Pathways to policy: lessons learned in multisectoral collaboration for physical activity and built environment policy development from the Coalitions Linking Action and Science for Prevention (CLASP) initiative.

Politis, Christopher E. ; Mowat, David L. ; Keen, Deb 等

Coalitions Linking Action and Science for Prevention (CLASP) was an initiative of the Canadian Partnership Against Cancer (the Partnership) that aimed to reduce the risk of cancer and chronic disease in Canadians through the implementation of evidence-based program and policy interventions. Twelve projects were funded through CLASP in two phases: seven CLASP1 projects from 2009 to 2012, of which three were renewed for an additional two years, and five CLASP2 projects from 2013 to 2016. The projects addressed the spectrum of cancer and chronic disease risk factors in a variety of settings (e.g., municipalities, Indigenous communities, schools, workplaces, health care, etc.). CLASP brought together project coalitions that were multijurisdictional (partners from two or more provinces/territories) to scale up what had been demonstrated to work in one jurisdiction to others. (1) The coalitions were also multidisciplinary (research, practice and policy partners) to facilitate the uptake of evidence into practice and policy. (1)

The development of new policies and policy change was pursued as a key outcome across the CLASP projects as a crucial mechanism for sustaining a population-level impact beyond the funding period. Both laws and regulations enacted by governments (i.e., "big P policies") and organizational rules, practices and decisions (i.e., "little p policies"), (2) either newly developed or changed through CLASP, were considered policies impacted by CLASP. At the conclusion of the seven CLASP1 projects, 239 policies were tallied through the initiative's evaluation as newly created or changed through CLASP efforts (policies impacted by CLASP2 projects will be available at the conclusion of the CLASP initiative evaluation in December 2016). Of these, 163 pertained specifically to policies focused on creating healthier built environments and increasing physical activity and were the result of efforts from two CLASP1 projects: Children's Mobility, Health and Happiness (CMHH), led by Green Communities Canada, and Healthy Canada by Design (HCBD), led by the Heart and Stroke Foundation of Canada.

Physical inactivity is an important risk factor for chronic disease and cancer in particular. It is estimated that one third of cancers worldwide can be attributed to physical inactivity, diet and weight, and physical activity has been shown to reduce the risk of over a dozen cancers by 20% or more. (3,4) The built environment has been directly implicated in levels of leisure-time and utilitarian physical activity. Communities where built environments have elements such as greater density and transportation network connectivity have higher levels of physical activity. (5,6) The built environment has also been shown to impact health through effects on air quality, (7-9) injury prevention, (10,11) social connectivity, (12,13) and exposure to the natural environment. (14,15)

Population-based health interventions aimed at changing environments, such as land use and transportation policies, must be implemented in non-health sectors. (16) The successful development and implementation of policies outside of health therefore necessitates effective partnerships and collaboration across sectors. (16) These same policies also provide benefits beyond health--for environmental sustainability, climate change (17) costs of municipal infrastructure, (18) and economic development. These are issues which have involved urban planners and their allies in the "Smart Growth" movement for many years. New York City's many innovative healthy public policies under Mayor Bloomberg's term (2002-2013), including a trans-fat ban, point-of-sale calorie labelling, complete streets and cycle lane expansion, and supermarket construction incentives, among others, are all attributed in part to a commitment to collaboration across sectors. (19) While multisectoral collaboration to address health issues and catalyze policy development is increasingly understood, what makes a multisectoral partnership successful is less well defined. (20) To this end, it was important to understand the lessons learned--or "pathways to policy"--underlying the success of CMHH and HCBD's multisectoral efforts in developing and revising 163 policies to create supportive built environments for health and opportunities for physical activity. Box 1. Children's Mobility, Health and Happiness CLASP description Children's Mobility, Health and Happiness focused on increasing the number of children doing daily physical activity and on promoting healthy lifestyles by changing the way elementary schoolchildren travel to school through School Travel Planning (sTp). STP is an established model that promotes the use of active transportation. CMHH encouraged the creation of policies and practices that went beyond using school buses as transportation by engaging local practice and policy partners to develop and implement travel plans that created conditions that make it safe for families to use active transportation to and from school. Partners: municipalities (planning, transportation, and enforcement departments); schools (principals, teachers, parents and students); regional health authorities/public health units; national/provincial/territorial NGOs (focused on health and environmental issues); and academic institutions. Box 2. Healthy Canada by Design CLASP description Healthy Canada by Design aimed to accelerate the integration of health considerations into community planning policy and practice. Through a "practice collaborative" approach and national framework, health regions engaged with local planners to put a health lens on community planning and ensure that the physical layout of Canadian communities encouraged activity and healthy living. An array of strategies, from team-based activities to peer exchange and technical assistance, supported the uptake of best practices and tools as health regions, planners and other stakeholders focused on community engagement, the enhancement of data translation systems, and the application of innovative, health-promoting community designs. Partners: municipalities (planning, transportation, and health departments); regional health authorities/public health units; national professional associations (planners and transportation engineers); national NGOs (focused on health issues); and academic institutions. (21) Box 3. Making the case for multisectoral collaboration as integral to policy change for healthier built environments At their core, both CLASPs brought local public health together with municipal planners and transportation engineers to bring physical activity-promoting elements into community design. In documenting HCBD's successes, one public health CLASP member reported: "We have been told by municipal staff that there are many built environment policies that [public health] was instrumental in supporting: if [we] had not been a strong supporter of policies for connected neighbourhood centres and active transportation, it is quite possible that these policies would have been diluted in the Plan. " (22)

