Implementing Healthy Planning and Active Living Initiatives: A Virtuous Cycle

Factors including internal local government functioning, collaboration and the use of co-benefits have been noted to assist in the uptake of healthy planning policies and projects by local governments. However, less commonly noted is a possible reverse relationship: that implementation of healthy planning projects can contribute positively to organisational functioning and collaboration, and can result in a range of co-benefits that then can be used to support projects. Such a concept is explored in this paper, with a focus at the local government level in Australia. Findings from surveys with local government practitioners and in-depth interviews with healthy planning and community health advocates are presented. The findings indicate four key areas through which the implementation of healthy planning policies and projects and active living initiatives demonstrates a ‘virtuous cycle’. These areas include (1) project ‘wind-up’, or circumstances in which implementation and/or health outcomes exceed initial expectations; (2) improved partnerships that can create opportunities for future initiatives; (3) improved internal organisational functioning; and (4) greater project sustainability. The paper concludes by exploring some possible repercussions of these emerging findings, which indicate that beneficial settings to healthy planning considerations can be a result of as well as a contributor to healthy planning and active living initiative implementation. In turn, this presents another potential co-benefit of project uptake and implementation to those commonly identified.


Overview
The continued impacts of climate change, high urbanisation rates and noncommunicable disease (NCD) prevalence present significant, and related, global challenges to urban areas [1][2][3][4][5]. Efforts to address climate change such as through mitigation [6][7][8][9] or adaptation [10] strategies, as well as ways to address the inevitable challenges of increased populations living in urban settings [11,12] are now central urban planning considerations, especially in local government (LG) settings in Australia [13][14][15][16][17]. Efforts to address relatively high NCD rates through changes to the built environment to promote physical activity have seen relatively slower uptake in urban planning practice, despite the profession having its roots in public health [1,18]. Nevertheless, the impact that the built environment has on community and individual health is well-recognised [19][20][21] and the need for horizontally and vertically integrated responses from governments and other actors has been noted [22,23]. Efforts to improve population health through changes to the built environment can also contribute positively in addressing many of the other challenges facing urban areas, such as minimising the impacts of climate change [5,8,24,25] and providing efficient transport systems in growing urban areas [2,15].

Significance of Work
There is currently relatively limited knowledge of factors that enable the implementation of healthy planning and active living programs in Australia, particularly locally [40]. Limited attention has also been afforded the ongoing benefits of healthy planning and active living project implementation to the organisation (such as a LG) involved. This research aims to address this gap by seeking the perspectives of advocates and practitioners operating within, or who work with, LG. It is hoped that an examination of the potential ongoing organisational benefits of project implementation will have value for practitioners and advocates who are looking to implement healthy planning and active living initiatives, or to those advocates or practitioners looking to 'bring lasting and wider health gains' for communities [38] (p. 31), particularly decision-makers and those responsible for project evaluation.

