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Sustained impact of community-based physical activity interventions: key elements for success Haggis, Callista; Sims-Gould, Joanie; Winters, Meghan; Gutteridge, Kaitlyn; McKay, Heather A Sep 27, 2013

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RESEARCH ARTICLE Open AccessSustained impact of community-based physicalactivity interventions: key elements for successCallista Haggis1*, Joanie Sims-Gould1,2, Meghan Winters3, Kaitlyn Gutteridge1,2 and Heather A McKay1,2AbstractBackground: Compelling evidence supports the cost effectiveness and potential impact of physical activity onchronic disease prevention and health promotion. Quality of evidence is one piece, but certainly not the soledeterminant of whether public health interventions, physical activity focused or otherwise, achieve their fullpotential for impact. Health promotion at both population and community levels must progress beyond healthintervention models that isolate individuals from social, environmental, and political systems of influence.We offer a critical evaluation of lessons learned from two successful research initiatives to provide insights as tohow health promotion research contributes to sustained impact. We highlight factors key to success including thetheoretical and methodological integration of: i) a social ecological approach; ii) participatory action research (PAR)methods; and iii) an interdisciplinary team.Methods: To identify and illustrate the key elements of our success we layered an evaluation of steps taken atop areview of relevant literature.Results: In the school-based case study (Action Schools! BC), the success of our approach included early andsustained engagement with a broad cross-section of stakeholders, establishing partnerships across sectors and atdifferent levels of government, and team members across multiple disciplines. In the neighbourhood builtenvironment case study, the three domains guided our approach through study design and team development,and the integration of older adults’ perspectives into greenway design plans. In each case study we describe howelements of the domains serve as a guide for our work.Conclusion: To sustain and maximize the impact of community-based public health interventions we propose theintegration of elements from three domains of research that acknowledge the interplay between social, environmentaland poilitical systems of influence. We emphasize that a number of key factors determine whether evidence frompublic health interventions in school and built environment settings is applied in practice and policy sectors. Theseinclude relationship building at individual, community, and societal levels of the social ecological model, usingparticipatory action research methods, and involving an engaged and committed interdisciplinary team.Keywords: Physical activity, Built environment, Community-based research, Social ecological model, Participatoryaction research, Framework, Stakeholders* Correspondence: callista.haggis@hiphealth.ca1Centre for Hip Health and Mobility, 2635 Laurel Street, Vancouver, BC V5Z 1M9,CanadaFull list of author information is available at the end of the article© 2013 Haggis et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly cited.Haggis et al. BMC Public Health 2013, 13:892http://www.biomedcentral.com/1471-2458/13/892Background“Physical inactivity is the fourth leading cause of deathworldwide… Although evidence for the benefits ofphysical activity for health has been available sincethe 1950s, promotion to improve the health ofpopulations has lagged in relation to the availableevidence…” [1]Dr. Harold W Kohl, 2012Quality of evidence is one piece, but certainly notthe sole determinant of whether public health inter-ventions, physical activity focused or otherwise, achievetheir full potential for impact [2,3]. The literature speaksto a number of other factors at play. A central consider-ation is that health promotion at both population andcommunity levels demands that we progress beyondtraditional health intervention models that isolate indi-viduals from social, environmental, and political systemsof influence [4-7]. In public health research, researchersmust collaborate with stakeholders to generate know-ledge that end-users might apply to interventions re-lated to policy, practice, and/or product development[8-11]. Further, retrofitting interventions that are devel-oped in isolation from the population they seek to‘serve’ are destined to fail [6]. Importantly, the imple-mentation of health promotion research is but a firststep of an often-lengthy process toward sustained im-pact of effective outcomes [5,12]. We define sustainedimpact as the implementation of an evidence-based pro-gram or policy that has lasting influence on health pro-moting behaviour [5].We offer a critical evaluation of lessons learned toprovide insights on how health promotion research con-tributes to sustained impact. We highlight factors key tosuccess including the theoretical and methodologicalintegration of: i) a social ecological approach; ii) partici-patory action research (PAR) methods; and iii) an inter-disciplinary team. Although these three domains havebeen incorporated in many other studies, our aim is toextend this work and explicitly illustrate how the inte-gration of both their unique and overlapping character-istics are critical to our success in school-based-physicalactivity (with children and youth) and built environ-ment (with adults over 65) settings. More generallyspeaking, we show that how these domains intersect orare used in concert to maximize effectiveness dependsupon the problem being addressed and distinct envir-onmental settings.Therefore, our synopsis of lessons learned addressesa health issue of pressing importance -- physical in-activity. We focus on those elements of the three cen-tral domains that guide our approach and, illustrateit’s utility in two community-based settings: schoolsand the neighbourhood built environment.The pressing health and policy concern of physical(in) activityThe well-known benefits of physical activity and the chal-lenge of implementing physical activity models withinand across communities, sets the stage for our discus-sion. Compelling and incontrovertible evidence supportsthe cost effectiveness and potential impact of physicalactivity on chronic disease prevention and health pro-motion [13-17]. Alarmingly, physical inactivity is nowcited as the fourth leading cause of death worldwide [1].To address this pandemic, the Global Advocacy forPhysical Activity group identified ‘7 best investments’,well-supported by evidence to assist populations achieveguideline levels of physical activity [18]. Two of thoseseven investments are: (1) promoting physical activityin school environments, and (2) neighbourhood builtenvironments conducive to physical activity [18,19].The issue of physical inactivity, and in particular thesetwo ‘best investments’ serve as motivation and providegrounding context for our discussion, and its applicationin real-world research endeavours.MethodsThree researchers from our team initiated the criticalevaluation that identified key elements within the domainsthat contributed to impact and sustainability in two largeprograms of research (Action Schools and Active StreetsActive People). They layered an evaluation of steps takento develop and implement the research programs atop areview of the literature. In five separate team meetings, wecompared experiences and data from a process evaluation(where obtainable) with findings from a literature review.For this review we included 74 articles (Web of Scienceand EBSCO interdisciplinary academic databases, restrictedto articles published 2000–2013) related to health interven-tion research impact. We isolated key elements as part ofthis comparison. Strategies used to establish rigor for thisstudy included engaging with the research team for peerdebriefing (via team meetings and smaller focused discus-sion about the developing themes), memo writing through-out the analysis process, and recording an audit trail ofdecisions made throughout [20-22].The University of British Columbia (UBC) Clinical Re-search Ethics Board (C02-0537) approved the ethics forthe Action Schools pilot study, and the Action Schoolsdissemination (B05-0505). The University of Victoria alsoapproved the ethics for the Action Schools dissemination(07-05-149f). The UBC Behavioural Research Ethics Board(H12-00593) and the Simon Fraser University ResearchEthics Board (2012 s0435) approved the ethics forActive Streets Active People.Haggis et al. BMC Public Health 2013, 13:892 Page 2 of 8http://www.biomedcentral.com/1471-2458/13/892Results and discussionDomain 1: a social ecological approachSocietal problems, like physical inactivity, require compre-hensive multi-factorial solutions [1,23,24]. Social ecologicalmodels address the interaction and interdependency be-tween individuals, multiple settings (e.g. home, school)and levels (e.g. local government, family) that influencebehaviour [25-27]. Interventions that adopt a social eco-logical framework identify one or more targets for changeusing networking relationships and rely upon partnershipsacross sectors and disciplines [28]. The World HealthOrganization (WHO) also speaks to the need of a socialecological approach to combat physical inactivity as itrelates to the global burden of disease, death and disability[18]. The WHO deems it essential to engage differentlevels of stakeholders so that diffusion of context-specific,evidenced based findings can be integrated into institu-tions that influence uptake in the broader population[18]. Thus, social ecological approaches increase thepotential sustainability and impact of public health re-search [5,26,27].Domain 2: a participatory action research approachThe second domain of our praxis relates to participatoryaction research (PAR) methodologies. PAR mobilizes com-munity partnerships and engages stakeholders early andacross phases of research to ensure opportunities to investin research design, questions and outcomes [29]. Genuineopportunities for participation are necessary to overcomethe common research pitfall of superficial levels of en-gagement and therefore integral to the success of manypublic health research projects [6]. As one example, firstand foremost, researchers must engage potential usersto identify relevant research questions [6]. In PAR thecommunity identifies the “problem” to address. Researchfindings are directly applied (where possible) to solve theseproblems.Research conducted using PAR approaches seeks toavoid traditional “extractive” methods most often adoptedby universities and governments where “experts” enter acommunity without consultation, assess subjects and ex-tract data from the community to write theses and publi-cations and never report back to that