Obesity is a serious concern in the U.S. Almost half of adults (42.4%) are affected (Hales et al 2020), with higher prevalence among racial and ethnic minorities (Petersen et al 2019), and lower income populations (Zare et al 2021). Obesity is a leading cause of death (Remington et al 2016), and costs about $149.4 billion (US dollars) annually (Kim and Basu 2016).

Public health policy, in the form of laws, regulations, and guidelines, has a profound effect on health, including obesity (Brownson et al 2009, Gortmaker et al 2011). There are numerous effective or evidence-based policies (EBPs) to prevent obesity (Community Preventive Services Task Force, McKinnon et al 2016, University of Wisconsin Population Health Institute). Developing and implementing state and local-level EBPs is imperative (Brownson et al 2009, Institute of Medicine 2009, Mier et al 2013, Zaza et al 2005), considering policies often have a more sustained impact on health than individual-level interventions (Brownson et al 2006, Eyler et al 2016). Municipal and other local governments have unique roles in addressing obesity and shaping policies to support community health (Reeve et al 2015). Strategies such as enhancing access to healthy environments are operationalized locally through zoning and other land use ordinances, city or park master plans, food marketing, and transportation policies (Chriqui 2013, Lyn et al 2013).

However, formulating health policies is complex and depends on a variety of scientific, economic, social, and political forces (Spasoff 1999). Policies have greater odds of being adopted when the problem is clearly defined, potential solutions are identified, and politics and public opinion are supportive (Purtle et al 2023). This complexity underscores the need to understand how policymakers obtain, understand, use and disseminate evidence.

Local officials are often receptive to constituents and data about local issues (Yamey 2011) and local-level evidence can play an important role in policy (Fielding and Frieden 2004, Kneale et al 2017, Yost et al 2014). Additionally, relationships with key organizations in their community can impact the actions of local policymakers. Given the importance of local policy, it is imperative policymakers have access to high-quality research evidence, presented in a useful format and by opinion leaders. Yet, policymakers are often overwhelmed by the information they receive and prefer local data that are concise, visually appealing, current, and relevant (Bogenschneider and Corbett 2010, Oliver et al 2014, Tricco et al 2016).

Understanding policymakers’ perceptions on issues has been important aspect in translation of research evidence into policymaking (Oliver et al 2014). Most research on public health and obesity policies has been conducted with state legislators (Dodson et al 2009, Dodson et al 2013, Killian et al 2020, Welch et al 2012), and much less scholarship among municipal officials. Given the influence local officials have on health policy (McCarty et al 2009), understanding municipal officials’ perspectives on community health and the policies impacting it is vital to translating evidence to local policymakers and into policies that promote health (Bernier and Clavier 2011). This lends to conceptual use of research evidence, i.e., for enlightment or learning, introduced by Weiss (Weiss 1977), which aims to shift how policymakers or practitioners think about issues, problems or potential solutions.

To date, little attention has been paid to local policy approaches most useful for communities experiencing obesity disparities. There are pervasive disparities in obesity-related environments and policies that disadvantage low-income communities and racial minority populations (Ewart-Pierce et al 2016, Jones et al 2015, Lovasi et al 2009, Singleton et al 2016). The objective of this study was to understand the decision-making process for policies impacting obesity and community health, and perspectives on obesity and related health disparities among local policymakers from municipalities experiencing obesity disparities.

This qualitative study consisted of 20 semi-structured interviews with local elected and top-appointed officials from municipalities across the United States, conducted between December 2020 and April 2021. The Institutional Review Board of Washington University in St. Louis approved this study (#202001197).

Of 165 officials contacted, 20 (12%) agreed and participated. Two of the 22 consented contacts did not attend their scheduled interview or reschedule. Interviews were conducted with officials from 16 municipalities with an even split between council-manager and mayor-council governance types. Most participants were men (65%), elected officials (90%), aged ≥60 years (70%), and of liberal social ideology (60%). Table 1 provides additional participant and municipality background information. Interviewees varied according to position as an elected or appointed official. Primary responsibilities mentioned included passing and overseeing the budget, drafting and passing legislation, serving as ambassadors for the city, researching and meeting constituent needs, representing the people, and engaging in committee work. Appointed officials mentioned running day-to-day operations of the city and acting as a conduit between staff and the council.

