). Smaller, but also statistically significant, changes were found in physical health (0.07 and 0.05, P < 0.01). Specific dimensions of mental health which showed a large change in association with lifestyle change were those associated with ‘peacefulness’ and ‘happiness’.

Conclusions These findings suggest that, for residents of these neighbourhoods, positive lifestyle changes such as increasing physical activity levels and increase in fruit and vegetable consumption are associated with positive changes in mental health.

What this paper adds

What is already known?

Mental health, a key area of health inequality is related to physical health, and associated with education, employment, environment and community issues. There is known to be a relationship between improved lifestyle (increased physical activity levels and better diet) and better health.

What does this study add?

This study shows that over two years, measurable changes in lifestyle were associated with improvements in both mental health and self-reported overall health. The association of lifestyle changes with overall health, although statistically significant, were less significant than those with mental health over the same period, suggesting those wanting to measure the impact of community activity on health will be more likely to see a measurable short-term impact on mental, rather than overall self-reported health.

Keywords: behaviour, community, diet, exercise, mental health


   Introduction
TOP
 Introduction
Methods
 Results
 Conclusions
 Competing interests
 Funding
 References
 
Mental health, a key area of health inequality is related to physical health, and associated with education, employment, environment and community issues. There is growing international concern regarding the high prevalence of mental health disorders.1 Mental ill-health affects every fourth citizen in Europe,2,3 and is said to be the UK's biggest social problem4 with up to 25% of NHS costs attributed to neuropsychiatric disorders and diseases of the nervous system.5 The growing prevalence of mental ill-health is strikingly illustrated by recent trends in increasing number of claimants of incapacity benefit and severe disablement allowance for mental and behavioural disorders in the UK.6 Government statistics suggest that at any one time around one in six people of working age will have a mental health problem.7 Overall, these figures represent just the tip of the iceberg as they exclude those with mental health problems that remain undiagnosed.8

Across the UK, in both local and national government policy, the need to enhance the promotion of good mental health has been increasingly highlighted and a National Service Framework (NSF) for Mental Health has been developed to standardize care.9 Initiatives such as Health Action Zones,10 Employment Action Zones,11 New Deal for Disabled People12 and Connexions13 are beginning to tackle the problems of social isolation, which can often lead to mental health problems. There is a NSF for Mental Health9 and mental health is a priority area identified in ‘Saving Lives: Our Healthier Nation’14 and the government white paper ‘Choosing Health’.15

Here we explore the association between change in physical activity rates and diet and self-reported mental and overall health of residents living in deprived English communities. These data were generated by the New Deal for Communities (NDC) Household Surveys conducted in 2002 and 2004.16 NDC is a UK government funded regeneration project which aims to address inequalities in 39 deprived areas in England. NDC has £2 billion funding from the Neighbourhood Renewal Unit (NRU), within the Office of the Deputy Prime Minister (now the Department for Communities and Local Government). Community interventions exist in NDC areas to improve physical health by encouraging physical activity or dietary improvement. These are coupled with national promotion of healthy eating schemes e.g. five fruit and vegetables a day.17


   Methods
TOP
 Introduction
 Methods
Results
 Conclusions
 Competing interests
 Funding
 References
 
The NDC baseline Household Survey was conducted in 2002 by MORI and NOP for the NRU as part of the national evaluation of the NDC programme. Between July and April 2002, 500 residents aged 16 and over were interviewed in each of the 39 NDC areas (a total of 19 574 NDC residents). A sample of 848 addresses were randomly selected in each area (a total of 33 072). The interviewer then selected at random: one property at each sampled address, one household within each sampled property and one individual normally resident at that address (aged 16 and over). Where the originally selected household was not available or unwilling to participate, the interviewer selected the next address on the list. This process continued until the sample quota was reached.

A comparator neighbourhood, with similar demographic characteristics, was selected in each NDC local authority district and a total comparator sample of 2014 residents from these neighbourhoods was interviewed between November 2002 and January 2003. All interviews were conducted face to face in the resident's home, using Computer Aided Personal Interviewing.

Follow-up interviews were again conducted in the NDC and comparator areas in 2004. Where interviewees were still resident at their 2002 address, repeat interviews were attempted. This gave rise to the longitudinal sub-sample: those 2004 respondents who were interviewed at the same address in 2002. This consisted of 10 419 NDC respondents, with sample sizes varying between 182 and 341 per NDC, and 958 comparator area respondents, with area samples of between 15 and 35. The analyses in this paper are based on this longitudinal element or the 11 377 NDC and comparator ‘stayers’.

