Barriers to optimizing investments in the built environment to reduce youth obesity: policy-maker perspectives.

Grant, Jill L. ; MacKay, Kathryn C. ; Manuel, Patricia M. 等

Canadian researchers and policy-makers recognize increasing levels of overweight and obesity as creating a health crisis that requires macro-level policy changes. (1-3) Since eastern provinces have the highest rates of overweight and obesity in the country, (4) the issue proves especially salient for provincial and local governments in Atlantic Canada. Studies of children and youth in grades 3, 7, and 11 in Nova Scotia showed that participants in 2005/06 were less physically active than those in 2001/02. As well, students in grade 11 were significantly less active than those in grade 7, who were in turn significantly less active than those in grade 3. (5,6) Although physical activity levels revealed no significant differences between children in BMI weight categories, (7) income levels and dietary habits did influence weight status. (8) As policymakers increasingly adopt a social ecological model to understand the multiple and interacting factors that influence health, (9-11) they are casting their nets widely for strategies and interventions to address the problem of growing levels of overweight and obesity. (12)

Since the early 2000s, community design theory has argued that patterns in the built environment (such as the mix of land uses) affect physical activity rates in ways that may influence obesity outcomes. (13-15) Although empirical tests show mixed results about the significance of urban form on activity and weight, (16-19) policymakers have begun to ask whether strategic investments in infrastructure and community amenities may offer positive health impacts. Governments invest vast amounts annually into facilities and infrastructure improvements. In the context of the crisis of growing obesity rates, governments want to determine whether they can optimize investments to improve health outcomes.

This exploratory study consulted policy-makers and professionals in Atlantic Canada to elicit their perspectives on policy development regarding the built environment and the health of youth aged 12-15 years. The paper identifies factors which limit the ability of local governments to make appropriate investments in the built environment to promote youth health and reduce obesity outcomes in Atlantic Canada.

METHOD

Between July and October of 2008, researchers conducted seven focus groups with policy-makers knowledgeable about local government in Atlantic Canada. Forty-four people participated: 28 men and 16 women. The largest number (n=29) came from Nova Scotia, 8 from New Brunswick, 5 from Newfoundland, and 1 each from

PEI and Ontario. Researchers invited participants purposively to the first three focus groups to produce a mix of professional responsibilities within each group. Those sessions included recreation (n=6), planning (n=3), school board (n=2), health authority (n=3), and local council (n=2) participants. Invitations to municipal engineers and to town administrators did not attract participants, despite repeated attempts to elicit involvement. Four focus groups occurred at a professional planners' conference: professional planners from local (n=15) or provincial (n=4) governments, from private consulting practice (n=8), and a student registered for a professional development workshop on health and the built environment. Self-selection bias produced a sample interested in the study theme; about half of the participants had met members of the research team professionally. The groups, facilitated by the research team, lasted 80 to 120 minutes; sessions were recorded and transcribed for data analysis. A content and discourse analysis informed by a critical interpretation approach allowed research team members to identify salient themes through iterative readings of the transcripts. (20,21)

Focus groups offer a naturalistic setting for researchers to gain insights within an interactive social space. (22,23) They allow participants to share stories, compare ideas, and learn from each other. While focus groups do not produce results that permit generalization to larger populations, and elicit a limited range of perspectives, they reveal some of the social dynamics and complexities that surround policy-making within organizations such as government. (24) They provide a useful exploratory tool for initiating inquiry in a field where relatively little is known.

The protocols for the focus groups, approved through the university's ethics review process, included eight questions (Table 1). The analysis presented here focuses on the principal barriers and challenges participants described as limiting the ability of local government to intervene appropriately in the built environment to promote youth health and reduce obesity.

RESULTS

Participants' familiarity with issues related to youth aged 12 to 15 varied considerably: recreation and school board staff proved most knowledgeable about the needs and interests of the cohort, and reported direct experience engaging youth. Discussions in several groups indicated that public health concerns about obesity and federal funding programs influenced local government agendas. A recreation professional noted:

"I'm not one hundred percent sure if our municipality is really only concerned about the health of anyone. But it's the flavour of the month. Whether it is physically active and children and youth or if it's active living or whatever gets the job done! If you can promote what you are trying to do by pushing the health benefit, even over the economic benefit these days, then you are more apt to have your initiative moved forward with the decision-makers."

Analysis of the discussions revealed several barriers to acting to improve health outcomes. The challenges clustered around four themes: financial barriers, legacy issues, governance barriers, and cultural factors.

