Physical inactivity

At every age, the majority of people don’t achieve recommended levels of physical activity.

• Nationally, 60% of men and 71% of women are not active enough to benefit their health (Active People Survey 7 data)
• Only 32% of boys and 24% of girls aged 2-15 years met the recommended physical activity levels (The Information Centre, 2009).
• Only 38.3% of adults in Redcar & Cleveland take part in sport or active recreation once per week - 4 sessions of at least moderate intensity four times in the last 28 days. (Active People Survey 8).  This has increased since 2005/6 from 30.5% reflecting local initiatives and investment in facilities.
• 27.9% of adults in Redcar and Cleveland take part in sport and physical activity three times per week (Active People Survey 8).  An increase of 7.4% from baseline figures in 2005/6.
• Only 60% of schools locally meet the two hour target for PE.

Both adult and child obesity in Redcar & Cleveland are a cause for concern.

There is a lack of validated self-report physical activity measures, particularly for children, making it difficult to evaluate and compare interventions and populations.

Motorised transportation, digital entertainment, communications technologies and sedentary jobs are removing the physical activity out of daily experience, leading to an increase in inactive lifestyles.

There is increasing evidence of the negative health effects of time spent in sedentary pursuits independent of how active people are at other times.

Subsidised sport and leisure facilities and public transport are under increas-ing financial pressure.  For participants, cost, accessibility and time pressures are key factors to being physically active.

2014/01
Establish a Redcar & Cleveland Healthy Weight, Health Lives Partnership to en-sure a co-ordinated approach to prevent and manage obesity and reduce levels of physical inactivity across the borough.

2014/02
Facilitate and create increased opportunities for people of all ages to take part in sport and active leisure, wherever possible removing barriers of cost, transport, and perception. Programmes should focus on those who are currently inactive and seek to achieve moderate intensity activity levels. 

2014/03
Commission programmes to ensure young people have the opportunities to take part in sport and physical activity linking school sport with community sport and encourage life- long participation in sport and physical activity.

2014/04
Use events as a focus to encourage people to take up physical activity programmes and promote greater understanding of the health benefits of physical activity

2014/05
Increase the capacity of voluntary sector groups running sport and active leisure programmes to sustain higher numbers of participants through investment in work-force, facilities and infrastructure.

2014/06
Maximise use of facilities, including schools and green infrastructure, through com-munity use agreements, an up to date playing pitch strategy, open space study and other relevant strategies to encourage physical activity using the extensive natural resources of the borough.

2014/07
Ensure that the potential for physical activity and healthy eating is maximised through joint working with planning and transport departments including the use of health impact assessments to address the obesogenic environment.

2014/08
Improve detailed understanding of local population characteristics in relation to physical activity to enable better targeted interventions.

Previous commissioning priorities:

2012/01
Facilitate and create increased opportunities for people of all ages to take part in sport and active leisure, wherever possible removing barriers of cost, transport, and perception. Programmes should focus on those who are currently inactive and seek to achieve moderate intensity activity levels.

2012/02
Commission programmes which link schools with community sport and leisure opportunities including those in the voluntary sector and leisure centres to provide performance pathways and to reduce the decline in participation which occurs through the 11-19 years range.

2012/03
Promote greater understanding of the health benefits of physical activity and use events as a focus to encourage people to get involved.

2012/04
Increase the capacity of voluntary sector groups running sport and active leisure programmes to sustain higher numbers of participants.

2012/05
Maximise use of facilities, including schools and green infrastructure, through community use agreements and clear information and guidance. A strategic review of the allotment provision across Redcar & Cleveland should be conducted, which should explore the potential to initiate food growing projects in other settings such as schools and workplaces (using HMP Holme House in Stockton as a case study) and linking volunteers with any such projects. The successes and progress of existing and recent work such as the “Dig It” project should be built upon.

2012/06
Improve detailed understanding of local population characteristics in relation to physical activity to enable better targeted interventions.

2012/07
Commission a single website that brings together the physical activity opportunities available in Redcar & Cleveland instead of having multiple sources of information although steps must be taken to avoid increasing health inequalities via the ‘digital divide’. Any such site should incorporate the current and emerging opportunities offered by social networking.

2012/08
Consider the use of health impact assessments for a wide range of Council and partner activities such as transport and housing projects – all of which have the potential to influence the physical activity environment.

