An International Perspective on the Nexus of Physical Activity Research and Policy

Abstract

The traditional view of translating research to policy is reframed as a complex multidirectional interaction based on international case studies presented at the 2015 Active Living Research conference. The United Kingdom developed a process for reviewing and synthesizing evidence to inform policy, but policy makers were often ahead of the guidance. In Australia, translation of research to policy has been facilitated by brokering the relationship between researchers and policy makers. The best example of dissemination of the evidence for physical activity promotion into a national program comes from Brazil, but implementation has been markedly influenced by community and political factors. In Mexico, “physical activity policy” is being implemented at scale but without much research and with leadership from sectors other than public health. A more flexible understanding of the complex interplay between research and policy will increase the probability that the best available evidence will influence policy and that policy with the potential to increase physical activity will be evaluated.

Keywords

physical activity public health policy research evidence

Physical activity has been characterized as the “best buy” in public health (Morris, 1994). It provides substantial benefits across a wide spectrum of chronic diseases and contributes to mental health and quality of life (Physical Activity Guidelines Advisory Committee, 2008). Evidence on how to increase physical activity at the community level has mounted steadily over the past decades (Hoehner et al., 2008; Kahn et al., 2002), yet widespread application of this evidence occurs infrequently (Pratt et al., 2015). Many reports and papers conclude with calls for better translation of research to practice and policy (Giles-Corti et al., 2015; Haskell, Blair, & Hill, 2009; Heath et al., 2006; Morandi, 2009). While acknowledging the challenges of communication between researcher and policy maker and the complex multisectoral nature of physical activity promotion, the conceptual basis of translating research to policy to practice tends to default to linearity. There is an implicit suggestion that translation of research to policy is merely a matter of better packaging and communication (Brownson, Royer, Ewing, & McBride, 2006). Some deeper analyses have suggested that research and policy exist in “parallel universes” (Brownson et al., 2006), and a more comprehensive approach to partnerships between researchers and policy makers is required (Giles-Corti et al., 2015). It is not that research can’t inform policy, but the processes of research and policy, their implementation, dissemination, timelines, and rewards are substantively different. There are examples of research guiding physical activity policy and practice (Malta & Barbosa da Silva, 2012; Pratt et al., 2015), but more often public policy that influences physical activity is driven from outside of public health. Policy decisions tend to be made independent of research and often use different data from that favored in public health (Milton & Bauman, 2015; Pratt et al., 2015). Moreover, active living research may not resonate with policy makers outside of health or may be perceived as reinforcing what they already know (Allender, Cavill, Parker, & Foster, 2009). This does not suggest that research has no role in guiding public policy. Research can contribute to the sustainability or expansion of public policy initiatives (Sarmiento, Torres et al., 2010; Vuori, Lankenau, & Pratt, 2004). Comprehensive evaluation of actual policies or community interventions allows for a better understanding of and potential dissemination of public policies that may increase physical activity at scale (Craig et al., 2012). In this article, we reframe the traditional view of “translating research to policy” to what we believe to be a more realistic model of multidirectional interactions between research, practice, and policy based on experiences from four high- and middle-income countries each of which highlights a different aspect of the interplay between research, policy, and practice.

We use the definition of policy from Schmid, Pratt, and Witmer (2006, p. S22):

Policy provides an organizing structure and guidance for collective and individual behavior. It may be defined as legislative or regulatory action taken by federal, state, city, or local governments, government agencies, or nongovernmental organizations such as schools or corporations. Policy includes formal and informal rules and design standards that may be explicit or implicit.

We also draw on Kingdon’s concept of policy streams (Kingdon & Thurber, 1995; Figure 1). Kingdon proposed that successfully addressing an issue in the public policy arena requires that three conditions—“the policy streams”—be satisfied. First, the Problem stream: The issue must be recognized as a problem by policy decision-makers. Second, the Proposals stream: A variety of alternative, workable solutions to the problem must be ready to put in place. Finally, the Politics stream: Politicians must be willing and able to make a policy change. These three elements operate largely independently, but when realized simultaneously a “policy window” opens, and policy change is facilitated (Kingdon & Thurber, 1995). Scientists usually see their role as generators of evidence rather than implementers or advocates, but in order for their evidence to be translated into policy they may need to be alert to policy problems, political agendas, potential solutions, and be ready to advocate for reform when the window opens.

