Active ageing: Walking for Health evidence summary January 2017

Active ageing: Walking for Health evidence summary January 2017 About this summary Sport England recently announced their first step towards tackling inactivity by investing up to £10 million into projects that help inactive older people (55+) get active through their Active Ageing Fund. This paper has been produced to support schemes that are considering applying for Active Ageing Funding. The paper summarises the current reach of the Walking for Health national programme with older adults (aged 55+) and the outcomes of participation. It also identifies how local schemes could better engage with inactive older adults.

What is Walking for Health? Walking for Health is an England-wide programme of health walk schemes that deliver free, regular led walks that are designed to support people get active and stay active. Around 1,800 walks take place each week. In 2015/16 around 67,000 people participated. Walking for Health is an inclusive programme, open to all. However, with its focus on short accessible walks the programme is particularly designed for participants with restricted mobility or fitness; people with declining health who want to remain active but at reduced levels; people new to physical activity, and people recovering from ill health.

Targeted local delivery Walking for Health operates as a local delivery model which facilitates partnership working and can be adapted for different contexts or local needs. There are over 400 local schemes that operate under the Walking for Health umbrella across England. These schemes are supported by the national programme infrastructure which is run by the Ramblers in partnership with Macmillan Cancer Support. All schemes are funded and run at a local level which enables them to develop community- based, targeted provision to engage inactive people and people at risk of inactivity at a grass-roots level. All walks are led by trained walk leaders, the majority of whom are locally-based volunteers who are of a similar demographic to participants and are often recruited from existing participants.

Walking for Health and older adults Reach: older adults overall Walking for Health has a successful track record of engaging older adults to enable them to remain physically active through walking. Overall for the 2015/16 financial year, 85.9% of participants and 85.0% of volunteers were aged 55 or over. Participants over 55 attend health walks slightly more regularly than participants as a whole, attending 6.3 walks a quarter (about one walk a fortnight). The popularity among people in these age groups is unsurprising, given that the vast majority of walks take place on weekday mornings and are therefore suited to those who are retired. However, within the older age groups there are huge differences in their engagement with the programme and there are potential opportunities for schemes to better engage older adults between the ages of 55-64 and the over 75s+ in particular.

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Adults aged 55-64 Participation in Walking for Health by older people increases rapidly from the age of 55 years (figure 1). This suggests that the programme is currently doing well at reaching people at the key transition stage of retirement. It also suggests there is a bigger potential audience of people approaching retirement within the 55-64 age group. However, more work needs to be done to reach inactive people in this age group. As our evaluation shows, overall participants tend to be healthier, and no less active, than people of comparable age within the general populationi. Furthermore, it is underrepresenting participants from certain demographic groups that have higher rates of inactivity, including people from areas of deprivation and BME groups. This is particularly true of participants aged between 55-64 who, compared to older participants, are less likely to have been signposted to the programme from a health professional, be living with cancer or have another long term health condition, live in areas of deprivation or be inactive before joining the programme (figures 2 and 3). New approaches are therefore needed to better engage people from inactive groups and those at higher risk of inactivity, particularly as they approach the key transition of retirement age. Possible approaches to consider are: 

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Engaging more with health and social care professionals to signpost the people that would most benefit. We know that health and social care professionals are key partners for enabling schemes to engage inactive people overall, and inactive older adults in particular (figure 3). Another approach should be to increase opportunities for inactive adults who are still working to join walks. We can see from participation figures that those aged 55-64 attend fewer walks in each quarter than participants as a whole and participants in the older age groups (figures 4 and 5). Schemes should therefore consider how they can provide more opportunities for people aged 55-64, who are likely to be still working, to join health walks – such as developing new partnerships to offer evening and weekend walks or working with active travel and active workplace initiatives.

Adults aged 75+ Among participants aged 75 and above who are still walking with the programme, they attend more regularly than participants as a whole (figures 4 and 5), and have also been with the programme for longer (figure 6) suggesting that Walking for Health is helping older adults to maintain a regular physical activity habit. However, participation starts to drop off with people aged 75 onwards (figure 1), at the time when older adults are increasingly become inactiveii. More research is needed to fully understand the reasons for this, but poor health is often cited as a reason for leaving the programmeiii.This suggests that new approaches are needed to support individuals to say with the programme in older age as their health, fitness or confidence declines. A possible approach for schemes to consider: 

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To increase the number and range of short walks on offer. The average length of a health walk is around 60 minutes, and the majority are classified as grade two walks1. Grade one walks are aimed at walkers with limited fitness levels, the walks are no longer than 30 minutes and take place across gentle terrain. Grade one walks only make up around 15% of all walks on offer. However, they are popular with older adults (figure 7).