2012/09
Use the ‘wellness’ system in the leisure centres to better track and analyse the local population.

Children and young people

Physical activity among children aged 2–15 varies according to a range of factors including gender, ethnicity and socioeconomic status (The Information Centre, 2008a; 2008b).

Gender
A higher percentage of boys than girls aged 2-15 years meet the Government’s recommendations for physical activity (32% and 24% respectively). Among girls the proportion meeting the recommendations generally decreases with age, ranging from 35% in girls aged 2 to 12% among those aged 14. There was a less consistent pattern with age among boys (The Information Centre, 2009).

By contrast, most children perceive themselves as being either very or fairly active compared with children their own age (The Information Centre, 2011). In addition, a substantial number of British adolescents believe themselves to be more physically active than they actually are (Corder et al, 2011).

Ethnicity
Children from minority ethnic groups tend to be less active compared to their white peers (The Information Centre, 2006).

Familial factors
There is a strong positive link between a child’s activity levels and that of their parents, particularly among girls (The Information Centre, 2008b). Furthermore, in terms of childhood obesity, this may be confined to those whose same-sex parents are also obese (Perez-Pastor et al, 2009).

Parents are an important influence on their child’s physical activity behaviour, yet most incorrectly consider their children to be sufficiently active (Corder et al, 2010).

Socioeconomic Status
Physical activity levels in children are related to household income, with those in the lowest income bracket more likely to be active: 36% compared to 25% in boys, and 30% and 22% among girls. This is perhaps surprising, since children in lower income groups are often found to have less healthy lifestyles (National Obesity Observatory, 2011; The Information Centre, 2009b).

Age
Children are becoming less physically fit as they age.  51% of boys and 34% of girls aged 4-10 years met the recommended levels in 2008, but only 7% of boys and no girls aged 11-15 years did so (National Obesity Observatory, 2011).

Disability
Children and young people with a disability take part in physical activity and sport less frequently and their experiences are less positive than their non-disabled peers (Sport Scotland, 2006).

Sedentary behaviour
On weekdays, 10% of children aged 2 to 9 years old were sedentary for six hours or more, but the proportion increased steeply in older children to over 60% of 15-year-olds. The proportion increased significantly across all age groups at weekends.

Household income was significantly associated with sedentary behaviour - for both boys and girls, as household income decreased, the average number of hours spent watching TV increased (The Information Centre, 2009b).

The main method of children aged 5-16 years getting to and from school is walking (41%), while 33% of this age group is being driven to school. Just 2% used a bike to travel to school as their main mode of transport (Department for Transport, 2011).

Adults

Evidence shows that certain population groups tend to have lower levels of physical activity including over 55-year-olds, some black and minority ethnic (BME) groups, disabled people, young women aged 14-24 years and lower socioeconomic groups (Sport England, 2011).

Gender and age
Based on the 2008 Health Survey for England, 39% of men and 29% of women met the Government’s recommendation for physical activity.  Women were significantly less physically fit than men, and fitness decreased significantly with age. The decline was steepest for men, although more males were physically fit in every age group (The Information Centre, 2009).

Ethnicity
Physical activity levels tend to be lower in ethnic minority groups (except Black Caribbean/African and Irish), especially South Asians (The Information Centre, 2006). Only 11% of Bangladeshi and 14% of Pakistani women were reported to have achieved the recommended amounts of physical activity, compared with 25% in the general population (Department of Health, 2009).

Socioeconomic status
There is an association between household income and physical activity; more people are active in households with higher income.  The degree of association is stronger in women than men (The Information Centre, 2009).

People with a limiting long-standing illness and/or a disability are at particular risk from inactivity (Department of Health, 2009).

Physical activity has an important role to play in promoting mental health and well-being by preventing mental health problems and improving the quality of life of those experiencing mental health problems and illnesses. Physical activity can reduce the risk of depression, dementia and Alzheimer’s disease with evidence showing a 20-30% lower risk for depression and dementia for adults participating in daily physical activity. Furthermore, physical activity can enhance psychological well-being, by improving self-perception and self-esteem, mood and sleep quality, and by reducing levels of anxiety and fatigue (Department of Health, 2011).