Current State of the Research Field
Given the extensive scientific evidence base now linking urban environments, travel behaviour and human health [1,21], 'the claim of 'missing evidence' is no longer a legitimate excuse' for delayed healthy planning and active living initiative implementation [41] (p. 719). Yet in establishing this evidence base, '[m]uch effort has been directed into defining best practice [ . . . ] in terms of 'what' needs to be done while neglecting the 'how" [40] (p. 336). This tendency to focus on evaluation of 'what' as opposed to 'how' is particularly evident in Australia, with a burgeoning evidence base now linking the built environment, physical activity and human health [20,21,[42][43][44][45]. The establishment of these links has been essential in what is a re-emerging field, yet attention is gradually also turning to how health-promoting urban planning policies and active living projects might come to be implemented. This attention to-date has focused predominantly at a state or metropolitan level [34,42,46], and key themes to emerge include the value of collaboration and co-benefits, as outlined in Section 1.1.
Where academic studies on healthy planning have focused at the LG level in Australia, they have examined LG policies against a social determinants of health framework [47], evaluated practitioner understandings of central healthy planning concepts [48] and the viability of various project options [49], and examined factors that might enable health-promoting policy changes to occur [50]. Provision of sustainable funding and resourcing [29,50] has also been noted as enabling project uptake.
Yet relatively little attention has been given to why healthy planning and active living projects have seen slow uptake in Australia [50]. One potential reason for this slow adoption is that 'bureaucratic inertia' plays a role in the uptake and success of projects [51]. The planning profession [52] and LG [53] have been identified as being subject to 'institutional inertia', and existing governance structures have been noted as a barrier to provision of sustainable transport in Australia [54]. Literature on land use and transport planning, for instance, regularly refers to a notion of 'development paths' [15,55], while decisions that impact the urban form have been shown to be path dependent [54,56] (Note 3 in Appendix A). Illustratively, planning predominantly automobile-focused urban areas (a central element of planning that is detrimental to population health), has 'become institutionally "locked in"', yet 'small changes might well tip the car system in a different direction' [2] (p. 15). The operation of a 'vicious cycle' has been noted also to have relevance to obesity rates, though with a focus on food systems rather than the urban environment [57].
However, given the recognised importance of existing settings in influencing project uptake and implementation [29], limited attention has been given to these settings, or how they might come to be. The notion of a 'virtuous cycle', for instance, has been used with regard to health and medical research [58], clinical health expenditure [59] and other areas of health promotion, such as in tobacco control [60], but is relatively less common in literature considering implementation of healthy planning and active living initiatives. The notion can be borrowed from economics, such as where: a situation in which a series of sound economic policies sets off a chain of events in which improved economic performance produces sound currencies or other structural improvements. This in turn helps to improve economic performance further. [61] (pp. 180-181) The health promotion field more generally has acknowledged that additional beneficial outcomes might arise as a result of projects [38], and programs aimed specifically at capacity-building note that '[b]y building sustainable skills, resources and commitments to health promotion in health care settings, community settings and in other sectors, health promotion workers prolong and multiply health gains many times over' [62] (p. 2). Yet even in projects aimed primarily at capacity-building, these efforts and their benefits are often invisible [62].

Current State of Practical Guidance
Given the lack of explicitly identified virtuous cycle in the academic literature, as discussed above, more general practitioner guidance is examined briefly below, with regard to project implementation.
Local guidance on the delivery of healthy planning and active living initiatives commonly notes the importance of research, the need for integrated approaches, greater education and training (including skills development for practitioners) and the need for partnerships, as well as methods to evaluate projects [63]. Yet while such notions of a virtuous cycle might be inferred in such guidance (i.e., evaluation of projects is likely to inform and improve future project implementation) [63], rarely is it explicitly mentioned. Further, while such guidance focuses also on concepts of co-benefits, for instance that 'planning for health contributes to developing more sustainable communities' [63] (p. 15), potential for ongoing improved operation of LGs, or the opportunity for improved implementation of such projects subsequently, are generally not included as co-benefits. Various guidance documents detail what actions to promote health might look like, including case studies, however the focus remains on changes to the built environment rather than (organisational) settings that might allow for their implementation [64,65].
The Healthy by Design guidance produced by the Australian Heart Foundation places importance on strategic development, policy integration and project initiation, alluding to the notion of a virtuous cycle by noting that demonstration projects are important initiators of subsequent projects [64]. The Heart Foundation Local Government Awards [66] offer best practice cases of successful initiative implementation. While instances of projects building momentum at a LG level are evident, the projects are given on a case-by-case basis with no explicit examination of a virtuous cycle [66], and this is similar to other guidance and cases available [67,68]. Guidance specific to LG in New South Wales [69,70] posits a cyclical framework regarding the way the policy setting can incorporate concepts of health, as well as noting that existing services and activities provided by LG impact on future planning and policy decisions. Guidance also indicates that program sustainability should be considered at the outset of initiatives, and that sustainability can be enhanced though incorporating such into existing settings and organisations [71]. However, even where guidance outlines stages such as initiative implementation followed by evaluation [71], a virtuous cycle is not directly referenced.
The above has explored both the academic literature and practical implementation guidance for healthy planning and active living initiatives. While likely to be part of many practitioners' and advocates' empirical knowledge base, the idea of a virtuous cycle resulting from healthy planning and active living initiative implementation has gained limited attention in the literature. While practical guidance offers examples of the themes identified in this study (refer to Section 4), again the idea is not explicitly addressed. Identifying such a process offers the opportunity for its further exploration, as well as the potential to highlight benefits of project uptake that might not currently be acknowledged.