Figure 1.

Kingdon’s model of policy streams.

In many countries, the Problem stream has been addressed: National governments have recognized physical inactivity as a public health problem and have begun to propose public policy (Kohl et al., 2012). Increasingly, this includes a focus on sectors outside of health (World Health Organization, 2013). However, the “Proposals” stream presents significant problems. This is a function of the complex and multisector and multidiscipline nature of physical activity policies and the relative youth of the evidence for effective interventions. By contrast, tobacco control researchers have consistently been able to identify and articulate a small number of evidence-based policy solutions (Green et al., 2006). Despite promising efforts of the International Society for Physical Activity and its advocacy council, the Global Alliance for Physical Activity (GAPA; International Society of Physical Activity and Health, 2015), the physical activity community has yet to achieve consensus on the key interventions. Thus, policy reform is difficult as it is not obvious how to operationalize the general consensus for integrating physical activity back into daily life. The following country case studies illustrate the complex interplay between research and policy. We examine innovative policies that spawn opportunities for research, instances in which research did guide policy, and cases where research and policy developed separately and converged synergistically or failed to connect.

Case Studies

The United Kingdom

The U.K. health sector has embraced the notion of using evidence to drive clinical practice through the Cochrane Collaboration (a database of high-quality independent evidence for informing health care decision making) and evidence-based medicine movement (Department of Health, 2004; Foster, Hillsdon, Thorogood, 2008). The transfer of evidence-based approaches from clinical settings to broader and more complex public health interventions has posed challenges. Since 2005, the construction of the evidence base for public health interventions in the United Kingdom has been the function of the National Institute for Health and Care Excellence (NICE; 2014; Sowden & Raine, 2008). NICE is an independent organization responsible for providing national guidance on health promotion and prevention and treatment of ill health in England (Sowden & Raine, 2008).

NICE is supported by a collaboration of academics who review evidence on public health interventions within settings, by type, or target groups. The development of NICE guidance passes through a series of consultations. The first stage takes place when the U.K. government’s Department of Health refers an area for guidance to NICE. Potential stakeholders register interest in the process, including national organizations, researchers, industry, and special interest groups. This referral is developed into a scope of work, defining what will be included in the guidance. The scope sets out terms of reference leading to a systematic review of the evidence including correlates, qualitative and intervention studies, economics, and cost-utility modeling. A committee of academics and practitioners are invited by the Department of Health with input from an independent advisory group to consider the evidence reviews and develop draft guidance. Further details about NICE are available from http://www.nice.org.uk/article/pmg4/chapter/1%20introduction (NICE, 2014).

Physical activity was one of the first public health topics to be addressed by NICE when the evidence for pedometers, exercise referral, and walking and cycling promotion were reviewed (NICE, 2006). This was followed by evidence-based guidance on the environment and physical activity (NICE, 2008). The relatively immature evidence base and cross-sectional design of many of the studies presented significant challenges for the reviewers. Despite this, NICE applied the maxim of using the best available evidence, supported by rigorous review methods (NICE, 2006), and produced draft guidance that set out comprehensive ways that the built and natural environments might be modified to enhance opportunities for physical activity. A further enhancement to the process of translating evidence into policy was the testing of the draft guidance with the target audience of planners, architects, and transportation professionals (Allender et al., 2009). The guidance appeared to lag behind professional knowledge on the subject. Many of the respondents to the field-testing agreed with the draft guidance and supported its publication by NICE but felt that they had “heard it all before.” In this example, the evidence to policy process did not appear to be enhanced by the specific ideas or proposals in the guidance but was helped by the legitimacy offered with publication by a respected public health body. The practitioners appeared to be “ahead of the game” and were already applying the guidance (i.e., practice-based evidence) but without mechanisms to feed that knowledge back into policy. Interestingly, NICE has since improved its methods and now combines evidence from literature reviews (including gray and qualitative) with expert testimony. This allows for consideration of innovations that are too new to have made it into the published literature.