SETTING

Two CLASP1 projects, CMHH (Box 1) and HCBD (Box 2), focused on increasing the number of Canadians who are physically active wholly, or in large part, through the creation of supportive built environments. CMHH was implemented in 128 schools and 48 municipalities/communities across all 10 provinces and 3 territories. HCBD was implemented in 32 municipalities across 8 provinces.

While all CLASP projects were multidisciplinary, CMHH and HCBD were distinct in their multisectoral approaches (Box 3).

A wide variety of other cross-sector groups, such as school administrators, law enforcement, community advocates, academics and others, were also engaged to facilitate the development, adoption and implementation of policies for supportive built environments and physical activity.

INTERVENTION

Definitions were established for "policy change" and "practice change". The CLASP knowledge product database was reviewed for policy relevance and supplemented by the Partnership's Prevention Policies Directory, and from these, 163 CLASP-impacted physical activity and built environment policies were identified, categorized according to five dimensions and further grouped as policy instruments (Table 1). Each dimension, adapted from the US Task Force on Community Preventive Services' Guide to Community Preventive Services, (23) describes specific areas where policy can change environments to be more supportive of physical activity--from large geographical, community-scale changes to smaller individual street, block or building-scale changes to policies focused specifically on enhancing transportation networks or providing places to be physically active. (24) Within each dimension, policy instrument refers to the types of policies that influence the built environment and physical activity opportunities. (25,26)

The majority of the policies influenced by the projects occurred at the school level as School Travel Plans (STP) under the Transportation and Travel category. Six examples of provincial policies, all higher-level strategy and framework documents designed to influence lower-tier municipal policy in the area of regional/city design or larger-scale transportation network design, were implemented by the CLASPs. The remaining policy instruments were developed and implemented at the municipal level. These municipal policy instruments spanned all five dimensions.

The identification of the pathways to policy was a two-step analysis. The first step was a review and qualitative analysis of 183 knowledge products produced by CMHH and HCBD, including peer-reviewed publications, grey literature and evaluation documents, to identify new or changed policies (where there was evidence that they were at least in part influenced by CLASP) and the related key lessons learned. Due to the lengthy policy process, some policies influenced by CMHH and HCBD were not adopted by the end of the projects. The findings were reviewed to find common themes in terms of processes and enabling factors.

In the second step, eight key informant interviews were conducted with former members of both projects, including health department staff (HCBD and CMHH), municipal planners (HCBD), and municipal transportation demand management staff (CMHH) who were closely involved with the project implementation and evaluation. The key informants were asked to verify and provide additional context to the preliminary lessons learned and expand on areas that were lacking depth. The feedback from the key informants was used to finalize the lessons learned into the pathways to policy--a list of critical success factors fundamental to the successful development and implementation of the CLASP-impacted physical activity and built environment policies.

Following the identification of the 163 CLASP-impacted policies, a thorough review and qualitative analysis of the CLASP knowledge products was conducted to understand the lessons learned underlying policy development and implementation from the CLASP experience. A total of 14 pathways to policy--critical success factors for physical activity and built environment policy development and implementation--were identified.