Materials and Methods
The study adopted a multi-method approach that included semi-structured, in-depth interviews, surveys and document analysis. The below sections provide an outline of these methods including the research framework used. Detailed descriptions of the multiple streams analysis (MSA) lens employed, as well as sampling, data collection and data analysis techniques employed as part of this study for the interviews [36] and surveys [29] have been reported elsewhere (see also [51]).

Multiple Streams Analysis (MSA)
An MSA framework was adopted for this study. An MSA framework presents three streams, or three primary processes of agenda setting. These include the problem stream, where conditions might be seen to be problems that are desirable to be addressed and that policy makers feel compelled to act upon [72], the politics stream, which considers the 'mood' or 'public opinion' at a LG scale [73,74]; and the policy stream, which considers possible policy options available to policy makers. Relevantly, the problem stream considers feedback from previous programs. When the three streams are brought together, a policy window presents itself, with change to policy more likely during this (brief) period.
An MSA lens allows a closer understanding of "policy world' realities' [75] necessary when examining the 'multiplicity and complexity of governance processes manifest within an urban area' [76] (p. 302). Importantly, MSA offers a lens through which to view changes to policy and other settings, offering an insight into why certain choices are made over others [74]. MSA avoids some of the shortfalls of alternative frameworks, for instance, more lineal theories such as path dependence [77][78][79][80]. Nevertheless, the theories of path dependence and MSA are compatible [81], with MSA able to offer an explanatory lens through which to view path dependence and/or deviation [82].

Sample
Potential healthy planning and active living advocates were recruited to participate in in-depth semi-structured interviews through a key informant, snowball sampling method [83]. Additionally, purposive sampling was used to engage practitioners in LGs that were identified as having recently undertaken one or more healthy planning and active living initiative(s) in case studies included in healthy planning guidance [84][85][86].
This approach provided insights from both advocates (interviews) and practitioners (surveys) operating in the healthy planning and active living space. As an example, an advocate from the built environment profession that participated in an interview could be identified as [IB1].
The involvement of practitioners associated with successful cases of implementation as well as healthy planning advocates limited participation to those with primarily positive opinions on healthy planning and active living initiatives and processes. While appropriate for this study, there is value in future studies exploring the opinions of those who might be critical of such, or who are excluded from these processes altogether.

Data Collection and Analysis
As outlined above, the study adopted a multi-method approach to data collection, allowing for triangulation of methods [87]. Twenty-eight in-depth, semi-structured interviews [33] were conducted with healthy planning and active living advocates and twenty open-ended surveys were completed by LG practitioners [29]. Different methods of data collection were deemed necessary to reach the different samples (advocates and LG practitioners), given preliminary contact with key informant practitioners in LG indicated time constraints, no process in LG to request time to participate in such a study, and in some cases ethical concerns over participating during work hours or on behalf of the LG as barriers to participating in interviews. Yet the perspective of these practitioners was an important component of the study, and so a survey was considered an appropriate and more accessible data collection method. Surveys have been employed previously to reach LG practitioners in roles that influence health in an Australian context [48]. No such barriers presented themselves in interviewing advocates, and in-depth, semi structured interviews are an appropriate method to reach those who could be considered advocates in this field [50]. The surveys and interviews asked questions on similar topics however the iterative approach to the interviews meant that data received and coded informed subsequent questions, and the semi-structured style allowed for additional lines of enquiry to be pursued as relevant. Additionally, the purposive sampling technique employed for the survey distribution allowed for some questions to be centred around a specific case of implementation.
Of the fifty-six surveys distributed via email across two rounds, twenty were returned (35.7% response rate) (see [29]). An introductory phone call or email was made to fifty-one advocates to request participation, with twenty-eight participating (54.9%). Of the remainder, twelve (23.5%) advocates indicated willingness to discuss the topic but declined formal participation in the study, and given ethics approval granted for the study permitted only formal in-depth interviews, these advocates did not participate further. Eight (15.7%) requests received no response, two (3.9%) individuals indicated that they did not meet the criteria outlined or had recently changed jobs to a role outside the field, and one (2%) potential interviewee indicated willingness to participate however an appropriate interview time was unable to be arranged.
In some cases, additional materials were provided by respondents or mentioned during the in-depth interviews or in the surveys. These documents were also included as data to be analysed. Data collection proceeded until data saturation was deemed to have occurred [88], with no further interviews and no further survey distribution rounds deemed necessary following that point.
Interview audio recordings were transcribed and checked by respondents. NVivo 11 data analysis software was used to analyse both the interview transcripts and completed surveys (and any supplementary material). Thematic analysis of both data sources was undertaken, with an MSA lens used as an initial sensitising concept, allowing for flexibility throughout the coding process [89]. Data analysis was undertaken iteratively with regard to the interview transcripts, with initial themes informing subsequent interview themes. Once emergent themes had been coded across perspectives of both practitioners (through survey responses) and advocates (through interview transcripts), findings were further verified through triangulation across these data sources [87].