Australia

Research translation is a focus for many Australian academics, and this is being enhanced through work with knowledge brokers. The Heart Foundation of Australia is a key advocate for physical activity–related policy reform, serving as a knowledge-broker between academics, policy makers, and practitioners. In the mid-2000s, its National Physical Activity Committee (comprising Heart Foundation staff and academics) prepared evidence-based reviews underpinning advocacy activities. Reflecting on tobacco policy success, a 10-point Blueprint for an Active Australia was prepared and subsequently updated (National Heart Foundation of Australia, 2009, 2014). Consistent with Kingdon’s model, the Blueprint defined the problem and proposed evidence-based solutions. However, its real usefulness has been as an evidence-based tool to assist advocates in policy reform when political opportunities arise.

The Blueprint provides evidence for encouraging partnerships with organizations outside of health. Examples of successful advocacy work as part of multisector coalitions that have influenced active living policy in Australia include the development of Healthy Spaces and Places guidelines (Planning Institute of Australia, Australian Local Government Association, & National Heart Foundation of Australia, 2009); work with bus and cycling bodies to create a Vision for Active Travel (ALGA, Bus Industry Confederation, Cycling Foundation Fund, NHF of Australia, & Transport, 2010); the development of national urban design guidelines,(Major Cities Unit, 2011), a national urban policy with a focus on active modes of transport (Department of Infrastructure and Transport, 2011); and incorporating the economic benefits of health into a discussion paper on increasing walking, riding, and public transport (Department of Infrastructure and Transport, 2013).

Across Australian states and territories, Heart Foundation teams have spearheaded the development of state-specific Active Design Guidelines (e.g., in Victoria, Tasmania, Queensland, South Australia, and more recently in Western Australia [http://www.healthyactivebydesign.com.au/]) and evidence-based documents on active living, including the benefits of pedestrianization for business (National Heart Foundation of Australia, 2011), consumer preferences for healthy urban development (National Heart Foundation of Australia, 2011), and the health impacts of density (Giles-Corti, Ryan, & Foster, 2012; Udell, Daley, Johnson, & Tolley, 2014). These activities exemplify the Heart Foundation’s role in advocating for state urban planning policies and promoting active transport (e.g., Department of Planning and Environment, 2014; State of Victoria, 2014). The Heart Foundation’s involvement in multisector state initiatives, including the South Australian Coalition for Active Living (The Heart Foundation, 2009), the Western Australian Physical Activity Task Force, and the New South Wales (NSW) Premier’s Council for Active Living (PCAL; www.pcal.nsw.gov.au; McCue, 2010) has been an effective strategy for incorporating active living principles into public policy.

For example, the NSW PCAL is an interagency collaboration between senior representatives from NSW Government, business, and the nongovernmental sector reporting to the NSW premier, with a focus on health promoting urban environments and active travel. Established in 2005, PCAL provides evidence-based advice to government and promotes legislation, policy, and guidelines to increase physical activity in NSW. The Council’s activities are informed by better practice recommendations highlighting the need for interagency collaboration as a strategy for increasing physical activity (Global Advocacy Council for Physical Activity & International Society for Physical Activity and Health, 2010).

According to Kingdon’s model, the NSW PCAL and the other state intersectoral collaborations are key knowledge brokers, translating synthesized research evidence and proposed solutions into the appropriate political context for the target jurisdiction. In PCAL’s case, its terms of reference include reporting to the premier, providing opportunities for identifying forthcoming legislative and policy windows, and aligning advocacy accordingly.

Since 2008, PCAL has hosted a series of Active Transport Roundtables with executive representation from health, transport, planning, and other relevant agencies. These roundtables provided opportunities for cross-disciplinary dissemination of active living research, examination of proposed solutions, and subsequent instigation of several state policy initiatives. Examples include the incorporation of walking and cycling targets within successive versions of the NSW State Plan (NSW Government, 2011), with subsequent state walking (NSW Government, 2013c) and cycling (NSW Government, 2013b) delivery strategies and resource allocations, and the release of an Active Living Position Paper (NSW Government, 2010) that articulates active living principles as a priority of the NSW Planning System.

