Translating active living research into policy and practice: One important pathway to chronic disease prevention

Global concerns about rising levels of chronic disease make timely translation of research into policy and practice a priority. There is a need to tackle common risk factors: tobacco use, unhealthy diets, physical inactivity, and harmful alcohol use. Using evidence to inform policy and practice is challenging, often hampered by a poor fit between academic research and the needs of policymakers and practitioners – notably for active living researchers whose objective is to increase population physical activity by changing the ways cities are designed and built. We propose 10 strategies that may facilitate translation of research into health-enhancing urban planning policy. Strategies include interdisciplinary research teams of policymakers and practitioners; undertaking explicitly policy-relevant research; adopting appropriate study designs and methodologies (evaluation of policy initiatives as ‘natural experiments’); and adopting dissemination strategies that include knowledge brokers, advocates, and lobbyists. Conducting more policy-relevant research will require training for researchers as well as different rewards in academia.


Introduction
Translation of research evidence into policy and practice is challenging for disease prevention researchers. This problem is not new: despite John Snow's mid-nineteenth century insights that providing clean water prevents cholera, this disease still devastates the urban poor in developing countries. A report of the World Health Organization suggests that "… toxic combination of bad policies, economics, and politics is, in large measure, responsible for the fact that a majority of people in the world do not enjoy the good health that is biologically possible". 1 To reduce risk factors for major non-communicable diseases (NCD)tobacco use, unhealthy diets, physical inactivity, and harmful use of alcoholrequires comprehensive public health action. Sometimes industries choose to create confusion. As part of a strategy to reduce pressure on food companies to change their practices, many in the food industry have attempted to overemphasize the role of physical inactivity in the obesity epidemic. 2 Such industry tactics should not deter public health efforts to promote physical activity.
Physical inactivity alone is estimated to cause over 5 million deaths annually, 3 and there have been calls for a greater public health response. 4 While here we focus on activity, translation of evidence-based solutions is required for all four leading NCD risk factors. Principles we identify for active living research may apply to other areas. We begin with a rationale for designing cities to enhance active living; then explore factors that limit the adoption of evidence-based policy and practice. We conclude with recommendations to facilitate the translation of active living research into policy and practice.

The Case for Urban Design that Facilitates Active Transportation and Leisure
Creating cities that facilitate physical activity through active transport and active leisure is now seen as a global priority from both environmental sustainability 5 and health perspectives. 6,7 Walking-and cycling-friendly cities are associated with more walking, 8,9 less obesity, 10 lower rates of chronic diseases, 10 less sedentary time in cars, 11 decreased risk of motor vehicle crashes, 12 and reduced greenhouse gas emissions. 10,13 Safe and attractive cities with access to high quality public open space also benefit health by encouraging recreational physical activity 14 and promoting mental health. 15,16 Despite this combination of benefits from creating physical activityfriendly cities, 13 there remains a gap between research, and policy and practice. Sprawling low-density communities with poor access to shops, services, and public transport continue to be built around major cities worldwide. 17 Creating healthier communities requires the involvement of sectors beyond those responsible for health, including city and transport planning, urban design, property development, finance, landscape architecture, road engineering, parks and recreation, energy, and environmental protection.

The Gap between Researchers and Policymakers and Practitioners
Influencing public policy and practice should be an explicit goal for active living research. 18 High-quality evidence can draw attention to what needs to change and to remedies likely to be effective. Yet, researchers are often frustrated that their research is ignored by policymakers and practitioners. 19,20 Choi et al 21 suggest that there is a 'gap' between researchersand policymakers or practitioners: "scientists are sceptical about the extent to which research is used" to inform policies; and "policymakers are sceptical about the usefulness and accuracy of research". At times, research findings do not support policymakers' agendas.
'Policy-relevant' research appears to be rare, and this may contribute to the research-policy gap. 19 As Green 22 challenges: if researchers want 'evidence-based policy and practice', they need to produce 'policy and practice-based evidence'. Figure 1 summarises the activities, partners, and strategies that differentiate policy-relevant research from other research, highlighting the need for partnerships between interdisciplinary research teams and policymakers/practitioners, plus a research approach explicitly designed to influence policy.
Translating active living research into policy and practice Until relatively recently, few active living researchers from the health and exercise science sectors obtained formal training related to the built environment and health; or on policy-making processes. Globally this type of training is not widespread. Thus scholars understand little about the sectors they seek to influencetransportation, urban planning, and parks and recreation. Similarly, until recently, few of those trained in urban planning, transportation, engineering, architecture, and parks and recreation learned how their sector's influence health and wellbeing.
Researchers may have unrealistic expectations about the role of evidence in influencing policy and about the extent to which policymaking is a rational rather than a process driven by political considerations, whether 'rational' or not. 23 A single piece of evidence is rarely used directly to solve a policy problem. 23 Rather, it is more likely that accumulated evidence leads to changing awareness and may be used retrospectively to justify a position. Understanding the different ways that evidence is used or refuted by policymakers can help researchers when formulating research questions, summarizing key findings, and communicating research in ways that can influence policymakers and practitioners. 24

