R ES E A R C H A R T I C L E Open Access
Identifying mechanisms for facilitating
knowledge to action strategies targeting
the built environment
Ghazal S. Fazli
1,4*
, Maria I. Creatore
1
, Flora I. Matheson
1,2,5
, Sara Guilcher
1,3,5
, Vered Kaufman-Shriqui
1,6
,
Heather Manson
2,7
, Ashley Johns
1
and Gillian L. Booth
1,4,5
Abstract
Background: In recent years, obesity-related diseases have been on the rise globally resulting in major challenges
for health systems and society as a whole. Emerging research in population health suggests that interventions
targeting the built environment may help reduce the burden of obesity and type 2 diabetes. However, translation
of the evidence on the buil t environment into effective policy and planning changes requires engagement and
collaboration between multiple sectors and government agencies for designing neighborhoods that are more
conducive to healthy and active living. In this study, we identified knowledge gaps and other barriers to evidence-
based decision-making and policy development related to the built environment; as well as the infrastructure,
processes, and mechanisms needed to drive policy changes in this area.
Methods: We conducted a qualitative thematic analysis of data collected through consultations with a broad
group of stakeholders (N = 42) from Southern Ontario, Canada, within various sectors (public health, urban planning,
and transportation) and levels of government (federal, provincial, and municipalities). Relevant themes were
classified based on the specific phase of the knowledge-to-action cycle (research, translation, and implementation)
in which they were most closely aligned.
Results: We identified 5 themes including: 1) the need for policy-informed and actionable research (e.g. health
economic analyses and policy evaluations); 2) impactful messaging that targets all relevant sectors to create the
political will necessary to drive policy change; 3) common measures and tools to increase capacity for monitoring
and surveillance of built environment changes; (4) intersectoral collaboration and alignment within and between
levels of government to enable collective actions and provide mechanisms for sharing of resources and expertise,
(5) aligning public and private sector priorities to generate public demand and support for community action; and,
(6) solution-focused implementation of research that will be tailored to meet the needs of policymakers and
planners. Additional research priorities and key policy and planning actions were also noted.
Conclusion: Our research highlights the necessity of involving stakeholders in identifying inter-sectoral solutions to
develop and translate actionable research on the built environment into effective policy and planning initiatives.
Keywords: Built environment, Population health, Urban health, Planning, Transportation, Stakeholder engagement,
Knowledge to action, Chronic diseases
* Correspondence: fazlig@smh.ca
1
Centre for Urban Health Solutions, The Keenan Research Centre, Li Ka Shing
Knowledge Institute, St. Michael’s Hospital, 209 Victoria Street, M5B 1T8
Toronto, ON, Canada
4
Institute of Health Policy, Management and Evaluation, University of
Toronto, Toronto, ON, Canada
Full list of author information is available at the end of the article
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Fazli et al. BMC Public Health (2017) 17:1
DOI 10.1186/s12889-016-3954-4
Background
Over the last few decades, obesity rates have reached
epidemic proportions globally, becoming one of the
most pressing public health challenges of our time.
Obesity is a major risk factor for type 2 diabetes, heart
disease, cancer, and premature mortality [1, 2]. The
economic impact of obesity is substantial, costing the
Canadian economy $4.6 billion in 2008 [3]. Indirect
costs are likely to be equally high due to development of
chronic diseases, disability and premature loss of life [3].
While public health experts emphasize the need to
decrease risk factors for obesity at a population level,
rates of physical inactivity and unhealthy eating remain
high in Canada [2].
In response to this public health challenge, poli cy-
makers and public health professionals have been
searching for broad, policy-based solutions to help curb
the rise in obesity [4, 5]. The notion that communities
can be designed to promote healthy active living is an
option that is gaining momentum [6–9]. A growing
number of studies suggest that residents living in sprawl-
ing, car-dependent communities engage in far less walk-
ing or other forms of active transportation, and spend
more time in cars compared to those living in older,
more compact neighborhoods [7–17]. Furthermore,
living in suburban neighborhoods is associated with
higher rates of overweight and obesity, and a greater
likelihood of developing diabetes [12, 18–21]. There-
fore, inter ventions that support changes to the built
environment through public policies and planning
initiatives may help stimulate healthy lifestyle choices
by providing opportunities for walking , cycling and
other physical activities [22].
