Healthy living environments create healthy physical activity-related habits (ELEVATE): A protocol for a smartphone-based mixed-method study

Physical inactivity remains a key risk factor for adverse public health outcomes, disproportionately burdening lower socioeconomic groups. While individual-level interventions may temporarily increase walking-related physical activity (WPA) for some, they rarely achieve population-wide benefits. In contrast, built and natural environments are better positioned to support sustained WPA at the population level. Despite the importance of the environment to WPA, state-of-the-art research has limitations: it often relies on cross-sectional self-reports, uses coarse, simplistic environmental indicators, and focuses narrowly on residential neighborhoods, overlooking the diverse streetscapes people encounter in daily mobility. Using a transdisciplinary approach, ELEVATE addresses these gaps by 1) assessing how adults perceive and experience the built and natural streetscape environment during their WPA, 2) longitudinally assessing the relationships between streetscape environments and WPA, and 3) developing an artificial intelligence-powered system to suggest place-based environmental interventions that promote WPA. ELEVATE will employ a mixed-methods study design grounded in participatory co-creation, on-site and walk-along interviews to capture the everyday practices and experiences of WPA. We will use deep learning to extract objective environmental features and perceived streetscape qualities from street view images. A sample of approximately 200 adults residing in Amsterdam, The Netherlands, will be recruited. To examine relationships between micro-scale streetscape features and WPA, we will collect seven days of intensive longitudinal data using smartphones, including global positioning system (GPS)-based mobility and step counts. We will use spatiotemporal clustering to identify where people are most and least physically active, and mixed models to assess associations between these environmental measures and step counts. Qualitative and quantitative results will be triangulated in co-created focus groups. Finally, to support evidence-based public health and urban planning interventions, we will develop an AI-powered recommender system that generates context-sensitive (re)design guidelines framing the built and natural environment as a modifiable determinant of WPA. This study will generate evidence on how micro-scale built and natural street environments encountered during daily mobility are associated with WPA in adults. The findings are expected to inform place-based public health strategies by identifying modifiable environmental characteristics associated with physical activity and socioeconomic inequalities in urban settings.