Financial barriers

As national and provincial governments develop funding programs for local governments, they "dangle carrots," as a planner put it, in front of municipalities with limited resources. Several focus groups discussed the problems created for municipalities unable to set their own priorities or in some cases even to participate in programs. One planner said:

"There are so many different kinds of things that you can get funding for through the new integrated community sustainability plan system. That opens huge doors in terms of infrastructure improvements towards healthy living. The trick toward all of it, though, is that you need to cost-share. A lot of municipalities just aren't in a position to come up with their portion of the cash to do these projects or even have the personnel to write the grant applications and oversee the projects."

Building and maintaining healthy places costs more than some municipalities can manage. Participants cited problems of poor infrastructure and inadequate maintenance; municipalities lack the means to ensure that the built environment can support walking and cycling. All groups raised transportation issues as a special concern for youth, but identified financial barriers as limiting government's ability to address those needs. They noted that trails are affordable and accessible, but youth in rural areas remain underserved. Some planners said that, with insufficient resources for park maintenance and operation, some municipal governments were asking the developers of new subdivisions for money instead of land, leaving youth without parks or playgrounds.

Legacy issues

In all groups, participants argued that historic decisions about the built environment created barriers to optimizing investments for health. Planners often described land use patterns as a problem, citing segregated land uses, oversized and disconnected street patterns, and car-oriented developments as the inheritance of poor planning and zoning choices. Local governments face significant challenges to get people out of their cars in a landscape that is not walkable. Planner participants commonly pointed to contemporary planning theory to advocate mixed use and connected street patterns to encourage walking and cycling.

Many participants had not previously considered that local government may play a role in promoting healthy eating through affecting where food facilities locate. While some US cities have passed zoning laws to regulate fast food outlets, (25) and a study of fast food outlets in Montreal suggested that cities should use zoning regulations to restrict venues in areas with young people, (26) planners in the focus groups noted that planning law in Canada does not permit communities to discriminate against particular food retailers. Some planners suggested that raising concerns about locating fast food outlets near schools or other places frequented by youth could influence land use and zoning decisions.

Planners identified practices of centralizing services as a barrier to physical activity. To reduce costs in a context of declining populations in small communities, provincial governments and school boards have consolidated schools on sites that preclude youth from walking or cycling. Given the time youth spend in school, and the facilities that schools provide in rural areas with limited amenities, the location and use of school facilities significantly affects opportunities for physical activities. Most groups raised community after-hours use of schools for recreational activities as a challenge. Recreation professionals argued that youth in rural areas cannot easily attend after-school programs because no late buses are provided. School board and government policies that made sense in the past may need adjustment to encourage optimal use of the built environment.

Governance barriers

Focus group participants commonly suggested that the organization of government induces competition and reduces opportunities for collaboration. Some participants described "silos," with government departments safeguarding their own autonomy while competing for resources and influence. No department has a clear mandate to coordinate programs to promote youth health. Health has traditionally been a provincial responsibility, but some delivery of the health mandate has occurred through local community health authorities. A recreation professional worried about new responsibilities.

"Again, health is not a core function of the municipality. I think that needs to be emphasized. The province just can't download everything onto the municipalities, although they try sometimes."

Within local government, the professional roles and priorities of staff may create competing agendas. Participants described engineers as powerful within the local government system, setting the criteria for roads and specifications for buildings. As one planner said, development decisions are:

" ... driven by the belief within the community and I would say within the political circles whether it's the elected or the most senior levels of administration within communities that what's more important than anything else is the really hard infrastructure which people rely on day to day to drive to and from their place of work, etc. That's what always gets first priority. The quality of the environment ... that's what gets short shrift."

Participants revealed their professional priorities in the issues they raised. Health authority staff embraced the health mandate; recreation programmers saw promoting physical activity as improving health. Planner participants thought their work could contribute to community health, but offered few specifics. None of the participants revealed a holistic view that effectively integrated health and built environment.

As a planner participant noted, local governments have traditionally seen development as good. The participant described a rural area where six small municipalities of under 1000 people each demanded an arena: now, with population declining, they are looking for new uses for the facilities. The legacy of political decisionmaking without adequate foresight may leave communities short on resources to meet contemporary needs. In most groups, participants called for effective political leadership to move the health agenda forward. Some planners thought that political champions within government could overcome institutional barriers that resist change. Others suggested that local government members need education about the issues and better training for their jobs.

Cultural factors

Participants pointed to cultural values and behaviours that led Atlantic Canadians to make extensive use of the car for travel and to live far from everyday destinations. Except in the largest cities, youth do not have access to public transportation: where they do have access, using public transportation may carry a stigma, participants said. Low-income families lack the means to participate in recreational activities and to buy healthful food. Just as members of the public surveyed in Calgary held parents responsible for children's obesity, (27) policy-makers attributed poor health outcomes primarily to parents who control mobility and food options for youth. They noted that parents do not let children walk or cycle because of safety concerns, mostly unrelated to the quality of the built environment. Several participants reported restricting their children's mobility because of their own fears.

