Institutional Engagement Practices as Barriers to Public Health Capacity in Climate Change Policy Discourse: Lessons from the Canadian Province of Ontario

Public health engagement in the communication, discussion, and development of climate change policies is essential for climate change policy decisions and discourse. This study examines how the existing governance approaches impact, enable, or constrain the inclusion, participation, and deliberation of public health stakeholders in the climate change policy discourse. Using the case study of the Canadian Province of Ontario, we conducted semi-structured, key informant interviews of public health (11) and non-public health (13) participants engaged in climate change policies in the province. The study results reveal that engagement and partnerships on climate change policies occurred within and across public health and non-public health organizations in Ontario. These engagements impacted public health’s roles, decisions, mandate, and capacities beyond the climate change discourse; enabled access to funds, expertise, and new stakeholders; built relationships for future engagements; supported knowledge sharing, generation, and creation; and advanced public health interests in political platforms and decision making. However, public health’s participation and deliberation were constrained by a fragmented sectoral approach, a lack of holistic inter-organizational structures and process, political and bureaucratic influences, irregular and unestablished communication channels for public health integration, and identities and culture focused on functions, mandates, biased ideologies, and a lack of clear commitment to engage public health. We conclude by providing practical approaches for integrating public health into climate change discourse and policymaking processes and advancing public health partnerships and collaborative opportunities.


Introduction
Characterized as a "wicked problem," climate change is a contemporary phenomenon with unparalleled complexity [1][2][3]. It spans several social, environmental, and political issues; it requires the inclusion of various stakeholders and voices with different ideas about the nature of the problem. Achieving such complex yet interrelated needs of climate change management call for sound governance [4][5][6][7][8]. The concept of governance refers to pragmatic, democratic, and decentralized approaches for legitimizing and targeting complexities of climate change policies by accounting for participative structures and deliberative processes that match the scale and intricacies of the issue and

Conceptualizing Stakeholder Engagement and Climate Change Policies
A stakeholder is any person, group of people, or organization impacted by an issue addressed through a public policy [36]. Public policy represents a government's action or inaction on an issue [37][38][39]. That is, public policy portrays a claim of the legitimate role of the state and politics in the processes and outcomes of a policy and recognizes the role of government in administrative policies and policy instruments [37][38][39][40]. However, achieving the desired policy outcomes require government(s) to engage within (internally), across a variety of organizations and sectors, and with many stakeholders directly or indirectly impacted by an issue.
Broadly, involvement in government policy processes occur through public communication or public participation [41,42]. Public communication is one-way information transmission either from a government agency to the public (public communication) or from the public to an agency (public consultation) [42]. Public participation signifies the government's approaches to meaningfully engage different stakeholders its policy decisions [42]. Public participation is also synonymous with collaboration, which relates to a mutually beneficial relationship between two or more parties to achieve a specific goal through structured and shared responsibility, authority, and accountability [42][43][44][45]. Collaboration sometimes takes the form of and is synonymously associated with cooperation, coordination, networking, or partnerships [43][44][45]. While partnerships describe any form of engagement, cooperation (formal but independent problem solving), coordination (mutual problem solving without shared resources or authority), networking (information sharing), and collaboration, all represent specific forms of engagement [44][45][46]. Each level of engagement builds on the other (four-tier inter-organizational domains), with collaboration as the most critical tier [44].
Specific to climate change, decision making involves many stakeholders across multiple scales, sectors, and stages of policymaking [19,23]. Many impacts also transcend public health into other sectors due to the multiple pathways of climate change effects and sectoral actions [19,23,47] Collaboration connects decision makers and stakeholders throughout the various stages of a policy [48]. Thus, collaboration is the ideal form of public health engagement in climate change decisions because it connects multiple stakeholders, builds relationships, and supports working towards mutually beneficial actions [43,[49][50][51]. Communication and consultation complement participation by providing information that necessitates collaboration [42,43].
Stakeholder engagement in public policy is more than just an interaction between the government and key stakeholders. Rather, the quality of those interactions is defined by the institutional arrangements-structures, responsibilities, processes, networks, and organizations-that impact the integration of a stakeholder in the decision processes [9,38,52,53]. For instance, the failure and lack of inclusion of relevant actors in climate change governance have been blamed on legitimacy, conceived as an outcome resulting from an institution's activity [9,54]. This is because institutions (socially constructed norms, rules, and principles) supply individuals with reference points-physical arrangements, rules of behavior, values (interests, ideologies, and beliefs), and knowledge-that can influence how, why, when, and where public health is included in climate change governance [9,38,52,53]. In turn, designing and assessing approaches for public health stakeholder inclusion also requires the examination of institutions embedded in the participation structures and deliberative processes [9].
Several researchers have conceptualized approaches and principles of stakeholder engagement in various policies, including public health, environmental, or climate change policy [9,23,36,[55][56][57][58][59][60][61][62][63][64][65][66][67]. The literature provides both unique and common factors. However, a framework that integrates these diverse indicators is Cadman's "theoretical model for evaluating contemporary global governance" [9]. The framework provides two criteria for achieving meaningful participation (interest representation and organizational responsibility) and supporting five indicators (inclusiveness, equality, resources, accountability, and transparency). It also provides two criteria for attaining productive deliberation (decision making and implementation) and six supporting indicators (democracy, agreement, dispute settlement, behavioral change, problem solving, and durability). However, despite such extensive research on institutional engagement approaches, a holistic framework outlining how such factors are weighted and structured in the engagement processes are lacking [57]; but the studies provide essential elements for assessing the levels, impacts, and contexts of institutional engagements. and the impact of Ontario's institutions on public health's capacity to participate and deliberate on the province's climate policy decisions and discourse have never been examined. In addressing these gaps, we attempt to answer the following question: How have the existing institutions and governance (both processes and structures) in Ontario impacted, enabled, or constrained the inclusion, participation, deliberation, and capacity of public health stakeholders in the province's climate change policy discourse?

Methods
This study is part of interpretive and mainstream policy research [94][95][96] that uses the case study of the climate change policy discourse of the Province of Ontario (Canada) to examine the influence of public health inclusion, engagement, and integration in the climate change policy discourse. The study uses semi-structured interviews with 11 public health and 13 non-public health professionals engaged in the decision making of climate change policies and interventions in Ontario.