Despite the growin g body of literature linking the built
environment to health, little evidence has been trans-
lated to policy and planning actions [23, 24]. Designing
or re-designing communities to optimize health is chal-
lenging as it requires collective, coordinated efforts of
policymakers and planners across a range of sectors and
organizations ( i.e. publi c health, planning, transporta-
tion, economic development organizations, etc.) [4].
Thus, establishing efficient processes and mechanisms
to promote cross-sectoral stakeholder engagement and
collaboration will b e needed to effe ctively implement
such complex solutions.
The overarching goal of this work was to explore how
evidence on the built environment could be translated
into policy and planning actions to support healthy com-
munity design. More specifically, our objectives were to
identify: (1) the infrastructure, processes, mechanisms
and actions needed to drive such changes; and (2)
current knowledge and information gaps and othe r bar-
riers that impede policy and planning decisions related
to the built environment.
Methods
Study design and setting
To address these objectives, we engaged key stake-
holders who have an interest in built environment pol-
icies. This research focused on Southern Ontario, one
of the largest and fastest growing regions in North
America with a population of 8.76 million people in
2011, living primarily in urban centres [25]. The region
is expected to grow an additional 3.7 million by 2031
and there has been a call for action to create more
compact and complete communities to support healthy
and active living [26].
Participants
We recruited participants, including policymakers and
planners, from a variety of sectors (public health, urban
planning, and transportation) and levels of government
(federal, provincial, and municipal). We used a purposive
sampling strategy, [27] wherein public health representa-
tives from major metropolitan areas in Southern Ontario
(i.e. Toronto, Peel, Durham, York, Halton, Hamilton,
London and Ottawa) who were known to the research
team were asked to identify potential participants from
regional planning and transportation departments (in
each metropolitan area) with whom they were working.
We also identified key representatives from different
Ministries within the Ontario government, non-profit
professional organizations, and peer-review granting
agencies – to broaden the spectrum of stakeholders that
could provide insight on both existing and upcoming
policies as well as research funding initiatives related
to the build environment. These stakeholders were in-
vited to participate in a full-day stakeholder engag e-
ment meeting. Our recruitment strategy resulted in a
diverse sample of participants (N = 42) from government
and non-government agencies such as planning (n =12),
transportation (n = 10) and public health (n =20).
Data collection
Participants attended a full-day stakeholder engagement
meeting in October 2013. Prior to the meeting, we sent
participants an open-ended survey questionnaire to
gather information on existing research priorities and
initiatives in their regions to determine their level of
engagement and readiness to support actions relate d to
the built environment. Results from the pre-meeting
survey formed the basis for discussions with stake-
holders during the engag ement meeting. During the day,
we held facilitated small group discussions. The partici-
pants were asked to identify solutions across different
sectors to transform evidence on the built environment
into policy and planning initiatives, a s well as research
priorities and key actions that might be needed to
achieve these goals. Specifically, we asked participants to
Fazli et al. BMC Public Health (2017) 17:1 Page 2 of 9
identify: a) information and tools needed to advance
healthy built environment initiatives in their local re-
gions; b) knowledge transfer activities that would enable
research findings to have a meaningful impact on policy
and planning changes; and c) implementation strategies
to help move this knowledge from evidence to action.
To facilita te discussion, participants were grouped ini-
tially by sector (e.g. planning, public health, and trans-
portation) and subsequently by region. Two note-takers
were assigned to transcribe participant discussions using
laptops, and these data were later compiled and analyzed
using qualitative thematic analysis, as described below.