PCAL also worked with interdisciplinary partners to advocate for including an explicit health promotion objective within the 2013 NSW Planning Bill (NSW Government, 2013a). Of note, significantly greater resourcing and time were required to achieve the healthy planning legislative development (Thompson & McCue, 2015) than previous policy successes. However, the impact of the proposed “healthy planning” changes has been significant with the inclusion of a health objective for the first time within state regional delivery strategies (NSW Government, 2011, 2015). These case studies highlight the importance of partnerships between academics, advocates, policy makers, and especially knowledge brokers for translating physical activity research to policy and practice (Giles-Corti et al., 2015).

Brazil

Brazil provides an example of the interaction between research, the best available evidence, and policies that are guiding national scale physical activity promotion. As expected, this has not been a linear process. Rather, a series of parallel events occurred (Kingdon & Thurber, 1995), resulting in one of the largest physical activity promotion programs in the world.

The “problem” was identified in 2006 when a new National Health Promotion Policy defined physical activity as one of seven priority areas (Malta et al., 2009). Several strategic governmental actions followed: monitoring, evaluation, and promotion of physical activity. Brazil initiated comprehensive risk factor surveillance for adults (VIGITEL, Portuguese acronym for Surveillance System for Chronic Disease Risk Factors) and adolescents (PeNSE, Portuguese acronym for National School-Based Health Survey) that included physical activity (Malta & Barbosa da Silva, 2012; Malta et al., 2009). Along with these monitoring systems, the Ministry of Health initiated collaboration with universities and research centers from Brazil and United States to better evaluate community physical activity programs (Malta & Barbosa da Silva, 2012; Pratt et al., 2010).

This collaboration led to evaluation of several community-based physical activity projects, demonstrating convincing positive associations between program participation and physical activity (Hallal et al., 2010; Mendonca et al., 2010; Reis, Hino, et al., 2014; Simoes et al., 2009). These community programs have been in place for a decade or more and were developed and implemented by local government health and recreation departments and the public primary health care system (Parra et al., 2013). They appear to be especially effective at increasing physical activity among women, those living in unsafe areas, and for people with less education (Reis, Yan, Parra, & Brownson, 2014).

Although the evidence was not optimal (baseline data were not available for any of the programs; Hallal et al., 2010; Mendonca et al., 2010; Reis, Hino, et al., 2014; Simoes et al., 2009), the Ministry of Health has provided financial support since 2006 to local health departments to implement this type of program (Malta & Barbosa da Silva, 2012). By 2010, more than 1,500 cities had implemented community-based physical activity promotion (Knuth et al., 2010). The rapid program expansion was characterized by community demand, effective linkage to the primary health system, a focus on populations at high risk for inactivity, and strong political support. In 2012, a new national program “Academia da Saude” extended implementation of physical activity classes, infrastructure, and counseling to a goal of 4,000 cities (Malta & Barbosa da Silva, 2012).

Actual implementation of Academia da Saude has been affected by local and national political realities. As of 2014, the focus of Academia da Saude has shifted to include other health promotion priorities in addition to physical activity (Ministry of Health of Brazil, 2013a), and financing is more dependent on the local member of congress (Ministry of Health of Brazil, 2013b). Although imperfect, this case is a real world demonstration of policy streams (Kingdon & Thurber, 1995). Physical inactivity was recognized as a national problem; policy and programs were proposed, funded, and began to be implemented based on the “best available evidence”; and national and local policy makers and stakeholders have been engaged in tailoring the solution to the context of thousands of communities in Brazil.

Mexico

Mexico is an interesting case, where innovative policies emanating from outside of the health sector have the potential to guide physical activity research. Since the turn of the 21st century, city-level policies that might be considered “physical activity promoting” have emerged throughout the country. Mexico City has led the way, with multiple actions including: the introduction of a Bus Rapid Transit System in 2005, with designated lanes, elevated transit stations, and modern high speed, low-emission vehicles (Mexico City Government Sites, 2014b); a regular 40 km ciclovia (Sunday open streets program for bicyclists and pedestrians) on Reforma Avenue, connecting a business district to the historic downtown, and including the city’s most emblematic monuments, buildings, and landmarks (Ministry for the Environment of Mexico City, 2012); the pedestrianization of several main streets in the historic downtown (Ministry for the Environment of Mexico City, 2012); the introduction of a publicly subsidized bicycle-sharing program, “EcoBici,” currently in 42 neighborhoods in Mexico City (Mexico City’s Government Sites, 2014a); public bicycle parking adjacent to major transit stations (Mexico City’s Government Sites, 2014a); and the enactment in 2014 of a New Mobility Law to improve mobility and reduce congestion with prioritization of actions favoring pedestrians and cyclists over cars. The law also officially recognizes mobility as a right and will modernize and expand mass transit systems across the city (EMBARQ, 2014a, 2014b; Mexico City Official Gazette, 2015). Similar strategies are taking place in cities throughout the country (e.g., Guadalajara, Cuernavaca, Queretaro, Puebla, Hidalgo, Tlaxcala, etc.; Mexico’s Ministry of State, 2013).