Results
Findings from this research indicate four key areas through which project implementation demonstrates a 'virtuous cycle' effect. These areas include (1) project wind-up (Note 4 in Appendix A), or circumstances in which implementation and/or health outcomes exceed initial expectations; (2) partnerships and the improved opportunities for future initiatives these offer; (3) improved internal LG functioning; and (4) the continuation of projects beyond initial timeframes (refer to Table 1). Each emergent theme is discussed below.

Project 'Wind-Up'
Project wind-up was a commonly identified occurrence whereby the overall impact of a project (within the original planned timeline) was greater than initially anticipated. This idea was commonly identified by both practitioners and advocates. The most common types of project wind-up identified were where greater changes to the built environment occurred than originally anticipated [SH1, SH2], or where greater funding was released for the project than originally planned [LG] sort of went over and above whatever we signed in our memorandum of understanding. So I think it just built momentum and then they saw that they were winning, you know, getting runs on the board, their executive were coming on board with it, speeding up decision-making processes because they had a project which had an end date, like the intensive phase that they needed to sort of leverage. [IB4] Various examples of project wind-up were provided by respondents. In one instance the benefits of a program providing cycleways were noted among the community, LG councillors and LG practitioners, resulting in additional funding and allowing further cycleways to be provided than originally provisioned [SH1]. In another instance, a state-led (and state-funded) initiative included installation of active transport infrastructure and wayfinding signage. When the benefits of these were noted (again by the community and LG councillors and practitioners), the LG itself funded the installation of additional infrastructure and signage as part of the program, despite being outside the original project scope [IH1].

Partnership Development and Opportunities
Secondly, both advocates and practitioners commonly identified another often unintended or additional result of projects to be partnership development (between LG and an external organisation) and the incidental opportunities that these partnerships could offer. Two main types of partnership development resulted from initiatives: the formation of new partnerships [IH6, SH5], and the ability to strengthen and leverage existing partnerships [IH4, IH5, SH6]. In some instances, partnerships were a component of a project itself, yet of particular interest are cases where unexpected partnerships developed, or where formalised partnerships then had an unintended impact, such as subsequent opportunities to implement projects. An extended process of partnership formation resulting from initiative implementation was provided in the following: In many instances the partnerships that developed and opportunities they provided were an unintended consequence for the LG only; advocates and advocacy groups external to LG regularly saw projects as a way to engage with LG and develop long-term relationships. Such an attitude is typified in the following, whereby a 'program [ . . . ] has been in place in a few councils and that is been a real enabler as well, as like a way in [ . . . and] we've hooked up with them and done things collaboratively' [IH7]. For instance, an initiative implemented by a regional health service enabled partnership development, as follows: 'So the [initiative] was probably one of the biggest tools that has shown me and has given me a tool to use to engage councils' [IH8].
Such partnership development was seen to have multiple benefits. Firstly, it could improve the project itself (as discussed in Section 3.1). More importantly to advocates, however, this incidental partnership development provided greater opportunities for healthy planning and active living initiatives to be considered by a LG in the future [IH3, IH4, IH8]. This then presented benefits both to external advocates (having developed formal/informal links to a LG or LG practitioners) and to the LG itself (with greater guidance from advocates leading to improved project efficacy, and greater likelihood of future project opportunities). The importance of this element of project success and the ongoing opportunities such relationships can provide are summarised in the following response, from an advocate external to LG: 'I think establishing relationships is really important, and you can get so much more done when you've had a few good wins, and then you can kind of keep pushing it' [IH2]. Similar themes arose from an advocate within LG, such as where a project: really helped for us to get a few little wins in, and plus it's given us long-term networks to do things [ . . . and] we now know who in [an advocacy group and state department] to give us a hand is, and those relationships will last for years hopefully. [IH1]