Comments made during the focus groups revealed participants' perceptions that youth received limited attention from local government and often prove challenging to engage. The most common built environment features that focus group members associated with youth were schools, skateboard parks, and ice rinks. Several participants described events that portrayed youth as unruly or unresponsive, or linked them to concerns about vandalism, rule-breaking, or graffiti. One planner said youth only get attention after a crisis; several suggested that youth are not the priority population that seniors or children are for local government. Some participants revealed negative attitudes towards youth. By contrast with other participants, recreation staff proved most likely to describe youth in positive terms and to report having engaged them in developing facilities.

DISCUSSION

As health promotion and obesity reduction have become issues for local government, they have served the interests of staff members within local health authorities, recreational programming, and active transportation departments. Others managing and producing the built environment are beginning to identify the implications of the health agenda for policy-making. The Canadian participants, like policy-makers in a UK study, (22) saw health concerns as giving them leverage in promoting their own concerns. New programs, like the integrated community sustainability plans required for municipalities to access the Gas Tax Fund, (28) may provide mechanisms for planning staff to profile health matters. At present, however, professionals in local government may have limited understanding of the complexity of the issues contributing to youth obesity and have yet to acknowledge the need for a comprehensive multi-stakeholder approach to finding solutions.

Focus group participants suggested that it will not be easy to address the fiscal imbalance that leaves local governments with inadequate means to fulfil their obligations, overcome the legacy of a built environment designed for the car, overturn traditional ways of doing business and running government, and change cultural attitudes that undermine youth health. As a recreation professional suggested, however, the time may be right to begin the transformation.

"The fact is that the government agencies provincially and federally are pumping dollars and resources. Everybody is stepping on everybody's toes to get involved. It's great for me to see planners and architects now involved, so we are broadening the horizon of the partners. It's going to take a generation. Change at this level doesn't happen overnight."

Researchers found the focus group method useful for generating insightful discussions around the questions asked. Greater consensus developed within focus groups that were less diverse in composition; however, mixed groups of professionals showed greater evidence of learning from each other and enhancing the complexity of issues discussed. Facilitating focus groups within local government could contribute to bridging the differences between departments which participants saw as limiting opportunities to advance a comprehensive health mandate to reduce youth obesity.

Acknowledgements: This research was supported by the Canadian Institutes of Health Research (CIHR)--Institute of Human Development, Child and Youth Health and Institute of Nutrition, Metabolism and Diabetes, and the Heart and Stroke Foundation of Canada (HSFC), through the Built Environment, Obesity and Health initiative (2007-2010). The authors are grateful to the Co-Principal Investigator on the project, Renee Lyons, and to the other members of the project team: Mike Arthur, Chris Blanchard, Andrea Chircop, Trevor Dummer, Sara Kirk, Louise Parker, Robert Pitter, Daniel Rainham, Laurene Rehman, Cindy Shearer and Chris Shields.

Received: October 10, 2009

Accepted: January 23, 2010

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Jill L. Grant, PhD, [1] Kathryn C. MacKay, MPlan, [2] Patricia M. Manuel, PhD, [3] Tara-Leigh F. McHugh, PhD [4]

Author Affiliations

[1.] Professor, School of Planning, Dalhousie University, Halifax, NS; Research Associate, Atlantic Health Promotion Research Centre, Halifax, NS

[2.] Planner, Cities and Environment Unit, Dalhousie University, Halifax, NS

[3.] Associate Professor, School of Planning; Associate Professor, School of Occupational Therapy, Dalhousie University, Halifax, NS

[4.] Assistant Professor, Faculty of Physical Education and Recreation, University of Alberta, Edmonton, AB

Correspondence: Iill Grant, School of Planning, Dalhousie University, Box 1000, Halifax, NS B3J 2X4, Tel: 902-494-6586, Fax: 902-423-6672, E-mail: [email protected]

Conflict of Interest: None to declare.

Table 1. Discussion Questions for Planners' Focus Groups

* What is your (or your agency's) role in creating physical or
built environments that support healthy living, especially among
youth?

* In what ways do the physical (built) environments of your
jurisdiction (municipality, province) support healthy living? In
what ways do they undermine healthy living?

* What policies or programs available to you (and your
jurisdiction) help communities choose to invest in
health-supporting improvements to the built environment?

* What are the biggest changes needed in your jurisdiction to
facilitate these environments?

* What challenges do you (or your agency) face in trying to
implement changes such as these?

(If not covered by answers to the above questions)

* What kind of policy, regulatory, or administrative changes in
your jurisdiction would make it easier to build communities that
support healthy living, especially for youth?

* What tools and resources would be helpful to local
decision-makers in facilitating a built environment that supports
healthy living?

* What initiatives should planners take to promote better
decision-making about investments in the built environment?