Sampling and Recruitment
Cases included the Office of the Premier and 10 provincial ministries, as shown in Table 1, and 7 public health regions (representing 34 local public health units (PHUs)) in Ontario, as illustrated in Figure 1. The cases selected directly engage in the formulation, discussion, and communication of climate change-related decisions at provincial or local levels.   Quota purposeful sampling was used to discriminately identify policy experts with unique or relevant perspective about the study topic by setting a minimum number of at least one participant per case [98][99][100]. Provincial agency participants were identified from the Ontario government website, INFO-GO (a directory of government employees) [101], environmental registry [102] and from grey literature publications by the various ministries. PHU participants were solicited through a research participation request sent to each PHU through the Association of Supervisors of Public Health Inspectors of Ontario (ASPHIO), which comprises of directors and managers serving the 34 PHUs in Ontario [103]. Additionally, we employed snowball (referral) sampling to complement purposeful sampling via all recommendations of qualified experts [100].

Inclusion Criteria
To be included in the study, the participants were required to communicate their experiences, opinions, and events effectively and concisely. Categories such as job positions and roles served as the starting point of participant selection. Participants were current employees or former employees who had had actively taken part in climate change policies within Ontario as well as participated in inter-agency collaborations and interactions with other agencies on matters relating to climate change. They needed to be a public health or policy experts holding leading roles in climate-related areas in respective jurisdictions. The level of responsibilities included managerial, directorship, or persons in senior-level positions, including policy analysts, Medical Officers of Health, environmental specialists, or those holding managerial roles over climate change programs, strategies, policy analysis, planning, formulation, implementation or research. The participants were required to be familiar with the legislation, standards, and policies relevant to climate change actions. A participant who either changed jobs, job description, or position but had previously participated in the climate change policy formulation or implementation at a senior position was considered. Those who did not fall within the sampled jurisdictions, employee type, or without the nature or level of responsibility defined above were excluded from the study. Quota purposeful sampling was used to discriminately identify policy experts with unique or relevant perspective about the study topic by setting a minimum number of at least one participant per case [98][99][100]. Provincial agency participants were identified from the Ontario government website, INFO-GO (a directory of government employees) [101], environmental registry [102] and from grey literature publications by the various ministries. PHU participants were solicited through a research participation request sent to each PHU through the Association of Supervisors of Public Health Inspectors of Ontario (ASPHIO), which comprises of directors and managers serving the 34 PHUs in Ontario [103]. Additionally, we employed snowball (referral) sampling to complement purposeful sampling via all recommendations of qualified experts [100].

Inclusion Criteria
To be included in the study, the participants were required to communicate their experiences, opinions, and events effectively and concisely. Categories such as job positions and roles served as the starting point of participant selection. Participants were current employees or former employees who had had actively taken part in climate change policies within Ontario as well as participated in inter-agency collaborations and interactions with other agencies on matters relating to climate change. They needed to be a public health or policy experts holding leading roles in climate-related areas in respective jurisdictions. The level of responsibilities included managerial, directorship, or persons in senior-level positions, including policy analysts, Medical Officers of Health, environmental specialists, or those holding managerial roles over climate change programs, strategies, policy analysis, planning, formulation, implementation or research. The participants were required to be familiar with the legislation, standards, and policies relevant to climate change actions. A participant who either changed jobs, job description, or position but had previously participated in the climate change policy formulation or implementation at a senior position was considered. Those who did not fall within the sampled jurisdictions, employee type, or without the nature or level of responsibility defined above were excluded from the study.

Data Collection
Telephone interviews were conducted between May to December 2018, using semi-structured, open-ended questions. The interview questions and guiding themes were organized and guided by research themes, as presented in Appendices A and B. The interviews lasted approximately one hour. All interviews were audio-recorded and transcribed verbatim. The transcripts were then sent to the interviewees for confirmation of content and identification of possible personal identifiers that may have been missed during transcript editing. Data collection (interviewing) was stopped once no new information emerged from the subsequent interviews (theoretical saturation) [104][105][106].
Research ethics approval was obtained from Ryerson University's Research and Ethics Board (File number: REB 2017-390) and from one of the participating cases, as requested by the organization (File Number: 2018-14). Participation consent was received from all the study participants.

Data Analysis
Interpretive policy research characteristically focuses on meaning construction and symbolic language-written or spoken [95,[107][108][109]. On the other hand, mainstream policy studies explore policymaking and agenda-setting processes, policy networks, and governance [95]. Therefore, we use three forms of data analysis. First, focusing on language and discourse, we applied Fairclough's critical discourse analysis (CDA) to identify texts and themes that describe discourses and engagement practices (including actions, events, and interactions) [34,35,110,111]. Second, we supplement CDA with institutional analysis and analysis of narratives to connect the discursive practices to political contexts of climate change policies, account for social contexts influencing discourse and public health engagement, and to overcome CDA shortfalls. Analysis of a priori and emerging themes was conducted by two coders, focusing on each sentence, and guided by the literature on principles of stakeholder engagement, interview guiding themes, and the CDA checklist (Appendix C). The institutional analysis was guided by the Lomas Model of Decision making framework [112]. We applied the sociocultural approach to narrative analysis by locating the participants' stories within the sociopolitical contexts of climate change decision making in Ontario [34]. The analysis focused on five areas, as highlighted by Walter [34]. The act done, when and where the act was done (scene), who did the act and how they/he/she did it (agent and agency), and why the act was done (purpose). Lastly, we apply thematic analysis for systematic identification, analysis, and reporting of themes emerging from the data [34,113].
The data management, coding, and analysis were aided by the QSR international's qualitative analysis software, NVIVO (Version 12). Standardized coding and inter-rater reliability (using Kappa Coefficient) were applied for quality analysis and control [114,115]. The emerging themes explaining the contexts and impacts of collaborative engagements are reported under the two groups (public health (PH) versus non-public health (NPH).
To comply with the ethics requirements and minimize the reader's ability to connect the various quotes to a specific participant, no unique identifiers are included in participant's narratives. Instead, the quoted data is assigned as PH or NPH participants. This was required due to the specific focus of some interviewee positions, the personal knowledge that some policy actors may have about the participants, and the political nature of the information provided especially given the political climate at the time of the interviews.

Results
The results report on the characteristics of participants that produced the study data and the themes that emerged and reported under two headings: influences on public health stakeholder engagements, and effects of interorganizational engagement of intersectoral engagements on public health.