Improved Internal Organisational Functioning
LG functioning was seen to improve in various ways as a result of projects. In some instances, improved internal functioning was an objective or central focus of a project from the outset [SH6], yet more commonly were implicit or unintended improvements [IB3, IB6, IB7, IH1]. It is these instances of implicit or unintended improvements that are the focus of this section. Such outcomes presented themselves at both the LG scale, and at the individual practitioner level.
At the LG level, initiative implementation could turn attention towards the existing policy setting and internal practices of the LG, and could also strengthen the local evidence base. The policy setting could be incidentally improved as a result of actions undertaken through projects. This could occur when implementation of projects (or reviews of policies targeted at other sections) revealed opportunities for policy improvement elsewhere [IB3]. Examples of this included changes to funding mechanisms [IB5, IH2, IH9] and LG land-use legislation or urban design policies [IB3]. Commonly, where projects were undertaken concurrently (but separately to) the review of an LG policy, central components of those initiatives could be 'embedded' into that policy being reviewed (for instance, LG public health policies) [IB7]. Projects could also highlight opportunities to improve the existing policy setting, such as where an initiative 'highlighted to [a LG] where our policy and procedure work was lacking, so, we've definitely developed since then some really good policies to really support what we're doing' [IB6]. The notion of a project providing momentum for policy change is also evident where: there was no condition [prior to the initiative], but there now is, for an active travel officer [ . . . ] So that's a two-year commitment by Council for a senior position, to work on active travel as a result of the physical activity strategy that we put in place with others. So [ . . . ] the policy environment was receptive, but the policy environment's been enhanced. [IH5] In addition to an improved policy setting (and often related to this consideration), the internal practices of LGs could also benefit from project implementation. Particularly, ongoing interdepartmental partnerships within LG (distinct from LG partners with external stakeholders, as discussed in Section 3.2) were noted to result from projects, such as where: you need people who can provide a technical response, and you need people who can be that community interface. So we had a great partnership with engineering [following project implementation] that ensured we were able to bring those different types of skills together for that community benefit. Undertaking healthy planning and active living initiatives also provided opportunities for LGs to measure qualitative and quantitative benefits through project evaluation, which in turn enabled future project uptake [IB6, IH6, IH8]. For instance, one initiative allowed for a private developer, a university, a federal government research funder and a state government health department to collaborate in evaluating a locally-implemented initiative [IB3]. The benefits of this extended to improved practice by the developer, an improved knowledge base for the state government agency and localised results regarding project efficacy for the LG [IB3]. Where such opportunities arise, the virtuous cycle likely applies at a scale wider than just LG. Another project involved collaboration between LG, state government departments and a regional health service. Evaluation of that project provided: hard evaluation data at the end [ . . . ] I think if we can sort of succinctly and kind of show easily that this is what we're doing, this is where the money's going and this is what we're going to get, it might help I guess [in the] future, down the line, in terms of getting [the message] across a bit more. So, I think having those evaluation outcomes is pretty important. [IH6]

Sustainable, Ongoing Projects
The benefits of the three factors above then in some cases led to extension of project implementation times, or to changes that made future projects more likely. For instance, where project wind-up provided greater benefits than originally expected, where partnerships were strengthened or developed and where the organisational setting of the LG changed to become more favourable to healthy planning, these could help to ensure that projects were continued [SH6, SB3], or that other programs were implemented directly [IB2, SH1, SH5]. Such effects could help to overcome barriers such as lack of funding [SH2, SB4] or short-term, ad hoc implementation [IB2, IH10]. This fourth consideration is perhaps the best illustration of a virtuous cycle. In an example where the policy setting improved as a result of a project, for instance, one effect was that the LG was able to 'set in place [ .