Sedentary behaviour
The amount of time people spend in sedentary behaviours including domestically (for example use of remote controls, computers and other energy saving devices), as part of transport (motorised transport instead of walking/cycling) and for adults at the workplace is becoming increasingly a concern.  Evidence that suggests sedentary behaviour is independently associated with all-cause mortality, type 2 diabetes, some types of cancer and metabolic dysfunction in adults and children (Department of Health, 2011).

The latest UK physical activity guidelines emphasise that sedentary behaviour should be minimised.  Findings from the 2008 Health Survey for England (The Information Centre, 2009) suggests that:

• 32% of men and 33% of women were sedentary for six or more hours on weekdays, which increased to 44% and 39% respectively on weekends
• Average total sedentary time varied by body mass index level – men/women who were a healthy weight were less sedentary than obese men/women
• Sedentary behaviours in adults are affeccted by age, gender, socioeconomic conditions, occupation, weight status and some characteristics of the physical environment
• Only 41% of adults made walks of 20 minutes or more at least 3 times a week and only 14% of adults rode a bicycle at least once a week (Department for Transport, 2011).

Patterns of how people travel, including walking and cycling, are contained within the JSNA transport topic.

 

Physical activity behaviour is difficult to measure and many of the self-reported tools that are used are inaccurate whilst the cost and invasiveness of direct measures often precludes use of such methods.  Hence only limited data is available.

Behaviour and lifestyle
The Health Profile 2014 for Redcar & Cleveland shows smoking and obesity in adults are significantly worse than England.  Adult physical activity rates are also lower than England, but the difference is not statistically significant (PHE, 2014).  Binge drinking rates are significantly higher than England (LAPE, 2014).

None of the data discussed below compare physical activity levels of any of the population groups in the Redcar & Cleveland against current or previous Government guidelines, apart from the estimate of adult levels.  This is not measured locally but modelled from a national survey.

School sport
Schools in Redcar & Cleveland aspire to provide 2 hours of PE per week.  Due to current funding constraints only around 60% of schools are achieving this.   Primary schools receive a "top up" of funding (Sport Premium) and work with the School Sports Partnerships to deliver quality Physical Education outcomes but the lack of funding currently within school sport is a concern.  Data previously reported is no longer valid as schools are not required to complete data regarding PE.   Schools can apply for a School Games Mark to show commitment to school sport and in 2013/14 there were 17 schools in the borough who were successful in gaining this award (17 Primary schools, 5 secondary schools and 1 special school).

All schools in Redcar & Cleveland have committed to continuing to maintain their Healthy School Standards (which includes the promotion of physical activity as a key element) through an annual review process.

Walking and cycling to school

In Redcar & Cleveland, walking or cycling to school is more common than in England as a whole and the difference is greatest at secondary school.  Slightly fewer children use active travel for getting to secondary school compared to primary school.

Adult physical activity
The Active People Survey (APS) is the largest ever measurement of sport and recreation to be conducted in Europe. It started in 2005 and the latest results are from the eighth wave of the survey (APS8) ,which was conducted between April 2013 to April 2014.

The pure sports measure for Redcar & Cleveland, which relates to adult participation in three sessions of 30 minutes of moderate intensity sport a week (specifically at least 12 sessions in the previous 28 days), represents a significant increase since 2005/6 – the current figure is 27.9% of adults compared to a baseline of 20.5% in 2005/6.

There is however still a significant gap between male and female participation as measured by this indicator with 33.2% of males taking part compared to 23.1% of females.  Participation in sport and active recreation drops with age with 44.9% of 16 to 34 year olds taking part compared to 27.4% between ages 35 and 54.  This further drops to just 17.2% at ages 55 plus.

The APS also measures other key performance indicators (KPI) including:

KPI 1  Taking part on at least 3 days a week in moderate intensity sport and active recreation (at least 12 days in the last 4 weeks), for at least 30 minutes continuously in any one session. Participation includes recreational walking and cycling.

KPI 2  Volunteering to support sport for at least one hour a week.

KPI 3  Being a member of a club particularly so that you can participate in sport or recreational activity in the last 4 weeks.

KPI 4  Having received tuition from an instructor or coach to improve your performance in any sport or recreational activity in the last 12 months.

KPI 5  Having taken part in any organised competition in any sport or recreational activity in the last 12 months.

KPI 6  Percentage of adults who are fairly or very satisfied with sports provision in their local area.