Participant Characteristics
The study data were drawn from 11 PH participants (at least one participant representing MOHLTC and the seven PHU regions) and 13 NPH participants (at least one participant representing the Office of the Premier and 9 NPH ministries), as shown in Table 2. Of the 13 NPH participants interviewed, 5 had previously worked for and engaged in climate change policy decisions with more than one ministry (4 worked for 2 ministries; 1 worked with 3 ministries). Interview questions explored the processes and experiences from those previous ministries as well. Within the PH participants, 2 reported climate change collaborative work with several other PHUs that were not interviewed. Many PH participants were also affiliated with various public health non-governmental organizations (NGOs) in Ontario and worked together in multiple committees or workgroups to promote climate change policy and advocacy. Interview questions explored such engagements. Participants from both groups held positions such as managers, policy experts, policy advisors, policy evaluators, directors, team leaders, and policy analysts. For NPH participants, nine participants have had direct roles in agenda-setting and policy formulation, six participants reported functions in both formulation and implementation, and three participants reported roles in evaluation. PH participants had roles in all stages of policymaking at varying degrees. Interviewed and retained (includes four referrals from NPH and three from PH groups) 13 11 Accepted to participate but not interviewed (theoretical saturation) 5 6 No reasons provided for declining participation 7 -

Influences on Public Health Stakeholder Engagements
Participation, deliberation, and partnerships on climate change policies occurred within and across public health and non-public health institutions in Ontario. Themes that emerged as influences of public health inclusion, participation, and deliberations in the climate change policy discourse are summarized in Table 3 and are discussed in the five proceeding subheadings.  Some of the emerging themes may appear in more than one element because they apply to both the elements of discursive approaches and institutional influences.

Fragmented Discursive and Communicative Interactions with Irregular and Unestablished Communication Channels
Interactions were divergent between the NPH and PH groups. However, participants from both groups, (7 PH and 5 NPH participants), acknowledged the 'silo' approach to climate change governance in Ontario. The silo approach was evident in the type of stakeholders each group reported to have included in the deliberation of climate change policies, as illustrated in Table 4. PHUs 0 9 Federal government 3 8 Municipal government 2 7 Communities 0 4 Non-governmental organizations 3 5 Health agencies (other than PHU) 0 6 Academia 2 4 Corporations 11 0 * Participants reported engaging with at least 4 or more ministries; ** Participants reported engaging with no more than one ministry except one participant (who reported engaging with two ministries).
The NPH group portrayed a horizontal approach to climate change engagement (i.e., engagement with stakeholders within similar areas or sectors), a minimal to lack of inclusion of public health representatives (MOHLTC, PHUs, or other health agencies), and extensive engagement with corporations. No direct collaborations were reported between the agencies and the Premier's office. However, NPH participants (n = 8) indicated that the office was represented by the cabinet ministers and their assistants based on their roles within the specific ministries and committees.
Conversely, the PH group reported working with those within and outside the area (or sector) of public health. Engagements with ministries (mandated and non-mandated) were limited, and the PH participants (n = 9) reported that there is still a significant gap in public health's participation in the provincial mitigation and adaptation strategies. Engagements between PHUs and the MOHLTC were mainly related to the modernization of the public health standards, the vulnerability and adaptation assessment needs, and harmonized heat alert guidelines. However, fragmentation was also reported within public health, where some participants reported that larger PHUs within the Greater Toronto Area work closely together without reaching out to smaller PHUs. The four specific PHUs named included Toronto, York Region, Peel Region, and Halton Region. Some participants (n = 3) in the PH group also reported experiencing isolation and inability to connect with professionals who could help them meet their climate change policy goals (specifically relating to the completion of the vulnerability and adaptation assessment). A review of collaboration links revealed that such participants hardly reported collaborating with other health units or ministries in their climate change work.
Several NPH (n = 8) blamed the fragmented engagement on the status quo ("this is how we have always done it"). Participants also linked the piecemeal engagement approaches to historical relationships, organizational structures or cultures that limited broader stakeholder engagements and partnerships, and political and leadership influences, mandates, framing of climate change. As summarized in Appendix D, some NPH participants believed it was the role of public health agencies to reach out to other ministries for collaboration. Others suggested that the agency's area of focus did not have a public health perspective or alignment with public health needs. Still, others did not see the role of public health in their policies. Alternatively, when a public health issue is identified, the NPH participants reported that such issues would instead be transferred to public health instead of collaborations.
Many members of the PH group did not understand why public health connections are not made. However, the PH group blamed the lack of elaborate engagement of public health on institutional structures and arrangements that have alienated public health and historically denied public health the legal mandate on climate change policies (n = 9). The lack of public health engagement was also associated with the fact climate change was a new area of public health practice. Conversely, a PH participant's responses also alluded to the lack of relevance of NPH actors, and the relevance of several public health affiliated NGOs, in public health policies, as this quote demonstrates.
"For us, the sector is the public health sector. We also worked very closely with our key stakeholders. So, our key stakeholders would be the public health units; some of our key public health organizations like CIPHI (Canadian Institute of Public Health Inspectors), APHEO (Association of Public Health Epidemiologists of Ontario), ASPHIO. We also work very closely with OPHA (Ontario Public Health Association), and members from the OPHA." Progressing the fragmented approach was the lack of communication between the two groups. Although frequent and extensive communication was reported within each group (especially within NPH group), these communications were fragmented, minimal, and irregular between the groups. The lack of interaction between the two groups was obvious in participants narratives through sentences such as: "they are not the one that we have, kind of, the most regular contact with"; "I have never really worked directly with them"; "no, it's not something that typically comes up"; "no, I don't remember ever working with the ministries on our projects"; and, "perhaps the ministry (MOHLTC) has worked with them (NPH ministries), but we haven't on our side." Many participants from both groups emphasized the need for better communication to minimize the fragmented approach in Ontario. To leverage communication and engagements between the two groups, the participants (n = 18) made several suggestions, as summarized in Table 5. The structures for identifying stakeholders varied between the two groups. However, only PH group (n = 8) provided detailed strategic frameworks for stakeholder identification; these included utilization of laid out protocols, guidelines, and workgroups, whose role includes identifying stakeholders for engagement. Historical collaborative contexts were also evident within the PH group, where most participants (n = 7) referenced prior collaborations, as ways of identifying stakeholders As reported in Appendix E, the NPH actors mainly referenced bureaucratic structures (n = 9), the use of the Environmental Registry (n = 11) and using institutionalized stakeholders (n = 5). NPH actors also reported identifying stakeholders based on historical contexts such as previous collaborative projects or deliberations (n = 8) and political directions (n = 6). Political interests were reported, by the NPH group (n = 9), to influence how and who participated in the province's climate change policies. Political influences were perpetrated by political leaders and senior bureaucrats (e.g., premiers, ministers and assistant ministers), reflected in goals set by the Office of the Premier, and influenced by election promises, strategic framing that are dominated by economic narratives, directives to incoming ministers or through strategic plans or legislation (e.g., a new climate change plan or green energy legislation). As this participant explains, even when public health's role is acknowledged, the influence of politics determines who takes part in the policy processes.
"I know that public health can play a role in climate change policies. But as much as I recognize that, the work that we do, and the people that we collaborate with are sometimes determined by political structures, to some degree. We really don't have an influence on who we collaborate with in climate change policies. Our mandate, for example, and these are mandates that generally come from the Premier's office, specifies that we work with certain ministries and sectors and so we generally make a point to either directly or indirectly connect with such organizations. So, again, it is politics. Yes, I may have an area where I would like to work with public health in our policies, but our resources and actions are tied to certain actors and not necessarily to public health. Politics basically dictate the direction." Participants also reported a lack of direction and leadership from political leaders (Premiers and cabinet ministers and their assistants) and two lead ministries (MECP and MOHLTC) in advancing public health roles or providing supporting structures for public health inclusion. The MECP was reported to play a key role in climate change initiatives and was referred to as the lead agency on climate change issues. All NPH participants reported connecting and deliberating with the MECP. The nature of these engagements were mostly formal, arising from the legal obligations and mandates to consult between the ministries on the various climate change initiatives. However, NPH participants (n = 5) suggested that it was the role of MOHLTC or MECP to integrate public health stakeholder engagement needs or the Premier through the mandate letters that direct ministries' actions, as demonstrated below.
"Those we work with are mainly determined by the MOECC (now MECP). So far, I have not received an indication. I think if you believe that public health needs to be included in (redacted) then maybe that has to come from the ministry (MECP) or even the mandate letters that give directions to the top bureaucrats."

