The Aims
The need to raise the general fitness level of the British public is perhaps the greatest challenge facing the health service today. Government and health agencies now realise the urgency of encouraging people to become more active in order to reduce the risk of coronary heart disease, strokes, obesity and many other conditions.

What the health sector is slow to realise, however, is that the countryside and urban green spaces are the largest and perhaps the most cost effective health promotion facility in the UK.

Being outdoors can provide many health benefits, like relaxing, enjoying the scenery and sharing experiences with others. The importance of the countryside to people's health and well-being is reflected in a publication from the Countryside Commission, 'Quality of Countryside, Quality of Life'.

This article describes the pioneering 'Health Walks' project which the Countryside Agency has been supporting with Dr William Bird, a GP in the Village of Sonning Common in Oxfordshire. The aim of the project is to improve people's fitness and well-being by encouraging them to use their local countryside for walking.

The Theory
The Health Walks project, inspired and pioneered by Dr William Bird at Sonning Common Health Centre in Oxfordshire, encourages walking as part of a fitness or treatment programme for people of all ages. It is a holistic approach to health care which stimulates an awareness of the local countryside and provides a focus for the community.

The project is based on the belief that the community and local environment have a major impact on individuals' well-being. The theory is that standard approaches to health promotion focus largely on eradicating disease. If, however, people live in a place with poor community spirit and no recreational opportunities then, even without disease, many people will remain in what Dr Bird describes as a 'neutral' state. By actively involving the community the Health Walks approach attempts to take the individual beyond this state into a positive state of well-being.

In this respect, Health Walks offer the transition from health promotion to promoting well-being, an area which the National Health Service cannot usually afford to address. Well-being is not just a 'nice addition', rather it is the foundation on which the health of a nation should be based.

The Practice
The project is divided into four main parts, with each part being integrated with the other.

Circular routes are carefully selected, mapped out and colour-coded according to their difficulty. Walks are further divided into 'softop' (i.e. un-surfaced footpaths and bridleways) and 'hardtop' (e.g. pavements) although most walks are 'softop' as these are preferred by walkers. The walks are signed with 'Health Walk' waymarkers.

Health Walk Guides are published to accompany each walk. These are designed for people who are not regular walkers. Local history details, a three dimensional illustrative map and drawings are added to raise awareness of the local environment and to engender a sense of pride and ownership of the scheme. On the back of each leaflet is an innovative medical table indicating the calories used and a MET value (a measure of the energy used by exercising compared to resting) for each walk.

Daily organised walks are programmed in order to motivate individuals to continue exercising and because many individuals, particularly women, feel vulnerable walking alone. Each walk is led by two volunteers who have been trained to provide appropriate warm-up and stretching exercises before and after the walk. The front leader sets the pace while the back marker remains with the slowest member. The walking groups are graded according to the fitness of the members. Grade A is for fast walkers, Grade B for the moderately fit and Grade C for the unfit.

An annual fitness assessment is the goal for people to aim for and is open to everyone in the community. People's fitness levels are calculated and converted to a fitness index using 100 as the ideal average fitness. This allows individuals to follow the progress of their fitness year on year. Four hundred local people took part in the first Sonning Common event. It is now in its fith year. Hundreds of local people have taken part in the Health Walks initiative.

People's increasing awareness of their local environment improves the well-being of communities and opens up new opportunities for a range of physical exercises. In this respect the countryside can be seen essentially as a 'Green Gym'. For example, in Sonning Common there is now a project to work with the British Trust for Conservation Volunteers to refer walkers to undertake practical conservation work. The project is called the 'Green Gym'

Evaluating the success
Evaluation of the scheme has been co-ordinated by Professor Helen Bartlett, at Oxford Brookes University School for Health Care Studies. Data collected by the health centre during the life of the scheme is analysed and is augmented by data from a questionnaire survey of participants.

The results so far are very encouraging. Over 75% of participants reported a positive impact on their health. Over 25% said their stress levels were reduced, and 20% reported a reduction in weight. Stamina and energy levels were reported to be higher amongst 63% and 56% of people respectively. Health Walkers also tended to start off with lower walking speeds than others in the same community but over time became faster. This may be a real and independent measure of increased fitness.

Most people preferred walking in the countryside to walking in the village, because of the scenery, lack of pollution and easier terrain. Some women said they were inhibited from taking country walks on their own because they felt vulnerable, so the regularly organised nature of the Health Walks was a real bonus.

Overall, the evaluation showed Health Walks to be a very sustainable form of exercise, with 85% of people committed to continuing after more than a year's involvement. Three years ago Dr. Bird said "I expect that the number of people taking up Health Walks will keep increasing with growing awareness of the benefits". Now over three years on this has been the case. This is in stark contrast to many gym-based fitness regimes where high drop-out rates are common.

The Thames Valley Health Walk Initiative
Further development work in the Thames Valley area has occurred in the last two years. This is a major initiative based on a healthy alliance between BUPA, the Countryside Commission, the British Heart Foundation, Berkshire Health Authority, Berkshire County Council, Wokingham District Council and a number of local communities.

This initiative has formed the basis for advising and promoting a model Health Walks programme throughout the country. The Countryside Agency are actively promoting schemes through their 'Walking The Way To Health' scheme which was launched nationwide in October 2000.