Interestingly, physical activity does not seem to be the principal motivation behind any of these policies. Other aspects such as solving traffic congestion, reducing carbon emissions, increasing the city’s economic competitiveness, and augmenting social cohesion and equity appear to be the main drivers. For instance, the Bus Rapid Transit system in Mexico City was included as a central strategy in the city’s 2002-2010 Program to Improve Air Quality, led by the Environmental Ministry of Mexico City (Wöhrnschimmel et al., 2008). Likewise, the Ecobici initiative highlights in its name and mission the environmental benefits of bicycling for transportation, with less emphasis on the health benefits of physical activity (Almeida-Lobo & Herrera-Montes, 2012). Physical activity and health are noted as cobenefits of the Sunday ciclovia; however, emphasis on social equity and cohesion is also apparent. Improving access to the city’s most emblematic avenue for those who don’t own cars or live far from the city center is a powerful message to the community (Ministry for the Environment of Mexico City, 2012). This is not only true of Mexico City’s ciclovia but is also characteristic of other Latin American cities with ciclovias (Pratt, Charvel Orozco, Hernandez-Avila, Reis, & Sarmiento, 2014; Salvo, Reis, Sarmiento, & Pratt, 2014; Sarmiento, Schmid, et al., 2010; Sarmiento, Torres, et al., 2010). Finally, the New Mobility Law resulted from the need to integrate and better regulate all of the public transportation systems operating in the city. The law highlights the need for safe, efficient transit options for all citizens and, like ciclovias, emphasizes social equity, by recognizing residents’ right to mobility and prioritizing actions geared toward pedestrians, bicyclists, and public transit users (EMBARQ, 2014a, 2014b; Mexico City Official Gazette, 2015). Although several reports point out the positive effects of these programs on air quality and traffic congestion (Almeida-Lobo & Herrera-Montes, 2012; Wöhrnschimmel et al., 2008), a scientific evaluation looking at the impact of these policies on physical activity has yet to take place. This points to the need to understand the local research context when examining the interplay of research and policy. In Mexico, physical activity as part of public health remains nascent, and the country lacks research capacity in this field (Salvo et al., 2014). Although the importance of physical activity is gaining recognition due to the obesity epidemic (Pratt et al., 2014), there still is not a sense of urgency for preventing inactivity compared with other adverse health behaviors such us unhealthy eating or smoking (Bull & Bauman, 2011). Hence, the current research context in the country makes it unrealistic for health-related evidence to be the driver of policies for promoting physical activity. As academic capacity and recognition of the problem continue to grow in Mexico (Salvo et al., 2014), there may be more potential for physical activity research, focusing on multisectoral policy evaluation. In Mexico, policy seems more likely to drive physical activity research, rather than the reverse. There is real potential for enhancing the understanding of the effects of urban policies and environments on physical activity if these “natural experiments” can be evaluated (Craig et al., 2012). Consequently, there is a pressing need for increased flexibility in the conceptualization of public health research and in the funding mechanisms to achieve interdisciplinary engagement with fields such as transportation, environment, air quality, and urban planning,