(NPH participant)
Within the public health sector, the MOHLTC was regarded as the lead agency for advancing or steering broader public health stakeholder engagement at the provincial level. Participants reported that engagements and capacities across and between PHUs, and with other non-PHU stakeholders in general, would have been advanced by the MOHLTC. Unfortunately, as this participant highlights, many PH participants (n = 9) faulted the MOHLTC for not taking the leadership role or steering the public health sector's inclusion in climate change policy deliberations.
" . . . back to the Ministry of Health . . . you weren't finding someone there who is being the champion and leading the way and inspiring others, so this makes it hard." Even though some NPH participants mention including the ministry of health when public health issues arise, only one concrete example was provided across 13 participants. This related to the inclusion of public health stakeholders in an advisory committee for a disease outbreak to support the outbreak management. However, another example portrayed a transfer of responsibilities to public health for a policy modification instead of working together on the issue to gain consensus or provided hypothetical scenarios of public health inclusion.

Restrictive Structures and Processes of Stakeholder Engagement
Partnerships in climate change policies mainly occurred between actors viewed to have a mandate on climate change or those with mutual interests. This was mainly evident in NPH participants' narratives. Specific to NPH organizations, these mandates were associated with specific ministries with shared interests. While public health's mandate in climate change was supported in 2018, interviews with the NPH participants did not reveal evidence suggesting the new public health mandate in climate change had significantly influenced public health inclusion in provincial strategic policy discussions. Many NPH participants (n = 8) were not aware of this mandate, and public health was majorly regarded as not having a mandate in the climate change decision-or policy-making processes. In turn, the lack of public health partnerships with ministries was seen as a result of a lack of public health's role or mandate in the policies that were being formulated or debated. In some instances, NPH participants viewed the provincial policies as superior to those at the local level (e.g., local public health agencies or municipalities). Those at the local level were, therefore, to use such policies as templates for designing their own policies.
To support stakeholder participation, at provincial and local levels, strategic structures included committees, internal collaborative workgroups, professional workgroups, and the Environmental Registry. At the provincial level, engagements heavily relied on government-supported committees (as reported by NPH = 8) that comprised of the various ministries mandated with climate change, with no representation from public health. Such committees facilitated deliberative and participative approaches to climate change decision making resulting in collaborations between the ministries, shaped climate change policies, and influenced consideration of relevant stakeholders. The NPH participants (n = 4) also reported that the committees were monopolized by politicians and bureaucrats. However, the committees were also reported to influence relationships between stakeholders. The absence and lack of representation of public health stakeholders in the committees, including the exclusion of the MOHLTC, was acknowledged by PH participants (n = 5).
In addition to committee settings, informal communication (i.e., consulting with colleagues) across ministries was also reported by NPH participants (n = 6). However, 11 of the 13 NPH participants reported that engagement between ministries and other stakeholders are mainly through Environmental Registry online posts where stakeholder can comment on a government's policy, decision, or statement of the government on an issue. There is neither communication with the commenters nor individually provided feedback. As one participant puts it, the Environmental Registry is "a government's way of consulting and engaging on policy issues". Although the analysis revealed that public health professionals (n = 8) had utilized the Environmental Registry to comment on climate change decisions, meaningful consultation between the ministries and public health do not occur, as quoted below.
"Yeah, so whenever a policy is proposed, we are required to post it in the registry for public comment. We don't necessarily have a roundtable discussion with many stakeholders unless they are among the ministries that we work with, especially on the various committees we have. But to say that we do have a face-to-face consultation with the public, including public health people, no! But we always receive a lot of comments from many other organizations, including public health." Within public health, participation structures for engaging in climate change decisions were also evident. These included structures for engagements within the PHUs; between PHUs and MOHLTC; between PHUs and other municipal departments; and, between PHUs and numerous NGOs. Committees were the predominant form of multi-stakeholder engagement in public health. Some types of committees reported included advisory, steering, workgroup, and technical committees. For instance, steering committees formed to lead and guide the development of public health climate change policy guidelines. Internal committees within PHUs addressed vulnerability and adaptation assessment processes. A technical committee was created to integrate public health mandate in climate change. Committees within municipalities were, in some instances, formed to integrate public health's role in municipal climate change plans and to facilitate PHUs work with other departments within the local governments, such as planning, water, transportation, and emergency management departments. Within such committees, the main role of public health, as cited by the PH group, was around advancing public health needs in active and sustainable transportation systems. However, a few members of the group (n = 3) raised concerns about the gender composition of municipal committees. As this participant notes, the gender imbalance compositions resulted in anxiety and a feeling of inferiority.
"Some of the meetings I have attended barely have women in them. I think . . . maybe . . . this could be just the nature of issues being addressed because I find that many built environment areas are dealing with energy, transportation, or other infrastructure that are dominated by male, especially engineers. But it really makes you so nervous and anxious when I'm putting my points across. Are they even going to consider what I say, or I am even relevant here?"

(PH participant)
A review of the composition of study participants identified disparities in the gender-balanced composition which were outside of the study's control. To illustrate, the PH participants that that met the criteria for inclusion in the study, and that were retained or interviewed, consisted mostly of females (82%). Within the NPH group, female participants comprised 32%.
Other than committees, the public health sector's engagement in climate change policies was supported by workgroups. The two most cited workgroups within public health settings, as mentioned by 9 PH participants, were affiliated with the OPHA, an NGO. The Environmental Health Workgroup directly focused on climate change issues and other related issues such as air quality, water quality, and energy. The Built Environments Workgroup focused on issues related to the planning and implementation of various built environment components and their links to health. Other platforms for deliberation utilized by the group included forums, conferences, and webinars facilitated by Public Health Ontario.
The MOHLTC utilized committees, workgroups, and personal sessions to prepare PHUs for the new requirement of conducting vulnerability and adaptation assessment.