Survey data were collected on residents' health and health behaviours using validated questions from existing national surveys (e.g. General Household Survey and Health Survey for England). The interview schedule included questions on demographic characteristics (age, sex, ethnicity, household composition, tenure, education and employment) and four self-reported health measures: overall health in the last 12 months (measured on a three-point ordinal scale: not good, fairly good, good), health change in the last 12 months (five-point ordinal scale), long-standing illness or disability and items relevant to the SF-36 version 2 mental health score.18 The SF-36 mental health score, a combined measure of five items, has a range from 0 to 100; a higher score indicates better mental health and well-being. Physical activity was measured using a summated score (0–13) with one point awarded for every category of exercise the interviewee ‘does nowadays for 20 minutes at a time’ based on a measured used regularly by MORI in the General Household Survey. A score of 0 indicates the respondent does not take part in any physical activity for 20 min at a time. Quality of diet was rated on a scale of one (low) to five (high) and based on consumption of fruit and vegetables. The scale of one to five was used to reflect the current UK government recommendation to consume five pieces of fruit or vegetable per day.

These data were analysed to explore and model relationships between self-reported mental health and overall health scores in 2002 (Wave 1) and 2004 (Wave 2), and changes in self-reported physical activity and diet between the samples. Changes in self-reported activity and diet were computed as Wave 1 score subtracted from Wave 2 score. Change was classified as a large increase/decrease (a positive or negative difference of two or more points), a small increase/decrease (a positive or negative difference of one point) and no change (a difference of zero). For some analyses the change classifications were simplified to improvement, no change and decline.

Change measures for mental health and overall health were similarly obtained by subtracting Wave 1 score from that for Wave 2 and overall health change was also classified into three categories: improvement, no change or decline. In order to facilitate comparison with findings of Eurobarometer 248, changes in the mental health score were investigated in more detail. The SF-36 measure is a function of five items each scored on a five-point Likert scale which reflect the extent to which, over the past four weeks, a respondent has felt nervous, unable to cheer up, downhearted, calm and peaceful, and happy. Changes in these five elements were also computed and classified into the three categories.

After comparisons with mental well-being levels from the Eurobarometer 248 study, changes in mental well-being and overall health levels in NDC and comparator longitudinal samples were related to changes in lifestyle. Simple paired comparison approaches were first employed to test for changes in average SF-36 and overall health scores by each change category for physical activity and diet, and tests for linearity or trend applied.

Because of the hierarchical nature of the data, with samples of individuals (Level 1) drawn from NDC partnership and comparator areas (Level 2), multilevel linear methods19 were then used to model lifestyle change and SF-36 mental well-being change, between 2002 and 2004. The following Level 1 explanatory variables were included in these models: respondent age, gender, self-reported ethnicity and educational attainment; household compositional change, tenure and worklessness. In addition, change estimates were adjusted for individual lifestyle and mental well-being levels recorded at Wave 1. There was a methodological issue at Level 2, however, since the number of comparator respondents from each area were relatively small. It was decided, therefore, to treat these comparator respondents as a single group at Level 2 along with the 39 NDC samples. In addition, non-multilevel linear models were used to check for consistency with multilevel findings.

The extent to which changes in lifestyle may influence self-reported health was further assessed using, as separate change outcomes, the five items of the SF-36 mental health score and the overall health measure. As these outcome scores were not normally distributed, a transformation algorithm was applied to obtain ‘normal scores’ as approximations to normality;20 again, higher scores denote better or improving health. Multilevel linear models were then employed for these transformed measures. Further non-multilevel analyses were performed on the three change category versions of these six outcomes using multinomial logistic modelling. It should be noted that, although these outcomes are ordered, results from ordinal logistic modelling have not been given because the proportional odds assumption was contravened. Multilevel multinomial modelling was also attempted, but estimates failed to converge.


   Results
TOP
 Introduction
 Methods
 Results
Conclusions
 Competing interests
 Funding
 References
 
In order to place the health of NDC and comparator residents in a European context, Table 1 shows the percentage of respondents expressing positive mental health on SF-36 items from the EU 25 overall and UK samples compared with NDC longitudinal respondents in 2002 and 2004. The NDC/comparator respondents report consistently lower levels of mental well-being than in the EU as a whole and for the UK sub-sample.


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  		Table 1 Comparative percentages: self-reported health item responses, EU and NDC samples

 
Changes in mental health associated with lifestyle change
The unadjusted relationship between the change in physical activity and diet (from 2002 baseline to 2004 follow-up) and self-reported mental health (SF-36) at follow-up is tested and given in Table 2, together with average health scores for each sub-group. A strong association can be seen whereby those increasing or maintaining rates of physical activity also appear to increase their SF-36 mental health score. Conversely a reduction in physical activity levels was associated with a poorer mental health score compared to the baseline (2002) level. There is also evidence of a dose–response effect where a larger increase in physical activity is associated with the greatest improvement in mental health score, and this is confirmed by the test for trend (P < 0.01). The relationship reaches statistical significance for the groups that had made a small (1.38, P < 0.01) or large (2.86, P < 0.01) increase in their level of physical activity, and also in the large decrease group (–1.36, P < 0.01).