Between 30 - 60 minutes and may include some moderate slopes, steps, uneven surfaces and possibly stiles

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By increasing the number of short walks on offer, or increasing the support for participants who experience changes to their health and mobility, local schemes will be in a better position to help more people to be active as they age.

Outcomes Walking for Health has been shown as contributing positively to a range of health and wellbeing outcomes. Increased activity levels An external evaluation of the programme found a significant short-term overall increase in levels of weekly physical activity among participants after first joining the programme. This increase is generally not sustained and participants returned to baseline levels. However, the fact that the programme encourages participants to maintain their activity levels is positive as the participants tend to be older, which is a time when many people decrease the amount of activity they doi . How does Walking for Health facilitate this outcome? The structural elements of the health walk model are key for facilitating regular participation as well as providing good ‘hooks’ to engage new walkers. This includes the fact that the walks are free, in a group, are well planned and led, and offer walks at a variety of locations and at different paces. This is particularly important for participants who lack confidence in their own capabilities after ill-health, which can be a key barrier among older adults. Walking for Health provides a quality walk offer and there is a high satisfaction rate among participants, which encourages continued participation. This enables participants to maintain activity levels throughout changing health or life circumstances and develop a regular physical activity habit. Improved physical wellbeing Qualitative evidence from evaluations highlight how participation with Walking for Health supports improved physical wellbeing for participants, including reduced blood pressure; improved mobility; reduced pain; improved balance and weight loss. How does Walking for Health facilitate this outcome? There is clear evidence on the health benefits of physical activity. Evaluations of the Walking for Health programme highlight how it can support people to increase their confidence and fitness levels so they are able to move on to other physical activities, including volunteering with Walking for Health. “I would never have attempted it (walk leading) if I hadn’t been walking so regularly. In the past I had trouble getting out of chairs with my arthritis” (Walk leader.) Walking for Health schemes provide a supportive and secure environment for people with a range of different needs to access a low impact form of exercise that is particularly beneficial to those people with physical disabilities and/or long term health conditions. However, as Sport England’s evidence highlights, many older adults are missing the intensity in the activity they do, as well as activities that support muscle strength, which would increase the physical outcomes achieved. New approaches should be considered for how Walking for Health schemes can better support these physical outcomes through the health walks programme and local partnerships. 3

Improved mental wellbeing External evaluation of the programme observed statistically significant improved scores for general mental wellbeing. There were also statistically significant improved scores for measures of loneliness and social interaction. Qualitative research specifically highlights the social benefits for older people, including those who had recently experienced bereavement. How does Walking for Health facilitate this outcome? Evidence shows that physical activity plays a huge role in enhancing mental health and wellbeing. There is also a link with improved mental wellbeing and contact with nature, which an outdoor walking programme providesiv. The regularity of the walks can facilitate an improved sense of wellbeing as it provides a regular opportunity to ‘get out of the house’ and see other peoplei,v. The social aspects of group walks are important for many participants and, as studies have shown, walking in a group facilitates social interactionv vi. Schemes are encouraged to include an additional opportunity for social interaction by ending the walk at a venue for participants to have a tea or a coffee. This can also help participants to maintain engagement, even if they are not well enough to join the walk as it helps to maintain the sense of routine, making it is easier for people to restart walking again when their health allows. Social and community development Qualitative evidence from evaluations highlight how participation can act as a catalyst for people to engage in further community activities, as well as providing an opportunity to bring members of a community together. How does Walking for Health facilitate this outcome? Research has shown that time spent in natural environments is associated with the promotion of social cohesion by providing areas for people to meet and participate in group activitiesvii. The social aspects of the walk create an environment that facilitates social interaction which enables people to develop new friendships, share knowledge and information about local events and activities, and make contributions to the local community (such as becoming involved with local fundraising events or volunteering). Individual development Walking for Health provides thousands of local volunteer opportunities: there are currently around 8,300 active volunteers. Volunteer satisfaction is high, and feedback highlights a range of positive outcomes from volunteering including increased confidence, improved health and increased social networks. How does Walking for Health facilitate this outcome? Regular walks provide local, flexible volunteer opportunities, and can be a progression opportunity for participants. Scheme coordinators have an important role in establishing a strong network of volunteers and involving them in a range of roles including route setting, walk leading, governance and administration. Regular volunteer meetings and social events provide opportunities for developing a strong ‘team ethos’ among volunteers.