Strategies to Close the 'Research Translation Gap'
We propose 10 strategies to help bridge the gap between active living researchers and those responsible for planning and implementing transport and land-use policies.
Understand the 'policy world' we are attempting to shift British transport officials and policymakers responded to public health guidance on the impact of the built environment on physical activity by saying "Tell us something we don't know". 25 Failure to translate research into policy and practice may have less to do with the evidence and more to do with 'policy world' realities that are inherently political and shaped by many inputs, including public opinion. 26 To have any impact, it is important to understand the policy context and the needs of the policymakers and practitioners responsible for the built environment. What influences decision making? 26

Establish links with policymakers and practitioners
To facilitate research translation, stronger links between active living researchers and policymakers and practitioners are essential. Innvaer and colleagues 27 examined factors that affected health policymakers' use of evidence to inform policy. Three key factors appeared to be important: (i) personal contact between researchers and policymakers; (ii) timely relevance of the research; and (iii) provision of research summaries containing policy recommendations. Their findings are consistent with other research 26 and the literature on the diffusion of innovations. 28 Establishing close research-practice relationships can result in a two-way interaction and a flow of information. Researchers become aware of policy-relevant research questions and practitioners are kept up-to-date on recent research findings. 26 Bidirectional communication and its benefits are illustrated in Figure 2.
Researchers successful at influencing policy and practice develop 'friendly and trusting' relationships with policymakers and with journalists. They see these relationships as 'critical for advancing researchinformed policy'. 26 Attending policy briefings and built environment conferences is a first step in creating contact and building a network.
Translating active living research into policy and practice

Work with knowledge brokers, advocates, and lobbyists
For research to have an impact, it needs to be communicated to the right people, in the right way, and at the right time. Despite the desire for stronger links between research and policy/practice, many argue that researchers and policymakers/practitioners are "travelling in parallel universes". [19][20][21] Knowledge-brokers constitute a strategy for closing the gap. They may work in scientific, advocacy, or professional organisations. They can communicate effectively with researchers, policymakers, and practitioners alike (see Figure 2). They can ensure that researchers are aware of issues confronting policymakers and practitioners, and by linking policymakers and practitioners with evidence or with the researchers themselves facilitate the dissemination of research findings.
Researchers can also work with advocacy groups to synthesise the evidence, participate in expert panels or advisory groups, and provide one-to-one briefings with policymakers. 23 During policy development, researchers who have well-established relationships with policymakers may work as 'trusted experts', helping policymakers formulate policy, 29 or meet with politicians to discuss proposed reforms.

Establish research agendas jointly with policymakers and practitioners
Establishing joint research agendas requires researchers to see the world through the eyes of policymakers and practitioners. What are the crucial policy-relevant questions that they need answered, and how can researchers align their desire to advance scientific knowledge with these policy imperatives? 20,26 Co-creating the research questions in conjunction with policymakers and practitioners before the research is undertaken is clearly ideal. 18,21 Undertake interdisciplinary collaborative research Transforming the way cities are designed and built has been called a 'wicked problem'meaning a complex multi-component problem that is difficult to solve, often because of interdependencies. 30 Kreuter has suggested that 'innovation and high impact' solutions are most likely when sought beyond disciplinary boundaries. 30 Multidisciplinary research teams conducting interdisciplinary research offer two main advantages. First, they can close the gap between researchers and policymakers by increasing the policy-relevance of the research. Those trained in public health, for example, need to collaborate with researchers trained in urban planning, urban design, transportation, and parks and recreation, who may be well-versed in current policy issues within their sectors.
Second, multidisciplinary research teams that include public health professionals can increase attention to health in decision making about the built environment. Despite increasing knowledge of the health implications of their decisions, 6 for many academics and policymakers, the impact on 'health' remains a minor consideration. Working with those outside of health may have long-term benefits. Health considerations may appear on the agenda when shaping the built environment. Interdisciplinary research teams can influence how decision-support tools for transport and planning place more emphasis on health. Travel demand modelling used in transport planning could be modified to fully incorporate active modes of travel. 31