Resources
Resource constraints-namely, financial, expertise, technology, and information-were a barrier to engagement, as reported by both groups. Within public health, the impact of financial resources was the most significant, as cited by all PH participants. However, smaller PHUs and PHUs with large geographical areas reported being most impacted. Other resources cited included lack of data, training, expertise, or technology for advancing public health needs. Despite such barriers, the fragmented approach to climate change governance in Ontario may be hindering public health's access to relevant data. As this participant narrates, some ministries may have relevant data that are never shared or sought.
"Because our ministry . . . and our applied research nature, we have been taking climate change into consideration, probably since as early as the 80s. We may have some long-term data set that we might be able to provide more of a service to public health institutions than they realize. Unfortunately, they don't reach out to us." (NPH participant)

Ideological Biases
Embedded in the various processes, structures, and interactions were the ideologies that trivialize public health's relevance in climate change decisions. For instance, lack of public health's role was implied by the NPH group views of public health belonging to the "humanities" or "social ministries", or "kind of the health side or the community safety" ministries and as "social-oriented" as opposed to the "applied nature of climate change policies" or "natural resources and infrastructure" focuses of climate policies. Public health agencies were also sometimes referred to as "other" agencies, "not part of the government" or organizations "outside of the government," signifying the structural features that NPH actors draw upon to identify the relevance of actors in climate change decisions and deliberations.
PH participants (n = 6) revealed that attitudes that deprecate public health's role are very prevalent in their work (both at the provincial and local levels), and not isolated to climate change competencies. In turn, some public health participants reported feeling devalued in various engagement platforms, as illustrated below.
"That is something we have come across as well. You know, sort of the question of why is public health here?" "It's pretty much the same conversation that we have been having related to public health and the built environment. You know, because really the lead ministries related to the built environment are the Municipal Affairs and Housing and Transportation and so through the (redacted) we have spent a lot and doing a lot of work on how do we engage the municipal planning sector. And now, how do we engage the transportation sector? And they say the same exact things. Like, you know, why would we invite public health? What interest would they have on a road plan? Same thing, we have talked to transportation engineers, we have talked to transportation planners about if they engage with public health and if so how or where the input would best be and . . . yeah, the same conversation, different topics." (PH participant)

Effects of Interorganizational Engagements on Public Health
Where institutional engagements were reported-whether across organizations or within the organizations-participants reported four types of impacts: strategic (n = 15), resource (n = 21), capacity building (n = 16) impacts, and opportunities and relationships for future engagements (n = 17).
Collaborations within the NPH groups were mainly viewed as efforts to improve strategic roles (i.e., advance the mandate on climate change actions). Resources, including access to skills, funds, and knowledge, were linked to the support for and the outcomes of institutional engagements in climate change frameworks. In turn, NPH participants reported sharing resources to advance the mandated roles through the pooling of funds, transfer of knowledge, and application of technologies relevant to the institutionally designated climate change actions. Within this group, impacts of recent government cutbacks in funds were blamed for the lack of engagement. While the NPH participants reported impacts of collaborative governance on their policies, such narratives mainly related to impacts within the ministries and did not reveal the influences in advancing public health needs in the climate change policy discourse or process.
For the PH group, collaborations expanded their capacities beyond climate change policy needs; supported access to funds and expertise; advanced the sectors approached to policy advocacy, and raising of climate change impacts awareness; created relationships, partnerships, and opportunities for future engagements while also revealing the role of public health in climate change policies; impacted knowledge transfer, sharing, and creation. Strategic impact included strategic planning, advancing public health agenda in various forums, both locally and provincially, including supporting inclusion of mandate, coal powerplants phase-out, and impacting municipal governments' climate change action plans. Partnerships also supported personal growth by helping collaborators to build confidence and overcome skepticism that such participants felt at the beginning of partnerships; such feelings were overcome as individuals interacted and clearly identified their roles within the broader partnerships. These impacts are summarized in Appendix F.