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Recommendations: delivering Walking for Health to inactive older adults This paper has highlighted how Walking for Health is doing well at engaging older adults and achieving positive outcomes for participants. However, new targeted approaches are needed to increase engagement with older adults in key groups who are inactive or at risk of inactivity, as well as supporting older adults to maintain participation as they age and their health declines. The following recommendations are considered in line with Sport England’s design principles for tackling inactivity. Developing quality partnerships We know that local signposting and delivery partnerships work best where the scheme is not operating independently of the community but links into a number of groups and initiatives and the wider health community. As this analysis shows, health and social care professionals are key partners that enable local schemes to better reach inactive older adults. We know that schemes need volunteer and staff capacity and resources to establish and maintain a high quality range of grade one walks which are most appropriate for GPs to signpost patients to. We also know that they need more support from funders and decision-makers to establish high quality and sustainable signposting partnerships with health and social care professionals. New approaches are therefore needed to establish high quality local partnerships with health and social care professionals. Using behaviour change theories We know there are many barriers preventing people from taking up regular physical activityviii. A more supported approach using behaviour change tools and techniques is required to help people to overcome those barriers to get started with Walking for Health and stick with it over the long term. One of the key challenges for local schemes is that they need the right skills, support and resources for local outreach and engagement to reach their target audiences initially, particularly those at ‘pre contemplation’ and ‘contemplation’ stage and then support them effectively using these tools and techniques. Therefore, new approaches need to be considered to upskill existing and new volunteers and partners to sustain this type of supported provision. Design the offer to suit the audience More research is needed to understand why participants leave Walking for Health as they get older, and what support older participants need to maintain the intensity of the activity to maximise the physical outcomes and ensure they are reaching the CMO guidelines in all areas. Local schemes should consider new approaches to establish regular grade one walks that are more suited to older adults, or providing more options for existing participants to maintain participation with their existing programmes. This includes new approaches to recruit and train volunteers to increase the support and capacity to deliver walks that suit older, inactive adults. It may also involve new partnerships with other physical activity providers to better support their participants when they are at risk of dropping off or decreasing intensity of walking, or to increase their physical activity outcomes in other areas (such as strength and balance).

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Measure behaviour change and impact As this analysis has highlighted, more evaluation and insight is needed to understand some key questions on how inactive older adults can be supported through Walking for Health effectively, such as:   

What type of supported provision works for inactive older people with different long term health conditions? What types of supported provision work when older people are at risk of dropping off and falling into inactivity? Do additional resources and support help us to reach people who wouldn’t have joined anyway?

Benefits of joining the national Walking for Health programme Walking for Health is a national partnership between the Ramblers, Macmillan and over 400 organisations and groups that run and manage local health walk schemes across England. There are a range of benefits for local partners to join this national programme: 

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It is a tried and tested model: Walking for Health provides a trusted and high quality model for local organisations, groups or individuals to develop an outdoor physical activity intervention that supports improved physical health, mental wellbeing and community outcomes. It is highly cost effective: Analysis of the programme outcomes using the MOVES model values Walking for Health at £3,775 per Quality-Adjusted Life Year (QALY) gained. Furthermore, based on the total value of QALYs gained, the potential Return on Investment (benefit-cost ratio) is estimated to be £3.36 per £1 invested in Walking for Health. MOVES also estimates that the programme delivers cost savings to the NHS of £0.58 for every £1 invested. This value can be maximised if the programme successfully engages inactive people and supports them to continue. It leverages additional resources: By joining the national programme, local schemes join a national partnership of health walk schemes and have access to the following additional resources: o Their own page on the Walking for Health website, which includes walk listings for each walk which can be searched for via a ‘postcode finder’ o Access to the Walking for Health database to enable monitoring and evaluation and records management o Walking for Health training materials for walk leaders o ‘Leading a walk’ kit for volunteers - including high-vis jackets; clipboards; pens o Promotional leaflets and flyers o Accreditation, a mark of quality assurance o Local networking opportunities with other schemes o Support and advice from national programme staff covering areas such funding, volunteer management and training, safeguarding, data protection, linking with Macmillan activities and networks, local policy consultations and best practice. o National reports and evidence, collating evidence and learning from schemes across the country o Access to the Ramblers insurance cover for walk leaders

For more information contact the national programme team: [email protected] or 0207 339 8541 6