OUTCOMES

The pathways to policy were grouped into three broad themes: 1) People, 2) Tools, and 3) Approaches and Ways of Working (Table 2). Four pathways within the "People" theme highlight the importance of the knowledge, skill sets and experiences that individuals bring to the policy process and how best to create opportunities for sharing the expertise of individuals across sectors. Two pathways under the "Tools" theme describe the role of evidence and resources in influencing policy work. The third theme "Approaches and Ways of Working" captures the final eight pathways that collectively describe strategies for research, practice and policy specialists to accelerate policy development and implementation.

From the CLASP experience, it was observed that many of the pathways blended together in practice, even across themes, and often several were observed working in tandem. It was also noted in the literature and key informant interviews that not all pathways were in play on every policy newly developed or changed. This accurately reflects the complexity and nonlinear nature of the policy process. (27)

Furthermore, through analysis of the lessons learned, the importance of multisectoral collaboration to successful policy development and implementation was reinforced by its prominence in 8 of the 14 pathways. The 8 pathways highlight civil servants in municipal planning and transportation departments, local and regional health units, and schools as key policy actors. They describe how relationships among staff members form the foundation of effective collaboration that facilitates policy development and implementation and the ways in which those relationships are best supported. The findings are described here.

Relationships

Key informants described interpersonal relationships as the most important factor in working across sectors, and in fact, the majority of the CLASP-impacted policies have some attribution--either in the literature or in key informant feedback--to a strong foundational relationship playing a key role. In the case of HCBD, informal and personal relationships were formed between local/ regional public health staff and municipal planners and engineers and were recognized as more effective for collaborating across sectors than the previous practice of health staff providing written comments on documents for their planning counterparts. Personal relationships between staff in different sectors working on the same policy issues built trust and a sense of reliability between partners, and fostered a greater commitment to continuing to work together. When working with individuals from other sectors to advance policy work, "knowing who to call" allowed for easier access to expertise from different sectors and for work to progress more effectively. The mechanisms for building strong interpersonal relationships are outlined through the Positive, Open Engagement Strategies and Collaborative Approaches and Partnerships pathways.

Staffing

Creating new staff positions or reallocating existing staff was a pathway used to support cross-sectoral policy work across both CMHH and HCBD. This often took the form of creating a coordinator role to manage the multisectoral partnerships and coordinate work between partners and assigning it to a new or existing staff resource--full or part time. Staffing was considered important, not just for the additional human resources to get the work done, but also because it signaled an organizational commitment to the work and partnerships: "... if anyone asks me what makes STP successful, I say the facilitator. Without the facilitator, it's volunteer led, and we know that it usually falters and fizzles out. The facilitator is key to success. " (28) Other staffing mechanisms included a department exchange of local/regional public health staff with the municipal urban planners for a period of time. This was important symbolically as a signal of collaboration, and also helped to bridge the culture gap that existed between the two sectors.

Expertise and technical assistance

One benefit of working in partnership across sectors is access to diverse perspectives and skill sets that can be brought to bear on developing solutions through policy. Access to multisectoral expertise was facilitated by inserting experts from outside fields into new venues where they could share their knowledge, build capacity of those they were working with and strengthen the approach to integrating health into built environment policies. For instance, in some HCBD municipalities, local public health staff were invited to participate on the planning departments' technical advisory committees in reviewing land use policies and provide expert commentary and evidence to ensure policy decisions included health considerations. Another example from HCBD included three regional health authorities accessing an experienced urban planner over the course of 1500 hours in a two-year period to directly work with staff. The result was an increase in expertise in working with local government on land use and transportation planning and a greater understanding of their municipal partners' needs. (29)

Tools and resources

The creation, enhancement and sharing of tools or resources was another mechanism employed by the CLASPs to support the sharing of knowledge between sectors for the development and implementation of physical activity and built environment policies. The tools and resources were predictable, consistent, objective, transparent and defensible in contrast to "professional opinion". Some examples of tools and resources that bridged the sector gap included: model policies/templates, health impact assessments, and modeling software. In the latter case, land use and transportation system characteristics were linked with health and travel behaviour data from the Canadian Community Health Survey and the Transportation Tomorrow Survey, which allowed the software to predict how proposed changes to a community could increase physical activity. (30) This tool integrated a health and physical activity lens directly into the municipal planning process. The development and acceptance of such tools required cross-sectoral technical assistance to reach their full impact and represented an opportunity to sustain cross-sector knowledge sharing. Box 4. Public health playing a support role to municipal planning colleagues to move policy forward Public health staff in one jurisdiction learned early on that what they thought they would bring to partnership was not what their planning counterparts needed: "We were surprised by the very clear message that came from the planners that day: they all understood the benefits of healthy built environments ... and didn't need more education on it. What they needed was support from health authorities in developing and implementing policy. " (22)