Discussion
Evaluating the full value of healthy planning and active living initiatives against a range of indicators is a difficult yet important task [90,91]. The findings of this paper indicate that partnership formation and an improved organisational setting (among others) can be a result of as well as a prerequisite for healthy planning and active living initiatives. In turn, this potentially presents yet another co-benefit of healthy planning and active living project uptake.
The concepts identified in Section 3 can be seen in other recorded examples of project implementation. For example, in an Australian project involving six Victorian LGs that aimed to 'strengthen local government capacity to adopt integrated planning to promote physical activity' [33] (p. 354), LGs each employed a staff member to help with this, and various other capacity-building efforts were made. Findings indicated that the project oriented the LG's focus towards physical activity promotion, although capacity building was an explicit aim [33]. Nevertheless, it presents an example of such a virtuous cycle in effect. The (explicit) capacity building efforts from the project then had impacts on understandings of how LG could influence constituents' health, such as through development of partnerships and through changes made to planning processes, structures and policies, to assist integrated planning [33], which supports the findings outlined above. In that study, 'the project was used as an opportunity to put into practice this approach by councils which had a preexisting readiness for this way of working' and where LGs 'used the MetroACTIVE strategy as a means of developing [integrated planning] further' [33] (p. 360). This reflects a virtuous cycle as outlined in Section 3.3, whereby LG internal functioning improved as a result of an initiative.
With regard to project wind-up, the possible (unintended) additional positive consequences of projects are widely acknowledged by advocates, yet specific examples of these have been largely overlooked in the literature and guidance, and so too has the notion that these might occur. While unintended positive consequences cannot, by definition, be identified prior to implementation, the fact they might occur can be. The possibility that projects might have even greater benefits than projected or forecast might assist in advocating for such changes. Forms of project wind-up are indeed often evident in evaluation of projects, such as where a program 'offered the capacity to generate substantial spin-off in terms of community activity around physical activity and healthy eating over and above funding levels' [92] (p. 14). The ability to communicate the possibility of this occurrence for future projects as 'project wind-up' (refer also Note 4 in Appendix A) could add weight to advocacy efforts of policy entrepreneurs [73], particularly with regard to the benefits of healthy planning policies and in settings where (healthy) planning decisions are politicised [36]. This consideration could also influence the political viability of healthy planning if unintended positive benefits are seen to commonly accompany such efforts.
In terms of partnerships and opportunities, while healthy planning literature has identified the need for partnerships for project uptake [29,51], relatively less attention is afforded the incidental partnerships that might develop as a result of implementation, and the opportunistic chances for future project uptake that they might provide. As an example, a healthy planning project implemented in Western Australia saw existing relationships, a result of previous projects, developed, with positive research and project outcomes resulting [93]. In this example, previous projects had a virtuous cycle effect through the relationships they had created. The importance of partnership development with 'external organizations, [such as with] community health centres, divisions of general practice and neighbourhood centres' has been demonstrated regarding implementation [33] (p. 358) (also [29,51]). As outlined in Section 3.2, healthy planning and active living projects can incidentally improve existing relationships and provide opportunities for new relationships to form. Yet if this often-unintended benefit can be explicitly identified, again with examples, it is likely to increase the political appeal of initial project uptake for practitioners and LGs, and add an extra benefit when healthy planning policy is considered against other options. Improved organisational functioning (or capacity building [62]) as a result of projects has also been identified in other instances of project implementation. For instance, following an initiative in New South Wales, Australia, a project review identified 'a "shift in consciousness" and renewed thinking [ . . . ] that had impacted on practice' as well as direct impacts to the policy setting [94] (p. 4, original emphasis). Evaluation of a LG capacity-building project noted that LGs are able to 'capitalise' on changes brought about by initiatives, finding collaboration across LG departments and from management roles to be one of these changes, which can also provide more benefit than where projects were undertaken by one division of the LG [33]. The same study also noted that 'cross-organizational ways of working' and 'new planning processes and structures to support integrated planning for physical activity' resulted from the project [33] (p. 358).
Improved internal organisational functioning has been found to have multiple benefits, such as being 'instrumental to multiplying health gains' [38] (p. 31) (also [62]). Increases in capacity building can relate to improvements in service development provided by an organisation, improve sustainability of a program (refer also below), and increase problem-solving abilities of an organisation [38]. Capacity building can also change perceptions of health promotion activities, build knowledge, and shift organisational attention towards such efforts, including through the policy setting and resource allocation [62,95]. Changes to the policy setting have previously been framed as a co-benefit of reduced duplication, such as a Victorian program in Australia that promoted integrated planning [33]. Improved internal operations can also include individual-level capacity building for practitioners within a LG, such as through greater awareness of the health challenges of a community, and potential ways an LG might influence these [62,94]. If projects can incidentally benefit the internal functioning of an LG, project uptake is likely to appeal to LGs hoping to improve their internal structures, particularly given the multiple benefits this can offer. Considering this, where healthy planning and active living initiatives are implemented, there might be value in measuring capacity building that results from such projects (such as, say, interdepartmental collaboration), in addition to community health benefits [38] and more commonly identified co-benefits.