community. PARproceeds through iterative, continuous cycles where re-searchers and community partners work together to firstidentify major issues, concerns and problems, then initiateresearch, subsequently to originate action, and then tolearn about this action; after which they proceed to a newresearch and action cycle. Participants continuously reflecton their learning from previous actions and proceed toinitiate new actions.Another key aspect of PAR in public health settingsis early and close engagement of policy makers [30].Political context is a significant and sometimes ‘intangible’barrier that traditional research models do not consider.Context may determine the degree or nature of involve-ment, but actors from political and policy arenas shouldhave a role in the research development and implementa-tion process. Economic feasibility and cultivating sharedvalues in partnership with decision makers that togethertranslate into political will are critical for sustained impact[2,31]. Policy makers have commented upon the naivetyof public health researchers regarding political processesthat lead to policy action including lack of recognition thateven ‘rigorously validated’ evidence requires an enablingenvironment to be applied in policy and practice [2,8,11].Providing local examples with clear connections and directimpact on local community, family and constituents is keyto policy makers implementing research outcomes [11].Domain 3: interdisciplinary teamsConvening interdisciplinary research teams is the thirdelement we deem essential to guide the sustained impactof community-based public health interventions. The grow-ing trend towards an interdisciplinary team approach inresearch addresses complex scientific and societal prob-lems that cannot be effectively addressed within a singu-lar disciplinary setting [32,33]. It also acknowledges thatinterdisciplinary teams are preferred to create a holistic,integrated view of complex phenomena [34]. Teams ideallyinclude a cadre of trained scientists with specialized know-ledge across different fields and other relevant stakeholderssuch as policy analysts/makers, government officials, healthcare workers/managers and citizens. The definition of a‘successful’ team varies most often depending on expec-tations of stakeholder groups and may range from thenumber of publications related to the project on the onehand to the teams’ ability to translate research findingsinto programs, practice or policy, on the other. Giventhe complex conceptual, methodological and translationalnature of community-based public health research weadvocate an interdisciplinary approach to address keychallenges that span micro, meso, and macro levels ofinfluence [35].Example 1: promoting physical activity in the schoolenvironment- a focus on children and youthChildhood obesity rates in North America continue torise [36]. In Canada alone, research indicates that as manyas 93% of children and youth may not participate inenough physical activity to maintain healthy bodies andminds [37]. Innovative strategies are necessary to en-courage health-promoting behaviors, such as physicalactivity and healthy eating, for youth. Schools providean important intervention environment – this settingreaches youth of diverse racial and socioeconomic back-grounds and children spend approximately 50% of theirday in a classroom [38,39]. Further, evidence suggestsHaggis et al. BMC Public Health 2013, 13:892 Page 3 of 8http://www.biomedcentral.com/1471-2458/13/892that school-based interventions that target health be-havior modification in school-aged children, includingphysical activity and healthy eating, are the most prom-ising strategies to date [38].We integrated elements from three key domains todevelop our research approach and implement, evaluateand disseminate Action Schools! BC (Action Schools) --a province-wide physical activity focused, whole school,health promotion model. The Action Schools model wasbuilt upon the premise that to ‘provide more opportunitiesfor students to make healthy choices more often’ withinelementary and middle school environments, family, school,community and provincial level support is essential. Im-plementation of the Action Schools model was efficaciousand increased children’s physical activity, cardiovascularfitness and other health-related outcomes [40,41]. Thedesign of the model enhanced buy-in by principals andteachers and influenced adoption of the model withinschools [40]. Importantly, political will and public inter-est figured prominently in the sustained impact of theAction Schools model [42]. Currently, 1455 schools areregistered as Action Schools, and the model has reachedmore than 400,000 children across BC [43,44]. Thisscaling-up of Action Schools was influenced by a hier-archy of factors that traversed individual, institutionaland environmental levels [40].The scope and impact of Action Schools provides oneexample of how elements from the three domains ofour framework work in concert to inform our practice.Specifically, in-line with the principles of PAR, we hadearly and sustained engagement with a broad cross-section of stakeholders to address physical inactivityin a young population. In the pilot phase, we createda research partnership with five government agencies toaddress the role of two-way knowledge exchange in up-take and application of innovations (Table 1) [45]. Also,taking from the social ecological approach we