Qualitative thematic analys is
Data from stakeholder consultations were analyzed
through qualitative thematic analysis by adopting an in-
ductive approach that would allow for themes to emerge
from the transcripts without any preconceived topics or
directions [27]. Transcripts were first reviewed inde-
pendently by two members of the research team (GF
and MC) to generate an initial list of themes. Three add-
itional researchers (SG, VKS, GB) then independently
analyzed the same transcripts from the stakeholder en-
gagement meeting to confirm the initial list of themes
and to identify any additional themes. The final list of
themes were discussed among team members and
assessed for saturation of ideas as related to the research
objective s. In addition, two members (SG, VKS) of the
research team independently re-analyzed the data to
identify research priorities and key next steps to address
the challenges and opportunities for translating evidence
on the built environment into policy and planning deci-
sions. Overall, there was little disagreement in the final
list of themes, research priorities and ne xt steps; any
discrepancies were discussed among all team members
to achieve consensus.
A post-event survey was conducted via email to gain
feedback from participants on the importance of each
theme identified in the qualitative thematic analysis
process, by rating it on a scale of 1 (not important at all)
to 5 (very important). We asked participants to align
each theme with potential policies or strategies that
would positively enhance the built environment in
Southern Ontario. On average, all the themes were rated
as important or very important. Using a likert scale, par-
ticipants also ranked each research priority and know-
ledge gap and key policy and planning action on the
built environment. We calculated the average ranking of
each research priority/ knowledge gap and key policy
and planning action item. The rankings were divided
into top and lower priorities.
To aid in the interpretation and discussion of results,
we used an adapted version of the Knowledge to Action
(K2A) framework created by the Centre for Dis ease
Control and Prevention (CDC) [28], to cla ssify themes
to one of the three pha ses (research, translation, and
implementation) required to develop and translate ac-
tionable research into effective policies targeting the
built environment [28].
Results
Overarching themes
The analysis revealed five themes on knowledge gaps,
barriers and challenges in translating evidence on the
built environment and health into policy and planning
decisions, and implementation strategies needed to do
so. A detailed description of each theme is provided
below and shown in Table 1, where the CDC K2A
framework is cross-referenced to reflect the alignment
between each identified theme and the K2A cycle [28].
Policy informed and actionable research
The need for policy-informed and actionable research
was a recurrent theme among participant s across various
sectors and levels of government. Stakeholders identified
four research priorities: 1) understanding the collective
benefits of built environment changes on the health and
wellbeing of the populatio n; 2) identifying threshold ef-
fect s of built environment attributes and their health im-
pact on different populations (“what works, for whom,
and in what context”); 3) assessing the health economic
impact (costs and benefits) of competing policy options;
and 4) evalua ting the impact of natural policy experi-
ments targeting the built environment. Research evi-
dence that considers these approaches is needed in
order to build a business case for changes in policies tar-
geting the built environment. As several participants
pointed out, we “maybe need to create a business case
for [the] physical environment”, “built environment
changes must work in the context of economics…health
priorities are understood, but we need to compare costs
and benefits of changes to the built environment”. As fur-
ther noted “economics is an issue because the payoff is
very long-term for built environment changes”; however
“if there is evidence of an impact on health it may pro-
vide evidence for the true need of action even if it costs
more”.
Targeted and impactful messaging
Participants identified effective and timely communica-
tion of research findings to policymakers, planners, and
the public as an important step to guide the adoption of
evidence on the built environment into policy and prac-
tice. For research to have the greatest impact , it needs to
be accompanied by tailored, impactful, and solution-
oriented messages that reach all target populations and
sectors. In other words, messaging needs to increase
awareness and engender buy-in from politicians and the
Fazli et al. BMC Public Health (2017) 17:1 Page 3 of 9
public-at-large as reflected in this quote from a partici-
pant, “Helpful to have a ‘simple sell’–a simple and clear
message from the research”; although many cautioned
that messages need to be “tailor ed to different knowledge
users, including the public, policymakers, media, plan-
ners , and engineers”. Participants suggested engaging in
“public consultation” to promote awareness, “prompt
grass roots movements”; and to provide an avenue for
which public input can then be fed back to inform pol-
icies and research. Politicians were noted to be a key tar-
get for knowledge translation efforts to champion active
transportation as a major issue. This is a vital step for
creating the political will to develop policies and plan-
ning initiatives to promote healthy community designs.