Furthermore, as governance structures have been identified as a barrier to provision of more sustainable transport systems and urban forms in Australia [54] and as Australian LGs can be subject to bureaucratic inertia [53], situations that can change these governance structures and redirect bureaucratic inertia take on greater importance. In settings where there is a lack of a mandate for actions by LG at the state level, 'the challenge for local governments is to integrate healthy planning into their core business' [64] (p. 7). Undertaking initial projects, even as pilots or demonstration projects, can be a way to positively influence the governance structure and contribute to a positive inertia through changes that can result in the policy setting and practices of LG, while simultaneously contributing to the local evidence base to support action within that LG. Improved internal operations resulting from projects can be seen to be conducive to policy windows for LGs [73], or opportunities to make positive changes. This is likely the result of an improved political setting in LGs, where the benefits of healthy planning become evident, and of an improved policy setting, where the legislative setting becomes more conducive to healthy planning, or where it is considered more desirable to make such a change. A changed problem setting might also contribute to the improved likelihood of a policy window, such as where opinions might change to see 'community health' as being within the remit of LG.
Lastly, the importance of sustainable program implementation (Note 5 in Appendix A), and the challenge to achieving this in health promotion, have been noted [39]. As an example, across the world many organisations that regulate and influence the urban form have been structured to preference private, automobile transport for many decades, with resulting urban environments (and population health) reflecting this [15,96,97]. Yet this is a problem that can be reversed.
The above three findings, for instance, indicate that a positive inertia can be created by project uptake. Consequently, one-off, ad-hoc projects in some instances become instated into LG policy and practice, improving project sustainability and offering the chance for subsequent initiatives to further offer such benefits. When viewed through an MSA lens, the likelihood of a policy window opening, with subsequent positive change, can be seen to directly relate to the above three occurrences, and is likely to both result from and cause more sustainable implementation of healthy planning and active living initiatives, throughout different stages of the policy cycle.
The findings presented above offer various, unintended benefits that can result from undertaking healthy planning and active living initiatives. The key implications of this are threefold. Firstly, added importance should be placed on LGs undertaking healthy planning and active living initiatives. Actually undertaking projects starts a positive cycle that creates conditions that make it both easier and more likely for subsequent healthy planning efforts to be considered and undertaken [29,51]. This can help to overcome bureaucratic inertia [78] and with each project subsequent project uptake and success becomes more likely [79]. As such, opportunities for project uptake could be considered 'critical junctures' [81,98] or as opening up 'policy windows' [73], improving the chance of subsequent, positive changes to enable healthy planning to be undertaken.
Secondly, when discussing the co-benefits of projects, advocates might be able to include the institutional and operational benefits that such projects can create, such as more integrated planning, reduction in siloed operations of LGs, improved policy efficacy and reduced service/policy duplication. Project uptake might be coined in more cyclical terms, or LGs might be shown to be starting on a path towards healthy planning as a result of project uptake.
Thirdly, and related to providing evidence to support the second aspect, when such initiatives are undertaken, monitoring should include the institutional setting in which projects came to be undertaken, the institutional benefits that projects provide, and the subsequent opportunities projects might afford an LG in this space. Monitoring should be flexible and broad enough to allow for longer-term and less tangible benefits to be identified, even iteratively as the project is undertaken.

Conclusions
A lack of progress to date in implementing healthy planning on the ground in Australia supports the notion that '[r]eflecting on the kind of city we want is one thing; it is quite another to convert this into reality' [41] (p. 719). The need for partnerships, integrated planning and the discussion of co-benefits, among other considerations, have been noted to assist healthy planning, and to aid implementation of healthy planning and active living initiatives. Yet this study posits that the reverse is also true: where projects are implemented they can provide incidental benefits to collaboration and also provide better outcomes than originally anticipated, improve LG functioning, and in doing so become part of more sustainable implementation. While the challenges of gaining project uptake remain, this research places importance on action by LGs in this space, potentially also incentivising action through the identification of various incidental benefits that might arise from project uptake. Healthy planning and active living initiatives can help to shift the sustainable future city from concept to reality, through a virtuous cycle that assists in improving both planning and practice.