Evidence and data

Evidence and data, as one would expect, emerged as playing a role in influencing policy decisions. Key informants noted that evidence can take many forms, such as briefs, literature reviews, case examples, pilot project evaluations, summaries of best and emerging practices, etc., and different groups preferred and were influenced to greater degrees by some forms over others. For example, public health partners may value systematic reviews and peer-reviewed evidence more than a transportation engineer who favoured traffic count data, or a city councillor who saw public opinion in a neighbouring jurisdiction with a similar policy as significant "data".

Positive, open engagement strategies

Approaching multisectoral partnerships with respect, openness and flexibility were seen as the key to productive relationships and ultimately policy success. This was best characterized in practice by partners engaging to understand the goals and needs of each party, and identifying what each partner can bring to the table.

Participation by health staff was felt to be more effective in situations where they supported their urban planner counterparts, rather than bringing their own agenda (Box 4). Likewise, where planning and engineering partners were being supported in policy development and implementation, it was important for public health staff to feel accepted in the planning processes and to have a clear understanding of how their input was being valued and utilized.

Collaborative approaches and partnerships

This pathway names multisectoral collaboration between key civil servants as a critical success factor. Effective collaborative partnerships arose when multisectoral partners had taken the time to find common ground and identify shared objectives. Key informants suggested that formal structures could be created to facilitate multisectoral collaboration (e.g., committees, working groups, etc.) and that the structures should be broad and inclusive to promote buy-in spreading through the constituent partner organizations and not have the work centred on a small number of individuals.

Creative collaborative approaches also included leveraging the status of partners from other sectors to influence stakeholders and decision-makers. For instance, planners in one jurisdiction felt that the Medical Officer of Health was respected by city council and better positioned to bring forward a proposed policy. In another jurisdiction, planners asked their public health partners to facilitate a public consultation because residents perceived them as unbiased.

Issue framing

Drawing on multisector expertise and perspectives was described as a way to position policy issues in a more attractive way to gather support from decision-makers and stakeholders. In HCBD, this often meant public health staff supporting built environment policy from an environmental sustainability perspective, or bringing forward data demonstrating the economic benefits of a policy to the municipality.

CMHH utilized student physical activity data to build the STP case. However, the project also leveraged greenhouse gas emission and traffic congestion reduction data to influence municipal decision-makers, and safety concerns about the danger of busy school drop-off and pick-up zones to gather support from parent groups. (31) How an issue was framed was viewed as secondary when the outcome was the same: increased physical activity through the development of policies creating supportive built environments.

IMPLICATIONS

The 14 CLASP pathways to policy represent demonstrated critical success factors for the development and implementation of policies for a healthy built environment through cross-sectoral action. Beyond illustrating the role of people, tools, and ways of working in policy, the pathways to policy describe the successful elements of multisectoral partnerships. The pathways to policy are intended to be practical and actionable. The context of this paper is mainly land-use and transportation policy, for the most part in large urban and suburban areas. Although further work involving a broader range of issues and smaller town and rural settings would be valuable, it is likely that the pathways to policy are similar. It is hoped that the lessons learned from the CLASP experience will inform and accelerate future healthy public policy work in Canada and internationally. The learnings from the diverse projects funded through the CLASP initiative will continue to be analyzed so that proven approaches to cancer and chronic disease prevention in other risk factor areas and settings, such as food environment policy and Indigenous health and wellness, can be synthesized and mobilized with the broader prevention community.