Organised sport Percentage of adults who have done at least one of the following: received tuition in the last 12 months, taken part in organised competition in the last 12 months or been a member of a club to play sport.

The APS results for each of the national KPIs are covered in the table above.  At the start of APS 5 the volunteering question (KPI 2) was changed to incorporate a wider definition of sport volunteering and, therefore, comparisons with previous data are not possible.

The Local Sport Profile Tool (Sport England, 2014) has been developed to help local authorities in England to generate a sporting profile for their area in the form of charts and tables, bringing together data on sporting participation and provision.  It shows that, in Redcar & Cleveland, men are more likely than women to do 3 lots of 30 minutes active recreation (33.2% and 23.1%, respectively).

The Mosaic social segmentation tool enables analysis of Redcar & Cleveland’s population to identify sub-groups that are the least active.  Mosaic groups E, J, K and O make up over half of Redcar & Cleveland’s population.  Groups J, K and O have higher than average rates of physical inactivity with 61% of group O and 58% of group K participating in no physical activity in the last month.  Group E  has a rate of inactivity above 40%, despite being better than the England average.

Using Sport England Market Segmentation data the dominant groups in Redcar & Cleveland are “Elsie and Arnold”  “Philip” and “roger and Joy” reflecting the apparent older population with projected increases in age 65 Plus (Sport England Local Sport Profile Tool 2014).

Swimming and Cycling activity is strong in Redcar & Cleveland according to the Active People Survey data but other sport and activities within National and regional top 5 lists are less strong.

The number of adults (16+) who wish to take part in more sport shows 22.4% of inactive adults who wish to take part in more sport whilst 35.4% of active adults wish to take part in more sport and physical activity.

Use of leisure facilities
Leisure centres are one place where a wide range of activities can be provided for individuals and groups of all abilities and backgrounds, including swimming which in  a coastal town is vital for health as well as to prevent deaths by drowning.  There are five local authority owned leisure facilities in Redcar & Cleveland and from 2013 these were operated by Everyone Active (SLM) on a 20 year contract.  Key headlines for leisure facilities:

• Usage in leisure centres has never been higher.  Following recent investment there is an expected usage of over a million visits per year.
• Fitness Membership is currently at 7281 (as at end April 2014)
• Group fitness classes now attract over 10,000 users per month, possibly resulting from an increase in both the variety and number of classes as well as the introduction of virtual classes to suit working lifestyles of clients. Over 8000 children access swimming lessons across the contract and these are being boosted by free access to swimming lessons for children aged under 36 months.
• In 2013/14 there was an increase in leisure centre attendance of 12%
• Investment of £1.5m across all centres was undertaken in 2013/14 resulting in higher quality fitness facilities, front of house and changing rooms.
• The new Redcar & Cleveland Leisure and Community Heart (a £30m investment in leisure and civic facilities) opened in 2014.  In the first five months of opening the centre has attracted 168,000 visits.   The additional swimming facility has resolved issues over latent demand for swimming in the borough and swimming remains the most popular sporting activity in the borough with over 12% of the population taking part at least once per month (APS7).

Sport and active leisure

• Five public leisure centres all with swimming pools operated on behalf of the Council by Everyone Active.
• Private fitness facilities
• Annual Mass participation events such as the Redcar Half Marathon, Redcar Triathlon as well as a number of events facilitated by the voluntary sector.
• Schools, including PE in the curriculum, bikeability and after school provision
• A weekly parkrun regularly attracting over a hundred participants per week.
• Countryside and green spaces
• School holiday activities provided by Everyone Active
• Exercise on referral programme operated by Everyone Active.
• Early years provision in children centres
• Over 40 sports clubs in the borough who have Clubmark accreditation (Local Sport Profile Tool 2014)
• Sporting activities in colleges and universities
• Walking and leisure groups
• Active travel programme, including guided rides and walks, advice on cycling routes, bike maintenance and cycle loan schemes. Links with schools, colleges, universities and workplaces in addition to supporting general community.
• Cleveland Fire Brigade ‘Firefit’ programme, including football, rugby and cricket

Infrastructure

• Cycle and walk ways
• Parks, countryside and nature reserves
• Skate parks
• Play equipment
• Allotment

Services that include provision to support people to increase levels of physical activity

• Weight management services for children and adults
• NHS Tees Healthy Heart Check programme (delivered by GP practices and in rkplaces/community venues)
• Cleveland Fire Brigade Vulnerable Persons Pathway, signposting to other services
• The School Sports Partnerships within Redcar & Cleveland.