Conclusion

The four country case studies highlight the complex interplay between research and policy. In the United Kingdom, a near optimal process has been developed for carefully reviewing and synthesizing evidence to inform policy. But, the real world of policy and practice often appears to be ahead of the evidence-based policy guidance. Public health researchers are advancing Kingdon’s problem and proposal streams while in parallel the politics stream flows with only occasional influence from the first two streams. In Australia, the translation of research to policy has been facilitated by explicitly brokering the relationship between researchers and policy makers across several sectors and across the policy streams. Perhaps as a result of this process there are many good examples in Australia of research findings systematically being incorporated into national, state, and local policy. A clear example of the dissemination of the “best available evidence” for physical activity promotion into a national program comes from Brazil where Kingdon’s three policy streams were synchronized and synergistic. But, Brazil also exemplifies the challenge of implementing and sustaining evidence-based policy when factors in addition to research evidence markedly influence policy. No matter the strength and logic of the problem and proposal streams, politics can take odd turns. In Mexico, “physical activity policy” is being implemented at scale with little or no research evidence. Rather, it is driven from sectors other than public health and for reasons ranging from social equity to global economic competitiveness. There is a window of opportunity in Mexico with convergence of the three policy streams, but public health’s role has yet to be defined. In both Brazil and Mexico, there is much potential to learn from innovative policy if researchers can catch up to it. Across all four cases, we can see that there are moments when public health research has the potential to influence policy. When policy is initiated with little influence from the health sector, research evidence may still be important for sustainability. Research can and does influence policy, but rarely in the tidy sequence that we as researchers are most comfortable with. In the messy real world, policy is often ahead of research, influenced by many other factors, or may be entirely independent of public health research. A more flexible understanding of the complex interplay between research and policy will increase the probability that the best available evidence will influence policy and that policy with the potential to increase physical activity will be evaluated.

Footnotes

Acknowledgements

The authors thank The Robert Wood Johnson Foundation and the staff of the Active Living Research Program for supporting the international sessions at the Active Living Research Conference in February 2015 from which this commentary was developed.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Michael Pratt is a professor in the Hubert Department of Global Health, Rollins School of Public Health at Emory University in Atlanta and in the Schools of Medicine and Government, Universidad de los Andes, Bogotá, Colombia. His work focuses on physical activity policy and interventions, and building research capacity globally for physical activity and public health.

Deborah Salvo is a postdoctoral research fellow at the Michael and Susan Dell Center for Healthy Living, University of Texas Health Science Center at Houston, School of Public Health–Austin Regional Campus, and an adjunct researcher in the Nutrition and Health Sciences Research Center, National Institute of Public Health of Mexico, Cuernavaca, Mexico. Her research focuses on the built environment and physical activity and physical activity policy in Mexico, the United States, and South America.

Nick Cavill directs an independent public health consultancy and is a research associate at the University of Oxford and an honorary senior research fellow at the University of Salford. He specializes in the development of policy and programs on sustainable transport and the links to physical activity.

Billie Giles-Corti heads the McCaughey VicHealth Community Wellbeing Unit, Centre for Health Equity, University of Melbourne. She and a multidisciplinary team of researchers and postgraduate research students study the impact of the built environment and public policies on health and well-being outcomes.

Peter McCue is the executive officer of the Premier’s Council for Active Living (PCAL) in Sydney, Australia. PCAL is a statewide interagency body that aims to link infrastructure and service agencies, industry, and the community sector to promote active living. Prior to PCAL, he worked for more than 20 years promoting physical activity in Australia, Asia, and Europe within the public health, recreation, and planning sectors.

Rodrigo S. Reis is a professor in the Department of Physical Education at the Universidade Federal do Paraná, and leads the Research Group of Physical Activity and Quality of Life (GPAQ) in the postgraduate program in urban management at the Pontificia Universidade Católica do Paraná, in Curitiba, Brazil. His research focuses on physical activity and the environment, and physical activity correlates, interventions, and policy.

Alejandra Jáuregui is a researcher at the Center for Health and Nutrition Research, National Institute of Public Health of Mexico, and a doctoral student at the School of Public Health of Mexico, Cuernavaca, Mexico. Her research focuses on the built environment, transportation, and physical activity policy in Mexico.

Charlie Foster is the deputy director, university research lecturer and senior researcher, associate professor, British Heart Foundation Centre on Population Approaches for Non-Communicable Disease Prevention in the Nuffield Department of Population Health at Oxford University. His research focuses on physical activity epidemiology, assessment, evidence-based interventions, and policy.

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