Common measures and tools
Participants unanimously identified a lack of user-
friendly and available data for municipal public health
and planning departments, and other agencies as a
common challenge. While studies evaluating the built
environment have grown rapidly over the past de c ade
[10, 11, 19–24], gaps in data acquisition and consistent
methods for measuring built environment characteristics
have hampered the adoption of evidence into planning
and practice. Participants suggested “better co-ordination,
alignment, and standardization of built environment
metrics and performance measures” that could be “easily
adopted by policymakers and planners”; and greater access
to low cost or publicly available data sources (including
“open access data”) that would increase the capacity for
ongoing surveillance work, allowing for comparisons over
time and across regions. There was a desire too for more
“granular”, “localized data” to contextualize “local needs”
in order to “tailor changes to individual municipalities“,
rather than taking a “one-size-fits-all approach” towards
how evidence of the built environment is implemented
into policy.
Inter-sectoral collaboration and alignment within and
between levels of gover nment
The need for collective actions was emphasized by all
participants regardless of their sector. As noted by one
participant, “(We) need more collaboration between silos…
and some setup/communication infrastructure that allows
sectors and governments to talk to each other”.Further-
more, there needs to be “horizontal accountability –
Table 1 Themes from stakeholder consultations on infrastructure, processes, and mechanisms that will facilitate positive
modifications to the built environment
Themes Knowledge to Action Cycle
Policy informed and actionable research
• Health economic evaluations for estimating costs, benefits and impacts
• Evaluation of natural policy experiments locally and abroad
• Examine effects among priority populations (what works for whom and under what context)
Knowledge Generation
Targeted and Impactful Messaging
• Build multimedia strategy to communicate evidence across sectors
• Tailor the message for different audiences (politicians vs. public)
• Powerful messaging through infographics, maps, fact sheet
Knowledge Translation
Common Measures and Tools
• Make user-friendly data on the built environment available for policymakers and planners Knowledge Generation
• Improve co-ordination & alignment of methods for measuring the built environment Knowledge Translation
• Develop and implement standardized metrics and performance measures to enhance
capacity for ongoing monitoring, reporting, and surveillance
Implementation
Intersectoral collaboration and alignment within and between levels of Government
• Align agendas and find common goals
• Identify political “Champions”
• Seek financial support for cross-sectoral interventions and evaluations
• Develop mechanisms for cross-sectoral performance measurement (benefits and impacts)
Implementation
Importance of Public and Private Sector Advocacy
• Seek support from NGOs and private industries
• Identify community ‘Champions’ and ‘Brokers’
• Roll out social marketing campaigns
• Develop mechanisms to coordinate advocacy efforts of different groups
Implementation
Solution-focused implementation
• Account for political context in all activities (identify important policy milestones and
“critical windows” for policy change
• Support local initiatives through provincial legislation
• Create tools to evaluate interventions for effectiveness & impact
Implementation
Fazli et al. BMC Public Health (2017) 17:1 Page 4 of 9
bringing together people from different areas” and “a
convergence of local and provincial government leaders to
get things done”. As an example, higher levels of govern-
ment could create the legislative environment and provide
the necessary resources (e.g. funding, tools, and data
platforms) to support local policies at the municipal level.