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  		Table 2 Paired comparisons [non-adjusted]: SF-36 mental health (2002 and 2004) and lifestyle change (2002–04)–NDC/comparator longitudinal sample

 
A similar pattern of association between change in physical activity and mental health is seen with self-reported diet quality and mental health (Table 2). Although the baseline values are more varied in this case, improved self-rated mental health is associated with a better diet in 2004 compared to 2002. A worsening of self-reported mental health is associated with worse diet. These associations reach statistical significance for those with the greatest improvement in their diet only (2.71, P < 0.01).

Changes in overall health associated with lifestyle change
Similar effects were seen for self-reported measures of overall health (Table 3). Better self-reported health is associated with large increased physical activity (0.07, P < 0.01) or dietary improvements (0.05, P < 0.01), as is worse self-reported health with poorer diet or reduced activity levels (although not statistically significantly in this case). Again, there is some evidence of a dose-related response effect (P(trend) < 0.01).


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  		Table 3 Paired comparisons [non-adjusted]: overall health (2002 and 2004) and lifestyle change (2002–04)—NDC/comparator longitudinal sample

 
Multilevel modelling results
Adjusted parameter estimates for three multilevel linear models linking lifestyle change and mental well-being change are given in Table 4. Physical activity change and diet change, both separately (Models 1 and 2) and together (Model 3) show significant associations with well-being change. Accounting for 2002 mental health and lifestyle scores and demographic individual and household characteristics, improvements in lifestyle are associated with relative increases in mental health-related well-being. Thus, in Model 3, compared with the reference category denoting a large decrease in relevant lifestyle score, respondents reporting large improvements in activity and diet recorded, on average, increases in the SF-36 score of 5.57 [4.16–6.98] and 3.75 [2.47–5.04], respectively. Though there was significant Level 2 variation in all models, such variation contributed less than 1% to total variation.


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  		Table 4 General linear Model 2 (multilevel): SF-36 mental health score change 2002 (Wave 1) to 2004 (Wave 2) and lifestyle change (2002–04)—NDC/comparator longitudinal sample

 
The association of lifestyle change with mental health change was examined in more detail by modelling change in the five constituent items of the relevant SF-36 dimension and change in overall health. These limited category outcomes were transformed to normal scores, with higher scores denoting less nervousness and a reduction in feelings of being ‘down in the dumps’ and downhearted, and improvements in feelings of calmness or peacefulness and happiness, and analysed using multilevel linear models. Adjusted parameter estimates for the simplified lifestyle change categories are presented in Table 5. For the mental health change items, improvements in lifestyle appear most strongly associated with the more positive items referring to peacefulness (physical activity 0.137 [0.098–0.176], diet 0.110 [0.071–0.149]) and happiness (physical activity 0.0.149 [0.0.112–0.186], diet 0.155 [0.0.116–0.194]). Though increase in physical activity is associated with a reduction in nervousness (0.073 [0.034–0.112]), this SF-36 item appears to be relatively weakly associated with lifestyle change. Improvements in both lifestyle elements are linked to overall health improvement (physical activity 0.149 [0.112–0.186], diet 0.090 [0.051–0.129]).


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  		Table 5 General linear models (multilevel): normal scores SF-36 mental health items and overall health change 2002 (Wave 1) to 2004 (Wave 2) and lifestyle change (2002–04)—NDC/comparator longitudinal sample

 
As normal scores may be viewed as difficult to interpret, simplified SF-36 item and overall health change categories were modelled using a multinomial approach. The adjusted odds ratios (OR) for the simplified lifestyle change categories are given in Table 6. As with the normal score linear models for mental health, lifestyle improvement is more likely to be reflected in greater feelings of peacefulness (physical activity OR = 1.48 [1.29–1.70], diet OR = 1.36 [1.18–1.57]) and happiness (physical activity OR = 1.49 [1.29–1.72], diet OR = 1.59 [1.37–1.85]) than reductions in nervousness (physical activity OR = 1.12 [0.96–1.31], diet OR = 1.15 [0.98–1.36]). Physical activity improvement (as opposed to that for diet), however, is also significantly associated with lower levels of feeling down in the dumps (OR = 1.39 [1.19–1.62]), and downhearted (OR = 1.35 [1.17–1.56]). Once again, positive lifestyle change appears to be linked to overall health improvement (physical activity OR = 1.33 [1.13–1.55], diet OR = 1.31 [1.12–1.54]).