Discussion
The analysis of perspectives from the public health and non-public health professionals engaging in climate change policies have revealed how the existing governance approaches impact, enable, or constrain the inclusion, participation, and deliberation of public health stakeholders in the climate change policy discourse. The results reveal incredibly low levels of interaction between the two groups (PH and NPH). Engagements were dominated by networking and cooperation, with collaborations existing within each group. Between the two groups, a few informal relationships existed without commonly defined missions, structures, or goals, and information was only shared as needed. The information-sharing was mainly from public health to the government ministries (public consultation). This cooperation was sometimes seen as a collaboration by public health agencies. On the other hand, some coordination or collaboration existed within each group. Such engagements were defined by both formal and informal structures for accessing information, some resource sharing, and mutual problem-solving. Within each group, evidence was gathered through collaborative networks and communicative platforms.
Fundamentally, discourse brings people together [116,117]. In Ontario, the analysis of discursive strategies revealed four types of discourses guiding Ontario's climate change policy discourse and propagating public health exclusion. First, authoritative discourse-a closed discursive interaction defined by authority, bureaucracy, and political ideologies-that define the legitimacy of actors in the discursive processes and structures, and produce and reproduce interactions, and reinforce specific procedures and structures of engagement while isolating other stakeholders [116,118,119]. Second, vertical discourse through systematic and standardized processes of deliberations and structures of participation, regulated by mandates and authority on climate change decisions [119][120][121]. Despite efforts to connect between the PHUs, the results reveal that the group was not only excluded from the provincial strategic frameworks, but some were also excluded from each other. Third, the public health sector mainly operated though a horizontal discourse. Defined as a discourse that "entails a set of strategies which are local, segmentally organized, context-specific and dependent" [121]. Horizontal discourse also manifested in functionally focused ministries approach and public health's (MOHLC and PHUs) independent approaches to climate change governance as dictated by the structure within the ministries and of Ontario's public health governance that has set them up under geographically specific and independent boards of health. Lastly, the public health sector has applied liberating discourse. This discursive approach liberates the sector from the confines of public health's formal structures by creating informal spaces for deliberation in climate change policies through affiliation with NGOs [119,122].
The four discourses are propagated by and draw upon Ontario's institutional arrangements and actors' values (interests, ideologies, and beliefs) that have shaped the roles of public health in the discourse and provided actors with ideas of relevant stakeholders and knowledge. This is further demonstrated by the large number of NPH participants that declined to participate (see Table 2) because they did not see the role of public health in their policies despite fitting the inclusion criteria of the study. The analysis also reveals Ontario's functionally specific institutions that have not been designed around public health inclusion-both at the provincial level (MOHLTC exclusion) and local level (PHUs exclusion). These interactions presented five major barriers to public health engagement in the climate change policy discourse. The impediments centred around the lack of holistic inter-organizational processes and structures of engagement, sociopolitical characteristics that influenced collaborative environments, irregular and poorly established communication, inadequate resources, and ideological biases on public health's roles in the discourse. Where public health stakeholder engagements were successful, those engagements impacted the public health's ability to support its role beyond climate change decisions, mandate, and capacities in the climate change discourse; enabled access to funds, expertise, and new stakeholders or relationships for future engagements; supported knowledge sharing, generation, and creation; and, advanced public health interests in political platforms and policies (e.g., coal phase-out). The study results correspond with studies conducted in Canada and other developed countries which have revealed a silo approach to climate change governance and the isolation of public health from such structures as well as the lower prioritization of public health needs, and prominence of horizontal collaboration [26,27,123]. Other studies have also identified the influence of discourses and prominence of politics and vested interests on public health's capacity [30,93,124].
Studies on stakeholder impacts have also linked stakeholder engagement to better evidence-informed policies, effective decision-making, successful uptake and acceptance of interventions, and better communication [36,58,60,125].
Despite strategic and resource impacts on public health stakeholder engagement, the fragmentation of work across climate change stakeholders, inadequate support and sometimes trivialization of public health's role, and the scarcity of interaction between the public health and non-public health practitioners is particularly worrying. The barriers are not only likely to negate public health capacities in climate change, but they are also likely to minimize climate change impact awareness and GHG reduction requirements in several ways.
Public health organizations have goals to achieve in fighting climate change. They want to minimize the health impacts of climate change, reduce own emissions, and support the development of healthy climate change policies capable of reducing GHG emissions while also protecting populations and advancing coping mechanisms to climate change impacts [19,23]. Achieving these goals requires focusing on a number of factors-social determinants of health, inequity, and injustices-that result from climate change impacts. The goals also rely on primary, secondary, and tertiary prevention strategies [126]. Primary strategies slow, reduce, or stagnate climate change by decreasing GHG emissions. Secondary and tertiary strategies relate to public health adaptation strategies, also referred to as preparedness [126]. Preparedness has a longstanding association with public health practice and is used by health agencies to reduce the population's vulnerability to the health impacts of climate change. However, mitigation strategies fall outside the public health sector and practice [126]. Institutional engagement is a significant component of building capacities, exchanging knowledge, deliberating on climate change policies, and addressing public health competencies that fall outside of the health sector [112,127]. The lack of inclusion of public health stakeholders is a hindrance to both the management of climate change and public health impacts.
Many climate change health impacts transcend public health into other sectors [19,23,47]. Decision makers may need the help of public health professionals to identify information and processes for integrating health needs into climate change decisions. Additionally, supporting positive health and environmental outcomes and highlighting the co-benefits of action in non-health sectors requires an understanding of the various health components of climate change and social determinants of health [128]. These include an understanding of health impacts at regional and local scales, the vulnerabilities and disparities within the various populations, the risk perceptions and individual risk assessment approaches, and the complex pathways within which climate change and its related actions impact health. While this is true, health impacts may not be entirely understood by other sectors that lack expertise in public health. Rather than applying the sectoral approach to climate change mitigation, public health leadership can enhance the knowledge of the immediate and long-term health benefits of actions to both public health and other sectors, and advance the integration of the benefits of the climate change actions. The knowledge of the mutual benefits can then influence stakeholder and political will [19,20,129]. In effect, the public health sector has an important role to play in shaping the climate change associated health and wellbeing outcomes by influencing sustainable interventions that connect public health to critical climate change debates [126,130]. Through its reports, the Lancet Commission on Climate Change and Public Health primarily advocated for a collaborative approach to climate change by emphasizing the cross-sectoral drivers of health impacts and public health needs [19]. Specifically, the Commission underscores the need for governments to facilitate collaborations between health ministries and other agencies of government in a manner that supports the empowerment of health professionals and integration of health needs in the climate policies [19]. And, as the Commission further advises, the silo approach to addressing climate change health impacts is detrimental to population health in the face of climate change [19].
Advancing public health engagement and participation in the climate change discourse requires holistic inter-organizational processes and structures that recognize the public health roles, mandates, and goals in the discourse. Efforts to include public health in the broader climate change policy discussions and deliberations must also include approaches for breaking out of the silo approach to climate change governance and advancing public health inclusion in climate change discourse. In addition to the suggestions by the study participants (see Table 5), the inclusion of public health in the climate change political agendas are likely to be leveraged in several instances. First, when public health needs are integrated into climate change planning and policy processes (mainstreaming) [18,131,132]. Mainstreaming can support the strategic identification of stakeholders, the definition of mutual goals, collaborative needs, and resources for jointly addressing climate change. Mainstreaming can occur when all sectors of governments systematically consider the social and health consequences of proposed climate change policies (health-in-all policy (HiAP) [18,131,132]. Advancing a HiAP approach to climate change policies can permit the integration of public health voices and evidence and the visualization of social determinants of health, inequities, and injustices of climate change policies. Mainstreaming can also occur when governments consider the human-animal-environmental health interface (One Health) and the resulting need for a multisectoral and multidisciplinary collaborative approach [133][134][135]. The One Health approach requires coordination of climate change policy activities, policy processes and discussions across institutions, sectors, and organizations to minimize the silos and support communication, knowledge exchange and awareness of each other's goals, mandates, areas of focus, roles and responsibilities that support the achievement of human-animal-environmental health outcomes which are also inextricably linked to climate change [18].
Second, there is a need for a climate change governance approach for multi-stakeholder inclusion. Deliberative (collaborative) governance, is a multi-stakeholder engagement approach, where governing institutions or agencies support participation by collectively working with and integrating values from a variety of stakeholders [41,42,132,[136][137][138]. The approach stresses the creation of partnerships where the need for a two-way communication and knowledge exchange is paramount [139]. As a result, the engagement processes initiated by either an agency or public health institution should bring stakeholders together through deliberative forums. An approach to achieving collaborative governance can be through framing for deliberation. Framing portrays a policy image and forms the basis for the deliberation and decision making of policies and advancing [17,140,141]. Advancing a policy image that considers a wide range of options and clarifies the different approaches to addressing the issue provides unique opportunities for broader stakeholder engagement in the political and elite-driven governance processes of climate change policies [11,13,142,143]. Specifically, including a public health frame has been shown to provide an approach for uniting the different stakeholders within the climate change dialogue [11,16,19,29,144]. Equally, collaborative governance implies that meaningful institutional engagements are not merely one-way information provision or consultation but rather a process where both the agencies and the public health organizations are participating and engaged in the decision-making process. Participation is situated as a form of public engagement where diverse stakeholders are included in the process as opposed to the "traditional models of governance' that only include mandated policymakers and select experts [41,42]. While this collaborative governance approach is necessary, an integrative framework that conceptualizes and legitimizes public health's discursive legitimacy and meaningful participation in governance processes and structures of climate change policymaking is lacking. The study results and interpretation postulate that advancing the public health frame in the discourse requires the legitimation of public health into the various institutional structures and governance of climate change. Future research can support the need by developing a framework for conceptualizing and guiding public health inclusion in climate change governance.
The paucity of the inclusion of local health agencies (PHUs) in the provincial climate change policy deliberation structures also shows that the province has not meaningfully included local municipalities in climate change policies, which may also imply that municipalities do not fit in the current model of provincial climate governance. The lack of inclusion of local governments in the broader climate change governance structures has been documented [145,146]. Such deficiencies are accompanied by limited public support and resources, competing priorities, inability to provide the local governments with opportunities for policy development, and inadequate climate change discussions, as were also reflected in our study [145][146][147][148].
The findings suggest that engagement in climate change policies is embedded in power influences portrayed in places and spaces of participation and politics and determined by the legitimacy of actors in the deliberation processes. For instance, despite public health's ability to create some spaces for engagement, their participation is constrained by restrictive deliberation platforms and the lack of equal opportunities for participation. The spaces for participation were defined by mandates, legislative rights, and formal invitation (e.g., to committees), of which public health was not included. Institutions can exercise power in several ways. Power may be visible, invisible, or hidden; it can be legitimate or illegitimate or can be concentrated (elitism) or diffused (pluralism) across institutional settings [38,149]. The influence of power dynamics in limiting actors' spaces and places for participation and deliberation on a variety of policies has been evidenced in a variety of literature. These have included climate change [146,150], the environment [151], health [152], economic inequality [153], mental health [154], participation and governance [155], policy processes [156], and water management [157]. The first approach to changing or balancing power relations is to understand how power works to influence policy engagement and outcomes [149,158,159]. While the analysis of power was beyond this study, future studies can investigate the influences of power dynamics and the resulting institutional processes, structures, and their implications on public health engagement in climate change. Such knowledge can support resources for integrating and legitimizing public health's role in the climate change discourse.
Gender disparity emerged as an influence on public health participation in climate change policies at the local level in Ontario. Climate change policies are intended to impact people's choices and behavior, and each policy has a gender perspective or impacts. There is also a growing recognition and awareness of the influence of gender diversity in advancing meaningful and diverse participation that reflects the needs of the society, better science, and relevant evidence [160][161][162]. As a result, the lack of inclusive and diverse participative and consultative platforms are alarming. Gender mainstreaming is a strategy that has been used to account for the gender sensitivity, diversity, equality, and women's perspectives in policies and programs proposed and forwarded by institutions [163,164]. The approach can be legitimized through discursive practices that integrate the application of language that influences how women are perceived in consultative platforms or through institutional approaches that integrate the voices and needs of diverse groups in policy areas [163][164][165]. Institutional advances can include strategic approaches such as political commitments and legally binding frameworks (e.g., tools for assessing statistics, budgeting, impacts, stakeholders, etc.) for integrating gender perspectives into policy contents [166]. Such approaches can also include the establishment of institutional frameworks that highlight approaches for integration as well as the roles and responsibilities [166]. Gender-based plus (GBA+) is a framework commonly used, specifically in the Canadian federal government consultation processes, to overcome the gender differences and the historical or power structures of public participation in policies [160]. However, given this study's limitation on gender integration, future studies can examine the strategic approaches and political commitments to gender inclusion in Ontario's climate change policies, since gender emergence as in impediment to public health engagement. Such studies can benefit from a survey, using large study samples that also examine additional social characteristics (such as age and education), that allow for would also allow for statistical inference of gender influences and additional social characteristics (e.g., age and education), as opposed to the qualitative, function-specific approach used in this study.

