WITHDRAWN: (Un)Healthy Lifestyles, Environment, Well-being and Health Capability in Rural Neighbourhoods: A Community-based Cross-sectional Study
Authors: Azul Anabela Marisa , Almendra Ricardo , Quatorze Marta , Loureiro Adriana , Reis Flávio , Tavares Rui , Mota-Pinto Anabela , Cunha António , Rama Luís , Malva João Oliveira , Santana Paula , Ramalho-Santos João 
Published: November 2020

Abstract
Background: Non-communicable diseases (NCDs) are a leading cause of health loss worldwide, in part due to unhealthy lifestyles. Metabolic-based diseases are rising with an unhealthy body-mass index (BMI) in rural areas as the main risk factor in adults. Health loss risks in rural areas may be amplified by wider determinants such as socio-demography and surrounding environments. We assessed weather (un)healthy lifestyles and environment in rural neighbourhoods are reflected into metabolic risks and health capability, and how community circumstances may impact the self-ability for making balanced decisions.Methods: We conducted a community-based cross-sectional study in fifteen Portuguese rural neighbourhoods (with high ageing index and high illiteracy) to describe individuals’ health functioning condition and to characterize the community environment. We followed a qualitatively driven mixed-method design, using a healthy lifestyle assessment toolkit, to gather evidence-based data and lifestyles (incorporated in eVida technology), within a random sample of 270 individuals; and 107 in-depth interviews to determine whether environment influence the capability for improving or pursuing heath and well-being.Results: Men showed to have a 75% higher probability of being overweight than women (p-value=0.0954); and the reporting of health loss risks was higher in women (RR: 1.48; p-value=0.122), individuals with larger waist circumference (RR: 2.21; IC: 1.19; 4.27), overweight and obesity (RR: 1.38; p-value=0.293) and participants aged over 75 years (RR: 1.78; p-value= 0.235; when compared with participants under 40 years old). Metabolic risks were more associated to BMI and physical activity than diet (or sleeping habits); participants strongly evidenced the adherence to a Mediterranean dietary pattern. From the interviews, we identified seven environmental circumstances reflecting health needs, health expectations and health capability: economic development, built environment, social network, health care, demography, active lifestyles, and mobility. And, while the starting point of the interview addressed community needs, participants expressed the value of natural environment in their neighbourhood as the main positive effect to pursuing health and well-being, with particular emphasis to lower exposure to air / noise pollution, daily routines linked to nature or land use, and diversity of nature experiences.Conclusions: Our qualitatively driven mixed-method design, involving the community, uncovers environment contextual-dependent circumstances influencing the ability of individuals to pursue healthy habits. The active participation of local representatives, with its degrees of negotiation and flexibility, contributed to adapt the health-related messages. The co-benefits from this co-designing community program advance the evidence to support academy-community driven interventions for pushing health and well-being at a broader social, health care and (natural) environment agenda in rural neighbourhoods.