Participants mentioned that collaboration could be ac-
complished by: aligning agendas to find common goals
across different sectors (planning, public health and trans-
portation) and levels of government (federal, provincial,
and municipal); identifying “political champions” to bring
the built environment evidence to the forefront of policy-
making –for example, “real political leadership to push
forward our evidence and priorities”, perhaps through a
“Chief Planner counterpart to the Medical Officer of
Health”. Additional priorities include seeking financial
support for implementation research; and developing
mechanisms for performance measurement to understand
the impact of healthier communities on population health
–as well as its broader “environmental and social benefits”.
To support cross-sectoral and cross-regional collabora-
tions, some suggested developing the infrastructure for
sharing expertise and experiences on built environment
interventions on a broad scale, in a way that builds on
existing networks. This could provide a unique “data
repository” that would offer a “best practices portal” and
facilitate the design and evaluation of natural policy
experiment s. Several opt ions w ere put forth re gard ing
where the governance and accountability of such an ini-
tiative would lie – with one participant recommending
a “national collaborative center for environment health”
to oversee this infra structure to p rovide oversight and
sustainability.
Aligning public and private sector priorities
Participants also suggested the “need to modify percep-
tions of both public and private sectors to generate public
demand and support for community action”. Strategies
to address this issue may include: “seeking support from
non-government organizations and private industries to
understand their priorities in implementing changes to
the built environment”; “identifying community ‘cham-
pions’ to act as ‘brokers’ or agent s of change in this
process”; “developing social marketing campaigns”; and
other mechanisms to coordinate advocacy efforts of
different organizations working in the public and private
sectors in order to collaborate in a more cohesive way and
achieve common goals. It was noted that “behavioral
economics may have useful insights/ideas for encouraging
“better” behaviors”; an example being an “insurance com-
pany cutting their premiums for less miles driven”. How-
ever, several participants highlighted the need to change
social norms, noting, for example “people think it’ssaferto
drive their kids to school, although statistically it’snot”–
and the difficulties in doing so; querying “how do you drive
culture change?”. Participants identified the need for “some
sort of social marketing campaign around urban design”
that would link “active transportation to weight loss” akin
to messaging campaigns encouraging stair use.
Solution-focused implementation
An important contribution of implementation research is
that it promotes a better understanding of how to effect-
ively and efficiently translate evidence into action by con-
sidering the political contexts in all activities. Participants
highlighted the importance of bringing researchers and
policymakers together to tailor the research to be more
solution-focused and to meet the needs of policymakers
and planners. “An important contribution of implementa-
tion research is that to increase walkability and transit
options, we need to get regional organizations like the prov-
ince on board with the local issues. There needs to be con-
vergence of local and provincial government leaders to get
things done. So, to do solution-focused implementation how
do you get politicians on board? We all have our own
agenda but we ’re not all going to get what we want. If there
are competing agendas, decisions often depend on the polit-
ics of the day”. In order for policies and programs to have
an optimal impact, they need to capitalize on “critical
windows for initiating change”– for example, when existing
policies are up for renewal – and account for local political
and economic contexts of the region.
Research priorities and knowledge gaps
Participants provided important insights on actionable
research priorities and opportunities as next steps that
would address current knowledge gaps and facilitate the
effective application of evidence on the built environ-
ment into policy and planning initiatives. These research
and knowle dge gaps are shown as top or lower priorities
in Fig. 1 and reflect potential barriers that may impede
policy and planning actions to improve the built envir-
onment. Some of the top research priorities included
economic analyses on the benefits of policy and planning
changes made to the built environment and standardized
metrics and methodologies for measuring the built en-
vironment. Examples of items tha t were rated less highly
included research approaches that may be of greater
interest to scientists than politicians (e.g. population
attributable risk analyses) and research on built environ-
ment and workplaces.
Policy and planning actions on the built environment
Key policy and planning actions recommended by par-
ticipants that would support changes related to the built
environment are provided in Fig. 2 (in order of priority)
based on stakeholder input and ranking. For example,
actions that were rated most highly included establishing
Fazli et al. BMC Public Health (2017) 17:1 Page 5 of 9