Conclusions
Over the years, the significance of public health engagement in climate change policy discourse has been advanced and emphasized. Our study suggests that there still exists contextual and systemic institutional barriers to the sector's involvement in the processes, discussion, and communication of climate change. We have identified five broad elements and the corresponding factors that hinder public health's effort in climate change policy discourse. Such factors relate to the influences of collaborative environments (how stakeholders are identified, political, and bureaucratic influences and leadership that steer cross-sectoral collaborations), institutional structures and process and characteristics of collaborators as depicted in the goals, responsibilities, mandates, ideologies, interests, and identities or characteristics of collaborators, resource constraints, and the lack of established and supported cross-sectoral communication. Despite the challenges, stakeholder engagements impacted public health's roles beyond climate change decisions, mandate, and capacities in the climate change discourse; enabled access to funds, expertise, and new stakeholders or relationships for future engagements; supported knowledge sharing, generation, and creation; and, advanced public health interests in political platforms and policies. To meet the public health and adaptive governance needs of climate change, holistic inter-organizational processes and structures that recognize public health needs are necessary. These can be achieved through mainstreaming of public health in the broader climate change policies and through deliberative approaches that legitimize the participation of different actors in the discussion of climate change policies. Funding: This study was not supported by any funding.

Conflicts of Interest:
The authors declare no conflict of interest.

Appendix C. Main Issues Analyzed in Textual Analysis and Discursive Practices
Thematic frames (climate change framing in Ontario) • Involved analyzing the historical presentation (framing) of the climate change issue.

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The theme only focused on preexisting documents (from government websites) to establish how climate change has been historically presented in Ontario (between 2007-2018) • A priori themes guiding frame analysis; the themes included economic, environmental, health, moral, and scientific frames.

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Analyzed how the frames were ordered and the narratives (rhetoric) that guided the framing.

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Analyzed the types of genres and their characteristics; activities regulating and managing climate change decision processes within institutions (e.g., types of options for participating in climate change decisions).

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Analyzed genre mixing (e.g., activities for promoting climate change decisions locally or internationally or alternating reporting structures using a mix of quotations and facts in a single report).

Intertextuality
• Involves the processes of embedding other texts within a text-that is, integrating other voices into the texts other than the voice of the author (Fairclough, 2003;Walter, 2013). (E.g. references or embedding direct quotations within a document or providing links) • Analyzed texts for links, quotations or any form of embedded in texts other than those of authors.

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The type of discourse drawn.

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Analyzing the discourse guiding Ontario's climate change actions was guided by Dryzek (2013) and included analyzing the types of entities whose existence is recognized or constructed; the presence of assumptions, metaphors and features characterizing climate change discourse (s); characterization of agents and their motives • Identification of orders of discourse; that is the power relation between the writer or speaker and the reader or listener if interviewing (Fairclough, 2003).