formedpartnerships horizontally across sectors and verticallyat different levels of governance by creating three guid-ing committees (1) Provincial Advisory Committee (2)School Advisory Committee (Action Team) (3) EvaluationCommittee [41]. Combining these elements, we maintainedongoing engagement during the research and imple-mentation process through a series of consultations andfocus groups. For example, we hosted meetings withprincipals and administrators to learn the pressing healthissues in their school environment. We also engagedteachers to overcome implementation barriers, and de-velop collaborative strategies to encourage students tobe more active and healthy. We conducted focus groupswith parents to understand their perceptions about theimportance of physical activity and the impact of ActionTable 1 Action schools: multi-level model of engagementIndividual level Elementary and middle school-aged childrenCommunity level* Elementary and middle school principalsElementary and middle school teachersParent Advisory Council (PAC)District school board superintendentsPost-secondary institutions (including University of British Columbia, University of Victoria)Sport and leisure governing bodiesAboriginal sport, recreation and physical activity councilsCommunity-based health promotion organizations (including BC Paediatric Society, Heart and Stroke Foundation,Childhood Obesity Foundation)School-based healthy living committees (Breakfast for Learning, BCRPA After School Initiative)Active transportation initiatives (including HASTe BC, Move for Health Day)Interdisciplinary working groups (including Physical Activity and Obesity Working Group, Physical Literacy Working Group)Municipal governments (including City of Vancouver, City of Burnaby)Vancouver Board of Parks and RecreationSocietal level BC Provincial Health Services AuthorityBC Ministry of Health (Healthy Families BC)BC Ministry of Community, Sport and Cultural DevelopmentBC Ministry of Education (Healthy Schools BC)2010 Legacies NowDirectorate of Agencies for School Health BC (DASH BC)Public Health Agency of Canada (Aboriginal Diabetes Initiative)*For complete list of current Action Schools stakeholders, please refer to Action Schools! BC report [43].Haggis et al. BMC Public Health 2013, 13:892 Page 4 of 8http://www.biomedcentral.com/1471-2458/13/892Schools on their child’s life. We provided baseline pilotdata to the guiding committees within 4 months of thebeginning of evaluation, immediate process evaluationdata to program developers and actively involved stake-holders in the dissemination of findings and plans forprogram sustainability.Consistent with principles of PAR, our guiding commit-tees transformed with the scale-up of Action Schools to in-tegrate more diverse interests and stakeholders. Currently,over 50 organizations, initiative or committees 2011–2012are engaged with Action Schools including Heart andStroke Foundation (BC and Yukon), Childhood ObesityFoundation, BC Paediatric Society (Table 1) [43].Our interdisciplinary team integrated committed scien-tists from 6 disciplines to design and implement ActionSchools. Research team members spanned education, medi-cine, kinesiology, cardiovascular physiology, psychologyand health policy. This interdisciplinary research teamcomplemented the needs and expertise of stakeholdersand was positioned to integrate stakeholder perspectivesand insights into research questions and methodologiesspecific to investigators’ specialized area of enquiry (e.g.cardiovascular health, psychosocial health, bone healthand so on).Example 2: the intersection of physical activity and theneighbourhood built environment- a focus on older adultsThe built environment, that being the physical form ofneighbourhoods including land use patterns, street-scapefeatures and transportation systems, has the potential tosignificantly shape health outcomes, positively and nega-tively [46-48]. The WHO positions healthy urban planningas a top priority to improve health globally [49,50]. Re-searchers and practitioners identify a need to realign thebuilt environment with public health to overcome theweak dialogue and disconnections that currently characterizethe relationship between the disciplines of urban healthand planning [51,52]. Further, the National Centre forEnvironmental Health of the Centres for Disease Con-trol and Prevention argues for the “reintegration of landuse planning and public health, explicitly linking trans-portation and land use planning to public health out-comes such as increased obesity, asthma and mentalhealth” [51].Importantly, engagement across multiple levels of gov-ernment and community are important determinants ofwhether evidence based recommendations for health pro-motion at the built environment level are applied in prac-tice and policy environments [51-54]. Taken together, thecomplexity of these issues suggests that health interventionsthat involve urban planning, the built environment andphysical activity may benefit from an integrated approach.Our research program in this arena, “Active Streets,Active People”, is predicated upon the notion thatneighbourhood design mediates the decline in health andphysical activity that accompany ageing. A walkable neigh-bourhood may delay the often traumatic transition ofolder adults to residential care or assisted living facilitiesand the substantial health care costs that ensue [55]. Theaim of Active Streets, Active People is to identify