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Received: June 28, 2016

Accepted: February 5, 2017

Christopher E. Politis, MPH, [1] David L. Mowat, MBChB, MPH, FRCPC, [2] Deb Keen, MPA [3]

Author Affiliations

[1.] Program Manager, Prevention, Canadian Partnership Against Cancer, Toronto, ON

[2.] Senior Scientific Lead, Population Health, Canadian Partnership Against Cancer, Toronto, ON

[3.] Director, Prevention and Research, Canadian Partnership Against Cancer, Toronto, ON

Correspondence: Christopher E. Politis, Canadian Partnership Against Cancer, 1 University Avenue, Suite 300, Toronto, ON M5J 2P1, Tel: 416-619-5567, E-mail: christopher.politis@partnershipagainstcancer.ca

Conflict of Interest: None to declare. Table 1. CLASP-impacted physical activity and built environment policies categorized according to five dimensions Policy dimension Policy instrument Number of CLASP- impacted policies I. Community-scale Official community plan 15 urban design and land use policies Change the physical Budget and resource allocations 5 environment of large Regional growth 4 geographic areas in strategy/regional plan ways that support Policy statement/framework * 3 physical activity and include design elements that address: * proximity of Zoning bylaw 2 residential areas to stores, jobs, schools, and recreation areas * continuity and Design guidelines for 2 connectivity of drive-through sidewalks and streets * aesthetic and facilities safety aspects of the Sustainability strategy 2 physical environment City centre plan 1 Community design standards for 1 suburban developments II. Street-scale Block plan 2 urban design and land use policies Change the physical Secondary plan 1 environment of small Road site plan 1 geographic areas, Street urban design plan 1 generally limited to a few blocks, in ways that support physical activity and include design elements that address: * improved street lighting * infrastructure projects to increase safety of street crossing * use of traffic calming approaches (e.g., speed humps, traffic circles) * enhanced street landscaping III. Building and Public facility design 1 public facility guidelines design policies Change the physical Municipal RFP evaluation 1 environment around criteria and within buildings and public facilities in ways that support physical activity and include design elements that address: * improved access to stairwells * secure, on-site bicycle parking facilities * on-site showers and change rooms * enhanced connectivity of buildings to public transit and green space IV. Transportation School travel plans ([dagger]) 98 and travel policies Transportation plan 7 Encourage walking and Budget and resource allocations 4 bicycling as a means of transportation by: * facilitating Provincial strategy/framework * 3 walking, bicycling, and public transportation use * increasing the Walking and/or cycling plan 2 safety of walking and bicycling * reducing car use Sustainability strategy 1 * improving air Zoning bylaw 1 quality Complete streets policy 1 Public transit plan 1 Official community plan 1 V. Enhanced access to Parks plan 1 places for recreational physical activity policies Change the local Playground design guidelines 1 environment to create opportunities for leisure-time physical activity through design elements and policies that address: * access to green space * access to existing recreational facilities through shared use agreements Total CLASP-impacted 163 policies * Provincial/territorial policies. ([dagger]) School policies. Table 2. Physical activity and built environment pathways to policy identified as critical success factors from the CLASP experience Theme Pathway to policy Description I. People Relationships Developing interpersonal relationships across sectors Staffing Creating new staff positions or new allocations of staff roles Expertise and technical Placing expertise from one assistance sector within another Engaging influential Engaging and supporting decision-makers decision-makers as champions II. Tools Tools and resources Creating, enhancing and/or sharing tools and resources Evidence and/or data Sharing evidence and data for evidence-based policy decisions III. Positive, open engagement Engaging with other Approaches strategies sectors from an open, and ways honest, flexible and of working Collaborative approaches supportive position and partnerships Supporting multisectoral collaboration through formalized partnerships and collaborative structures Issue framing Framing policy issues differently depending on target audience Learning from other Observing the experience jurisdictions of other jurisdictions to understand local impact Implementing regulatory Changing professional and approaches organizational practices to institutionalize new ways of approaching policy development Adaptation to local Understanding local context context through community engagement Demonstration projects Implementing a pilot project to demonstrate feasibility and impact Working with early Assessing readiness and adopters engaging where there is capacity and enthusiasm Theme Pathway to policy Multisectoral collaboration I. People Relationships X Staffing X Expertise and technical X assistance Engaging influential -- decision-makers II. Tools Tools and resources X Evidence and/or data X III. Positive, open engagement X Approaches strategies and ways of working Collaborative approaches X and partnerships Issue framing X Learning from other -- jurisdictions Implementing regulatory -- approaches Adaptation to local -- context Demonstration projects -- Working with early -- adopters