Style (identificational meanings)
• Relates to how people identify themselves and are identified by others within a social setting (Fairclough, 2003).

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Analyzed social (e.g., structure and agency) and personal identities and features that characterize the styles drawn upon by actors (including body language).

Social differences
• The salience of identities (e.g., identifying to belong to a particular group).

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Analyzed scenarios that characterize, recognize, accentuate or explore differences; how the differences are claimed (e.g., consensus over or normalization of, attempts to solve or suppression of the differences).

Social events
• Are practices within institutions that lead to the selection of specific structures and exclusion of others (Fairclough, 2003;Walter, 2013).

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Texts were coded for the emergence of themes related to social events and chains of social events (e.g., how the dominant frame is embedded in the networks of structures within institutions).

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Whether the text was part of or network of texts.

Representation of social events
• Analysis of how the social events were presented (e.g., abstract vs. concrete); the elements of social events represented; how the processes of the social events were presented and the predominant process types; metaphors applied; how social actors are represented (e.g., named, generic).

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Analysis of presentation of historical events or milestones.

Assumptions
• Refers to the implicitness of texts and based on three types of assumptions: existential ("assumption about what exists"), propositional ("assumptions about what is or can be or will be the case") and value ("assumption about what is desirable") (Fairclough, 2003).

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Fairclough (2003) uses globalization as an illustrative example. That it is assumed that globalization exists (existential) and that it is a process (propositional) which can 'help' achieve economic progress (value).

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Analyzed the various assumptions, perceptions and ideologies present in texts.

Modality
• Defined by Walter (2013) as a term for signifying "author's or speaker's commitment to the claim being made." • Related to speech functions in that modality supports the analysis of "what people commit themselves to when they make statements, ask questions, make demands or offers" because each signals a different commitment (Fairclough, 2003).

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Analyzed text for commitments, attitudes, judgements and stances of actors.

Actional Meanings (exchanges, speech functions, and grammatical mood)
• Exchange: relates to exchange in dialogue (Fairclough, 2003;Walter, 2013). Analysis of exchanges focused on two types of exchanges: knowledge and activity exchange. In knowledge exchange, analysis focused on the exchange of information, how information is given and elicited and how facts are stated. Activity exchange focused on the analysis of activities that people do or get others to do. • Speech functions: relate to acts of dialogue (Fairclough, 2003;Walter, 2013). That is, is an analysis of whether the knowledge exchanges are initiated by actor or by others through, for example, offers or demands; and whether activity exchanges are initiated by the knower(s) or others through, for example, questions and statements).

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Grammatical mood: analyzed how exchanges and speech functions (dialogues) are portrayed in sentences (e.g., declaratory, interrogative or imperative sentences)

Meaning relations
• Semantic relations are presented in grammatical structures of sentences; that is relations between sentences and clauses (or simple sentences) within sentences in a manner that legitimize the issue or creates classes of differences (e.g., power).

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Example by Fairclough (2003). "We are late because train was delayed." Conveys a causal meaning relation. The underlined word acts as a grammatical connector to elaborate a causal relationship indicating that the reason for the delay is due to train arriving late.

Historical contexts
"The ministry has demonstrated long-term collaborative work with partners across ministries who engage in climate change. These collaborations did not begin with climate change, but we have also engaged in other projects that impact the environment in general. And so whenever something new comes up, like climate change, for example, we have these people, from ministries, that we are already working with and who we know their expertise... I think it makes it easier that way, rather than finding new partners to work with.

Access to resources
"One piece that we identified within our key informant interviews was the need for a regional network that could help to bring different stakeholders together to support climate change mitigation and adaptation, and that's because most of our municipalities are quite small and they are resource-strapped, and they don't have either the money or the knowledge to be able to start some of the climate change adaptations. And so they wanted a way that they could have a community of practice or a sharing network or a way that they could collaborate to create regional actions. So the health unit has been working to pull that group together, and it is something that we are going to be continuing to lead over the next couple of years. We are calling it a [redacted], where we have conservation authorities, school boards, municipalities, and ourselves as health unit partners working together to identify what others are doing, where there could be collaborations and partnerships and what funding opportunities could be done collaboratively.
And so it was one of those pieces that everyone sort of said we need this, but no one was able or had the resources to step up and lead. And so, we were able to put those resources into that program, and we will continue to do so. Platforms for potential and future partnerships "What that [a previous collaboration] also did was set stage for further partnership work, and we have done a couple of interesting projects with partners that perhaps we wouldn't have worked with as closely in the past. For example, we developed a tool to look at [redacted] and brought in a social-economic lens, brought in a health protection lens. Looking at things like urban heat island. Looking at equity, all those kind of issues, . . . we are now doing a pilot project applying that tool in [redacted] and looking at communities that are disadvantaged for one reason or another and looking to see if we can try and impact things like the urban heat island. So there has been a lot of involvement in a lot of different projects and people have been, in my mind, very welcoming of the public health lens to the discussion. The engineers welcomed us; the planners have welcomed us. There has been learning of each other's languages and needs, and that takes time, but certainly, there has been no hesitation, whatsoever, to have public health sitting at the Accessing hard-to-reach communities "We did try to engage with our First Nation and Metis communities within the region. We were unsuccessful in engaging in that for the vulnerability assessment key informant process. I think we just didn't have the right contact. We weren't connecting with the right people. I personally didn't have any connections with any of our first nations partners from previous work, and like, I think we weren't just connecting with the right people, but we have since been able to work with some of our local communities, and we are involved in some projects that are supporting adaptation planning within First Nations communities within our region, and so, that was really great, having some conversations with an individual at First Nations who was doing some climate change adaptation, and I was wanting to see what they were doing and then meeting her at other conferences, and that allowed us to build a relationship, and she then brought us into her projects that she's doing. So that has been really great because we saw a gap in our vulnerability assessment . . . we didn't have any Indigenous views throughout the vulnerability assessment . . . . and so, now that we have those connections, it has been great, and there has been a real collaborative approach to being able to support them when we can with our vulnerability assessment and they are using traditional ecological knowledge as well to further adaptation planning, so it has been really great to be able to start to build those relationships." [PH participant]

Local
Advanced coal phase-out " [Redacted] appeared before the legislative committee and conservatives said, this is a waste of time, we don't need a legislation, we have already stopped burning coal for electricity . . . We said that we want to be there a legislation so that anybody who tries to reverse it, it's going to be harder to do that. And everyone was kind of like, we will never go back, and then what happened two years later? You know, you had a president [referring to U.S politics] who was now calling for burning of coal. So, I would say that was our role. So I'll just say, we have had this tradition of speaking out about the links between the environment and health and we are going to continue to do that." [PH participant] Provincial