linksbetween the built environment and older adult physicalactivity and health [56,57]. The study capitalizes on a nat-ural experiment, where major investments (> $5 MillionCdn) are being made by the City of Vancouver to developa greenway to encourage physical activity through activetransport routes and destination place making [58].To evaluate the impact of the greenway on older adults’physical activity and social interactions, we recruited 193older adults who live in surrounding neighbourhoods toparticipate in a mixed-methods study. A subset of par-ticipants completed a semi-structured, qualitative walkinginterview. We measured participants before the greenwaydevelopment (Fall 2012) and will meet with individualsagain upon completion of the greenway (Fall 2014).An integration of elements from a social-ecological model,PAR, and an interdisciplinary team approach guided bothdevelopment of the Active Streets, Active People researchprogram and the integration inclusion of older adults’ per-spectives into City of Vancouver greenway design plans.Adopting central tenets of the social ecological model,we engaged partners at multiple levels and across sectorsto identify feasible and high priority investments in thebuilt environment on a neighbourhood scale (Table 2).Specifically, we convened representatives from the BCMinistry of Health, provincial health authorities, City ofVancouver (Planning, Social Policy and Engineering), se-niors’ organizations and older adults themselves at a veryearly stage (Table 2).Table 2 Active streets active people: social ecologicalmodel of engagementIndividual level Community dwelling older adultsCommunity level South Vancouver Neighbourhood HouseSeniors Advisory Committee, City of VancouverWest End Seniors’ NetworkUnited Way of the Lower Mainland(Strategic Initiatives (Seniors),Community Impact and & Investment)City of Vancouver (Planning, Engineering,Social Policy)City of Surrey (City councillor)Union of BC Municipalities (Policy Analyst)Societal level BC Housing (VP Operations)Vancouver Coastal Health AuthorityMinistry of HealthCanadian Urban InstituteWorld Health OrganizationHaggis et al. BMC Public Health 2013, 13:892 Page 5 of 8http://www.biomedcentral.com/1471-2458/13/892In keeping with PAR principles, and very early on inthe research process, we hosted a day long symposiumwhere 140 stakeholders across multiple sectors cametogether to address the following question(s) “What makesa neighbourhood a good place to grow old?” “What pro-grams and services are currently available to keep olderadults active?” and “How can we do better?” Additionally,our research team guided neighbourhood-walking tourswith our stakeholders (older adult residents, representa-tives from community-based organizations, the media andpolicy makers). We used a street audit tool to discuss spe-cific features of the built environment with older adultsand to identify what helps or hinders their ability to bephysically active in their neighbourhood. Input from thesymposium and tour informed specific research questionsand the study design for research activities. In addition,institutional partners from the City of Vancouver andcollaborators from community-based organizations wereconsulted to provide feedback on the scope of the quanti-tative measurement toolkit and walking interview guide.Overlapping elements of these domains also informedour strategy of ongoing engagement. One example wasthe distribution of the walking tour findings report (writtenin accessible language) to our broader community of stake-holders (Table 2). Further on in the research process, toconnect stakeholders with outcomes, we provided baselineresults and additional supplementary reports for thosewho expressed interest in specific outcomes. Participantfeedback reports were distributed within 3 months of be-ginning the evaluation. Overall, this early and sustainedengagement created ‘joint’ ownership of problems andsolutions related to the intersection between the builtenvironment and the health and physical activity of olderadults.As the Active Streets, Active People research programprogresses into its second year we have regular (weeklyto bi-monthly depending on activities) meetings withstakeholders to discuss a range of issues. Topics include:progress to date; feedback on research questions andparticipant feedback reports; and the design of futurecommunity-based engagement events targeted at olderadult participants. Thus, in keeping with our praxis, olderadults, municipal and non-governmental organization part-ners helped define the problem addressed, methods used(quantitative and qualitative) to assess the problem and willengage with us to interpret and disseminate our resultsat study completion (2014).An interdisciplinary team is of particular importancewhen working at the confluence of the broad fields ofpublic health and urban planning - specifically whenaddressing how environmental changes affect physicalactivity and mobility patterns. These two disciplines havetraditionally focused on different strategies to address simi-lar issues [59]. However, the importance of interventionsthat address i.) factors that influence health on individ-ual, interpersonal, and societal levels and ii.) the inter-play of built environment features, lends itself to theformulation of an interdisciplinary team. Our Active Streets,Active People team is comprised of researchers withbackgrounds in: Public Health, Epidemiology, Urban