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  		Table 6 SF-36 mental health items and overall health change main effects (non-multilevel) multinomial Models 2: adjusted ORa–NDC/comparator longitudinal sample

 

   Conclusions
TOP
 Introduction
 Methods
 Results
 Conclusions
Competing interests
 Funding
 References
 
Main findings of this study
Significant associations have been established for mental health and both physical activity and diet when a ‘large’ positive behaviour change in diet or levels of physical activity is implemented. There is also an association between self-reported change in diet or physical activity and overall self-reported health; however, these relationships only reach significance for the most improved lifestyle group. These relationships suggest that, for residents of NDC neighbourhoods, a self-reported improvement in mental health (and to some extent overall health) is associated with positive lifestyle change; although the direction of causation is not clear.

What is already known on this topic
Previous research has generally shown self-reported conditions of physical and mental health to be strong predictors of risk of premature mortality and ill-health (both physical and mental). The World Health Report 200221 highlighted the potential of physical activity to reduce the burden of many diseases. Saxema et al. reviewed the evidence on the potential benefits of physical exercise on mental health.22 Nearly 2 million potentially preventable deaths per year worldwide have been attributed to lack of exercise.23 There is also a developing evidence base describing the association between lack of regular physical activity and mental disorders24–26 with those who report regular physical activity being less likely to meet the criteria for DSM-III-R major depression or anxiety disorders.27 Physical activity has also been described as a mental health promotion strategy28,29 and can enhance self-esteem in children.30 Physical activity is a moderately effective treatment for anxiety and depression.31

Self-reported health and psychological state have been shown to be predictors of future mortality and ill-health.32 This association remains even after accounting for well-known demographic, social and medical risk factors.33–35 Among elderly people, self-rated health was found to be a better predictor of future mortality than clinically assessed health.36 There have also been a number of studies which suggest that negative emotions such as worry, anxiety and depression may be risk factors for chronic heart disease.31,36–42 There is now strong evidence for the association between mental health, physical activity and diet; and poor diet quality has been suggested as a modifiable risk factor for mental ill-health.43–48

What this study adds
The relationship between changing lifestyle and mental health improvement is already established and there is a wealth of literature to support it. Here we have shown that improvements in exercise and diet mediated by community level projects are associated with improvement in mental health. As the associations of lifestyle changes with overall health, although statistically significant, were less significant than those with mental health over the same period, this suggests that those wanting to measure the impact of community activity on health will be more likely to see a measurable short-term impact on mental, rather than overall self-reported health.

Explanations for these associations may be that improved diet and exercise results in improved mental health; or that improving mental health leads to better diet and increased exercise. However, far more likely is that the relationship is cyclic and that having community level interventions which impact on mental health as well as diet and exercise (by improving social cohesion) increase the beneficial effects of this interaction. Findings from NDC projects published in previous reports,16 suggest that these changes in mental and physical health, associated with increased exercise and improved diet, may occur through increasing community cohesion and social capital. The kind of lifestyle interventions implemented in the NDCs (e.g. growing and cooking projects, walking clubs, dance classes) directly involve only relatively small number of people. However, their impact is felt more widely as the neighbourhood is seen as a place where things happen and people are invited to get involved. At some level, this will potentially have an impact on the mental health of all those who are aware of the projects even if they choose not to get involved. Also, those NDCs who have the most lifestyle projects are those who are likely to have most commitment to health-related activities16 and where community involvement in NDC and the health projects has been greatest.

Limitations of this study
This is a cohort study which follows the same population over two years, but due to the nature of health change being observed it is time limited, and therefore it is not possible to demonstrate that the observed associations represent causal relationships. However, we have demonstrated substantial evidence for an association including a dose–response effect: greater improvement in lifestyle with greater improvement in mental health.

There are issues arising around the choice of suitable measures for diet and exercise as well as self-rated health. However, all the measures used here were based on previous national surveys and as a result they reflect the same advantages (comparability) and disadvantages (questions on validity). The changes presented here are relatively small and only reach statistical significance in a couple of cases. However, it is hoped that as the NDC data collection continues these trends will persist and be amplified over time.

We have identified a positive association between the number of lifestyle projects implemented in an NDC and improved self-rated mental health (unpublished data). Further analysis is being undertaken to describe this association fully.


   Competing interests
TOP
 Introduction
 Methods
 Results
 Conclusions
 Competing interests
Funding
 References
 
The authors have no competing interests to declare.


   Funding
TOP
 Introduction
 Methods
 Results
 Conclusions
 Competing interests
 Funding
References
 
The NRU sponsored the 2002–2005 national evaluation of New Deal for Communities. This evaluation was undertaken by a consortium of organizations co-ordinated by the Centre for Regional Economic and Social Research at Sheffield Hallam University. The views expressed in this paper do not necessarily reflect those of the NRU. Those wishing to know more about the evaluation should consult the evaluation's website in the first instance: http://ndcevaluation.adc.shu.ac.uk/ndcevaluation/home.asp.


   References
TOP
 Introduction
 Methods
 Results
 Conclusions
 Competing interests
 Funding
 References
 

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