Appendix: graphs 42.0% 39.1%

27.0% 26.5%

4.9% 4.4% 3.2% 2.5% 2.2% 1.2% 16-24

25-34

35-44

14.9% 11.7%

9.8% 7.3%

2.0%1.3% 45-54

All (n=48,203)

55-64

65-74

75-84

85+

New (n=16,719)

Figure 1 - Walking for Health participants by age range (Apr 2015 - Mar 2016)

74.8% 69.4% 67.3% 64.3% 61.2%

18.4% 11.9% 11.6% 10.3% 10.1%

16.6% 10.1% 10.4% 8.6% 7.0% 9.5% 5.7% 6.6% 7.4% 8.1% 6.6% 3.5% 2.4% 1.8% 7.8% 7.4% 6.5% 5.2% 3.6% 2.1% Women

BME

Living with cancer From 20% most Long term illness, deprived areas health problem or disability

All participants

55 - 64

65 - 74

75 - 84

Inactive

85+

Figure 2 - % of all participants and of those in each over 55 age group who took part in 2015/16 who were from each of the key Walking for Health target groups

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10.9% 8.6%

7.7%

All participants

6.9%

7.3%

55 - 64

65 - 74

75 - 84

85+

Figure 3 -The proportion of participants who took part in 2015/16 overall, and in each over 55 age group who were signposted to Walking for Health by a Health and Social care professional.

6.6

6.5

6.4

6.3 6.1 5.8

All All over 55's participants

55 - 64

65-74

75 - 84

85+

Figure 4 - Average quarterly attendance amongst all participants, those who are over 55 and in each over 55 age group in 2015/16.

48.3% 42.0%

27.0% 21.8%

21.2% 14.9%

2.4%0.8%

3.2% 1.0%

25-34

35-44 % of all participants

7.3% 4.2% 45-54

2.0%2.7% 55-64

65-74

75-84

85+

% of participants who walked once a week or more

Figure 5 – All participants and those who attended at least once week in 2015/16 by age range.

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100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Aged 16-24Aged 25-34Aged 35-44Aged 45-54Aged 55-64Aged 65-74Aged 75-84 Aged 85+ All (n=233) (n=457) (n=648) (n=1670) (n=6783) (n=12968) (n=5430) (n=769) (n=29789) new (n=1378)

1 year or less (n=9334)

1-2 years (n=4674)

2-3 years (n=3138)

3-4 years (n=2579)

4-5 years (n=2281)

5-6 years (n=2462)

6-7 years (n=2046)

7-8 years (n=1734)

8 years (n=163)

Figure 6 Length of participation with Walking for Health for all participants in q4 2015/16

77.1% 77.6% 77.2% 76.8% 77.1%

40.0% 35.8% 38.6%

36.4%

28.3%

24.3%

18.0% 14.6% 13.4% 12.0%

Grade 1

Grade 2 Overall

55-64

65-74

Grade 3 75-84

85+

Figure 7 All participants in 2015/16 by grade of walk

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i

France. J., Sennett, J., Jones, A., Fordham, R.,Williams, J., Burke, A., Meierkord, A., Fong Soe Khioe, E. and Suhrcke, M. (2016) Evaluation of Walking for Health. Final Report to Macmillan and the Ramblers. London: Walking for Health. Available from www.walkingforhealth.org.uk ii Sport England (2016) Tackling inactivity: active ageing prospectus. London: Sport England. iii Phillips, R. Knox, A. and Langley, E. (2011) Walking for Health: ‘inactive’ walkers – barriers to participation, and activity substitution. Natural England Commissioned Reports, Number 068. iv Bowler, D., Buyung-Ali, L., Knight, T., & Pullin, A. (2010) ‘A systematic review of evidence for the added benefits to health of exposure to natural environments’. BMC Public Health, 10(1), 456. v Grant, G. (2015) The Value of Walking. An ethnographic study of a Walking for Health group. Sheffield: Sheffield Hallam University. vi Hanson, S and Jones, A. (2015) Is there evidence that walking groups have health benefits? A systematic review and metaanalysis. Norwich: University of East Anglia. vii Maas, J., van Dillen, S. M., Verheij, R. A., & Groenewegen, P. P. (2008), Social contacts as a possible mechanism behind the relation between green space and health, Health and Place, 5(2):586-9 viii Britain Thinks (2016) People with long-term conditions and attitudes towards physical activity. Research conducted on behalf of the Richmond Group. London: The Richmond Group

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