Plan-ning, Gerentology, and Exercise Science. Additionaly, asenior member from the Active Transportation Divisionin the Department of Engineering Services at the City ofVancouver is a Co-Principal Investigator. Collaboaration,where different perspectives are valued, is key to playingto team members strength and overcoming tradtional pit-falls of narrow metrics and shortsightedness.Clearly, there is momentum across multiple levelsthat call for integration between evidence-based healthoutcomes and policy and practices within the built en-vironment setting. The Canadian Institute of Plannersadvocates for interdisciplinary partnerships that positionHealthy Communities “as a dominant public policy andresearch focus on the Canadian landscape” [60]. Closerto home, the City of Vancouver developed a HealthyCity Strategy that spans municipal departments and in-cludes events that facilitate interdisciplinary dialoguebetween health researchers and practitioners [61]. Toillustrate the mutual benefit received through our closerelationship with urban planners and our teams’ ability(through ongoing meetings with interdisciplinary teammembers) to translate research and make it applicableto audiences beyond applied scientists, we were the onlyacademic team invited to present our research at HealthyPeople, Healthy City Conference, a high profile eventwith city planners and policy makers. The integration ofelements from the socio-ecological model, PAR and aninterdisciplinary team approach has significantly strength-ened our research design, engagement with stakeholdersand our ability to translate new knowledge into meaning-ful outcomes for stakeholders so as to ‘scale-up’ or dissem-inate these outcomes, in future.ConclusionsWicked problems – defined as challenging issues withdiverse, changing, and context specific factors of influ-ence [62] such as physical inactivity do not have a single,or simple solution [63]. Complexity requires an advance-ment of processes, tools and teams that are attuned tothese conditions [64]. Specifically, to sustain and maximizethe impact of community-based public health interventionsin school and neighbourhood environment settings wepropose a praxis that acknowledges the interplay betweensocial, environmental and political systems of influence.We join others who have advanced beyond interventionsthat target individuals and small groups isolated from theircontext [2]. We emphasize that key factors for successare relationship building at individual, community, andHaggis et al. BMC Public Health 2013, 13:892 Page 6 of 8http://www.biomedcentral.com/1471-2458/13/892societal levels of the social ecological model, using par-ticipatory action research methods, and the involvementof an engaged and committed interdisciplinary team.The view supported by our work is that empowermentat multiple levels seeks to ignite changes that, in turn,contribute to sustained impact of outcomes [27]. We alsoadvocate for strong and early alliances with governmentand community stakeholders. These collaborators informedour process at every stage and become key disseminationpartners and generate evidence-informed policies, in future.Competing interestsThe authors declare that there are no competing interests.Authors’ contributionsThe conceptualization and development of this critical evaluation was led byCH and JSG. CH led the literature review and writing of the paper. KGassisted with the literature review and wrote portions of the manuscript. CH,JSG, MW, and HM refined the critical evaluation and wrote significantportions of the manuscript. All authors critically revised the manuscript andapproved the final version.AcknowledgementsAction Schools was funded by Canadian Institutes of Health Research (grantFRN: GIR-86122) with joint funding from the Institute of Nutrition, Metabolism &Diabetes and the Institute of Population & Public Health, and the Heart andStroke Foundation of Canada. Active Streets Active People was funded by PeterWall Solutions Initiative (grant FRN: PW-11-056) and Michael Smith Foundationfor Health Research (grant FRN: M. Smith KT-KTA-00002-112).Author details1Centre for Hip Health and Mobility, 2635 Laurel Street, Vancouver, BC V5Z 1M9,Canada. 2Faculty of Medicine, University of British Columbia, Vancouver, BC V6T1Z4, Canada. 3Faculty of Health Sciences, Simon Fraser University, Burnaby, BCV5A 1S6, Canada.Received: 22 May 2013 Accepted: 20 September 2013Published: 27 September 2013References1. Kohl HW 3rd, Craig CL, Lambert EV, Inoue S, Alkandari JR, Leetongin G,Kahlmeier S, Lancet Physical Activity Series Working G: The pandemic ofphysical inactivity: global action for public health. Lancet 2012,380(9838):294–305.2. Huberty JL, Balluff M, O’Dell M, Peterson K: From good ideas to actions:a model-driven community collaborative to prevent childhood obesity.Prev Med 2010, 50(Suppl 1):S36–S43.3. 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Conklin J: Dialogue mapping: Building shared understanding of wickedproblems. New York, NY: John Wiley & Sons, Inc.; 2005.doi:10.1186/1471-2458-13-892Cite this article as: Haggis et al.: Sustained impact of community-basedphysical activity interventions: key elements for success. BMC PublicHealth 2013 13:892.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitHaggis et al. BMC Public Health 2013, 13:892 Page 8 of 8http://www.biomedcentral.com/1471-2458/13/892

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