Adult participation in sport and active recreation
Adult participation in sport and active recreation (formerly National Indicator 8, NI-8) show a significant increase between the active people survey (APS) 1 in October 2005 and October 2006 compared with APS8 in April 2013 to April 2014.  Whilst the general trend is towards increasing participation there are still a high percentage of people not currently active once per week.

Population increases in Redcar & Cleveland are minimal with a 0.1% increase expected towards 2017.

There is a trend towards an increasing age profile in Redcar & Cleveland, in particular across the 65+ age group.  As this age group are typically the least active this may inhibit increases in sport and physical activity levels.

Declining participation in organised group sport and active leisure, could undermine the viability of clubs and leagues, leading to a further decline in opportunities and participation levels.

Activities currently taking place in school facilities or privately owned facilities may be reduced by removal of the opportunity, particularly arising from security and health and safety concerns.

Participation in active leisure in subsidised or commercial facilities, including pools and gyms, may be restricted by economic pressures and increased costs.

Reductions in subsidy to public transport may also increase barriers to participation for some forms of active leisure.

Increasingly inactive and increasingly overweight young people may feel excluded from traditional competitive or recreational group activities such as running, league football, tennis. There may be a lack of services aimed at beginners and people with low self-efficacy.

The increasing numbers of older people, as a proportion of the population, may require an increased number of activities designed to meet their tastes and lifestyles. These will represent an increased demand for subsidy at a time of declining resources.

Insufficient allotment provision and long waiting lists may prevent people taking part in this form of physical activity; the Council currently has 17 sites with 760 plots in total whilst some of the town and parish councils also have some provision. There are available plots in some areas, although these tend to be in the more deprived wards and have been subject to vandalism. Hence, there is a waiting list for plots in other more desirable areas with 746 people on the waiting list (January 2011).

Lack of awareness of the local environment and opportunities for active leisure may limit participation levels.

Evidence from the National Institute of Health and Clinical Excellence (NICE)
NICE has completed a number of evidence reviews around the effectiveness of various physical activity or associated lifestyle interventions. These include:

Four commonly used methods to increase physical activity PH2 (NICE 2006)
Physical activity and the environment PH8 (NICE, 2008a)
Promoting physical activity in the workplace PH13 (NICE 2008b)
Promoting physical activity for children and young people PH17 (NICE, 2009a
Behaviour change at population, community and individual levels  PH6 (NICE, 2007)
Cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease CG67  (NICE, 2008c)
Prevention of cardiovascular disease at population level  PH25 (NICE, 2010)

Reviews and meta-analyses of physical activity interventions

Public Health England (2014). Everybody Active, Every Day: An evidence-based approach to physical activity.  Actions include participating in more physical activity reaps greater benefits to individuals and consequently communities and local services. There is a three year difference in the life expectancy between minimally active and inactive people.

Department of Health (2011). Start Active, Stay Active: A Report on Physical Activity from the Four Home Countries’ Chief Medical Officers.

Interventions by age or population sub-group
Interventions delivered through the school setting are the most consistent, promising strategy whilst the effect of community or family based programmes remains unclear.  (Salmon, Booth, Phongsavan et al, 2007; Kriemler, Meyer, Martin et al, 2011; van Sluijs, Kriemler, & McMinn, 2011)

There is sufficient evidence to support the implementation of interventions designed to increase physical activity amongst adults and their cost effectiveness. (Foster, Hillsdon& Thorogood, 2005; Müller-Riemenschneider, Reinhold, Nocon & Willich, 2008 and 2009; Jepson, Harris, Platt & Tannahill, 2010)

Physical activity interventions can be effective with obese individuals. (Gourlan, Trouilloud. & Sarrazin, 2011)

Interventions by type
Community-wide promotional activities and improving infrastructure has the potential to increase cycling by modest amounts. (Yang, Sahlqvist, McMinn et al, 2010; Vuori, 2011)