Study the health-economic impacts of active living infrastructure
Cost-benefit analysis plays a key role in decision-making, and could be enhanced by greater attention to health impacts. 31 An approach that considers the combined benefits for health from investments in walking, cycling, and other transportation infrastructure could be used when calculating the economic impacts of these investments. 32,33 Studies appear in leading health journals (for example, The Lancet), 34 are now creating a growing body of literature on the economics of investing in cycling infrastructure, 35 sidewalks, 36 and more walkable environments.

Evaluate policy reform through natural experiments
Using 'natural experiments' to learn about the impact of policy decisions is now more common. 37 Natural experiments help evaluate legislation to create safe routes to school; 38,39 implementation of cycling infrastructure, 40 sub-division design codes, 41 or walking infrastructure; 37 and park renovations. 42 The UK Medical Research Council has published guidelines for designing natural experiments, 43 and the US National Cancer Institute has called for obesity policy research that includes natural experiments. 44 These studies can provide policy-relevant evidence, but only if they can: • detect small effects over time; 41,45 • incorporate policy-specific measures; 46,47 and • monitor implementation to learn what is needed to affect health outcomes. 47 Importantly, natural experiments are more likely to influence policy and practice when undertaken from the outset in partnership with policymakers and practitioners. 47,48 Conduct research focusing on community needs and preferences Greater attention needs to be paid to consumer preference. In what environments do people want to live? US surveys find strong support for urban design policies to increase physical activity. 56,57 Where people currently reside does not always reflect preferences that affect active travel. Frank and colleagues 49 found that many people desire, but do not live in walkable environments. In recent years, property prices in walkable neighbourhoods seem to reflect a latent demand for walkability. 50 Politicians may therefore promote walkability based on the expressed wishes of their constituents. Developers and their financiers may take note when trying to profit from the communities they build.

Highlight specific policy implications
Policymakers usually want to know about the problem, the effect, and the solution. 18 When writing journal articles, it is important to keep in mind that busy policymakers and practitioners may read only the abstract. 20 Avoid vague statements that 'policy implications must be considered'. Abstracts are most useful when they include specific research-informed policy recommendations on which policymakers can act. Perhaps they will read on.

Create interdisciplinary built environment and health training programmes
Formal interdisciplinary training in public health, planning, parks and recreation, transport, and related fields 51 may facilitate translation of active living and interdisciplinary research. For at least a decade, many have called on us to reconnect the disciplines of planning and health. 52 Training programmes in built environment and health, a nascent trend across universities, have emerged in North America, 51 the United Kingdom, 53 Australia, 54 Japan, and Canada. They are reflected in the WHO's Healthy Cities movement. 55 Courses on planning and transport policy should now be incorporated into public health degrees and vice versa, with the aim of building understanding across disciplines.

Conclusions
To influence policy, active living researchers must work in multidisciplinary teams that generate policy-relevant research. We have proposed ten strategies to encourage more policy-relevant research and more effective translation of research into policy and practice. Active living researchers will benefit from a greater understanding of the sectors they seek to reform. Built environment professionals and researchers will also benefit from a better understanding of the health impacts of their efforts. To improve research translation, universities and research funders must alter reward systems, shifting from a focus on publications and grant successes, to reward engaging with policymakers and practitioners, asking policy-relevant research questions, and communicating findings to those who can put research into practice. If this results in healthenhancing cities, the major beneficiaries of improved active living research will be the communities we serve. This work is licensed under a Creative Commons Attribution 3.0 Unported License. The images or other third party material in this article are included in the article's Creative Commons license, unless indicated otherwise in the credit line; if the material is not included under the Creative Commons license, users will need to obtain permission from the license holder to reproduce the material. To view a copy of this license, visit http://creativecommons.org/licenses/by/3.0/