Interventions to promote walking among targeted participants are effective along with interventions using a pedometer which have been shown to be effective both with young people and adults although the long-term sustainability of such impacts is unproven. (Ogilvie, Foster,  Rothnie et al, 2007; Lubans, Morgan & Tudor-Locke, 2009; Bravata, Smith-Spangler, Sundaram et al, 2007)

Improving the marking and physical environment of school playgrounds can increase the physical activity of school children. (Verstraete, Cardon, De Clercq & Bourdeaudhuij, 2006; Ridgers, Fairclough & Stratton, 2010)

The effectiveness of exercise referral schemes (ERS) has yet to be proven; a recent review shows very limited evidence as to the effectiveness of ERS for increasing activity, fitness or health indicators or whether they are an efficient use of resources in sedentary people without a medical diagnosis. A further analysis found that the cost effectiveness of ERS improves when ERS are targeted at individuals with existing conditions while an evaluation of the ERS on Teesside made a number of recommendations to improve the local programmes.  (Pavey, Taylor, Fox et al, 2011; Anoyke, Trueman, Green et al, 2011; Carlebach, Athey & Shucksmith, 2011)

Mass media campaigns targeting physical activity can have the effect of increasing awareness but evidence beyond this (including changing behaviour) remains unclear.  (Leavy, Bull, Rosenberg & Bauman, 2011)

Interventions targeting reduction in sedentary behaviour in children can have a small but positive impact; however, further research is needed to ascertain whether interventions targeted at adults are effective. (Biddle, O’Connell. & Braithwaite, 2011; Owen, Sugiyama, Eakin, et al, 2011)

One promising method of intervention is active video games, which “are capable of generating energy expenditure in youth to attain physical activity guidelines” (Barnett, Cerin & Baranowski, 2011, p. 724) although evidence is required on how to sustain the effect in the medium- and long-term.
 

As part of the Active People Survey (APS), respondents were asked about their satisfaction with sports provision – these results are summarised below.

Adult satisfaction with local sports provision as measured by the Active People Surveys, Tees, 2005/06 to 2009/10

In contrast, the National Benchmarking Service (NBS) reports undertaken in June 2010 in three leisure centres show above national average satisfaction rates at Loftus Leisure Centre, Saltburn Leisure Centre and Eston Sports Academy.  This was for a number of issues including activities available, cost, quality, cleanliness, helpfulness of staff and value for money. The difference in these results may be explained by the fact that the APS is a random telephone interview and many of these respondents may be non-users of the facilities whereas the NBS results are based on the responses of facility users (i.e. perception in the APS versus reality in the NBS).

NHS Stockton-on-Tees commissioned research to understand local young women’s views on physical activity, including mothers. The research revealed:

• In general, participants could explain what physical activity entails, however a few viewed it only as sport.
• Some participants suggested that physical activity was not a priority or does not play a role in their lives, others proposed participating for fun, too look nice and for health benefits.
• Mothers reported taking part in less mild, moderate and strenuous forms of physical activity, than the other three groups.
• The participants scored quite positively (all were above average values) on the beliefs and attitudes scale towards physical activity (enjoyment, perceived competence, self-efficacy, attitudes and social influence), with the exception of the Mums’ self-efficacy score.
• Participants were mostly aware of physical activity opportunities that included the gym and lifestyle activities.
• Main sources of physical activity information for participants were the gym, leisure centres and the internet.
• The most frequently cited barriers to physical activity were time and money.

The evaluation of the Stockton-on-Tees ‘Let’s Get Moving’ physical activity pathway pilot has shown interesting insights from the interim results, including:

• Most popular activities amongst sample of service users are unstructured activities that people can incorporate into their daily lifestyle, such as walking, cycling and swimming. These are followed by gym-based activities and then structured activities.
• Those service users who did not want to discuss increasing their physical activity levels or set goals for physical activity were mainly those who had mobility or health issues.

There are no measures of the physical activity levels (against Government recommendations) of specific populations within Redcar & Cleveland, namely:

• Children – both overall and in specific sub-groups (e.g. gender, ethnicity, socioeconomic groups, ward of residence)
• Older adults – both overall and in specific sub-groups (e.g. gender, ethnicity, socioeconomic groups, ward of residence)

Where possible, any future measurement of physical activity should use direct measurement methods instead of self-report.  Where self-report is used, validated measures that can be compared with other datasets should be used (e.g. against HSE results).