Policy action at the local level can greatly contribute to community health equity and address obesity (Gortmaker et al 2011, Kumanyika 2019, 2019). Findings from this qualitative study provide advocates and practitioners insights on factors affecting municipal officials’ policymaking, and policies that have been adopted to address obesity, community health, and health equity. The study also highlights key takeaways about local officials’ understanding of health disparities, such as the diversity in perceived causes of disparities and their limits on action, and the importance of working across disease and risk factor silos and ideological backgrounds.

Local officials in this study used a general approach when engaging in policy decision-making, whether the topic was health or another area. Similar to previous studies with state legislators (Ashcraft et al 2020, Dodson et al 2013, Purtle et al 2018), municipal officials value constituents’ opinions. Since local policymakers may not be directly affected by some of the challenges faced by their constituents, it is critical to engage the community in the co-creation of policies (Walker et al 2022). Municipal officials interviewed conduct their own research, referring to “go-to” or trustworthy sources, and look to other communities to see what they have done and the impact of those policy actions. Exploring the relationship between the officials and their sources may be another step in understanding policy actions.

The connection with and input provided from community organizations and stakeholders on an issue and ways to address it are important in facilitating policymaking at the municipal level, emphasizing the key role some local organizations or groups play as policy intermediaries. There is a growing body of work on the role of brokers, intermediaries, and boundary spanners (BIBS) in addressing the challenges in transferring research evidence between research and policy or practice communities (Bullock et al 2021, Neal et al 2022). Strategies include facilitating relationships, disseminating evidence, finding alignment, capacity building, and advising on decisions (Neal et al 2021). Current findings suggest the importance of researchers or knowledge producers identifying and establishing relationships with key community organizations or groups with ties to local policy actors or key community members (i.e., intermediaries) to provide timely research evidence to build understanding and support with constituents (to indirectly influence policymaking) and local officials (directly).

Importantly, local officials did not make clear distinctions between health and other policy areas. For efforts to address obesity, much of the progress will come from sectors outside of health (e.g., agriculture, transportation, city planning) (Gortmaker et al 2011). Successful implementation of EBPs across these sectors requires finding common ground (e.g., equity) among a diverse set of organizations, often with missions that do not focus on health (Mazzucca et al 2021). This aligns with local-level policies that emphasize health in all policies or equity in all policies (Brownson et al 2021, Puska 2007).

Local leaders in our sample appeared to understand the importance of addressing disparities along with the complexity of intersecting causal factors, including lack of job opportunities, the wealth gap, and racism. Yet, elsewhere US mayors have reported they do not always perceive accountability for prevalent health concerns (e.g., obesity) (Godinez Puig et al 2021) and are often unaware of the policies to address health disparities (Purtle et al 2018). Respondents in our study reported challenges in collaborating across departments and levels of government (municipal and county), which is necessary for addressing complex, interconnected disparities. It is also critical to bring on new equity partners, share power and decision-making, and break down funding silos (Brownson et al 2021).

As in previous studies (Oliver et al 2014), we identified multiple barriers to policy action. It is useful to categorize these challenges across a continuum of modifiability. Several barriers to policy translation can be changed in a relatively short time period (e.g., timely access to relevant research evidence, skill-building among intermediaries). Other barriers to policy progress are much more difficult to change (e.g., political ideology). Our study and others emphasize the role of framing—how something is presented to the audience (“the frame”) influences the choices people make about how to process information and act (Akl et al 2011, Rothman and Salovey 1997). In a review of effective advocacy for health equity, there is consensus on the need to frame messages to the political environment (Farrer et al 2015). Research in the US showed constituents of conservative ideology believe poor health results from “poor choices” and that messages should focus on how policies can help people make “positive choices,” whereas words like “equality,” “fairness,” and other terms or concepts that appeal to more progressive voters should be avoided (Westen 2010). Future research should examine data by political party to consider how ideology influences the way issues are understood by local policymakers.

In conjunction with these barriers, we identified several key facilitators for local policy progress, including the need for timely, relevant, and actionable data. While it is well-documented that local policy officials seek out local data (Fielding and Frieden 2004, Kneale et al 2017, Yost et al 2014), information systems at the city and county level are much less developed than those at state and national levels (Chriqui 2013, Haire-Joshu et al 2010).There is a small, but expanding list of user-friendly local data resources for health, social and economic factors in the US (County Health Rankings & Roadmaps (University of Wisconsin Population Health Institute), City Health Dashboard (NYU Langone Health), PLACES: Local Data for Better Health (Centers for Disease Control and Prevention)). This is accompanied by the need to build awareness of these resources among organizations and their workforce’s skills in accessing and using them. Our study illustrates the growing challenge of mis-information, though there are ways to address this seemingly insurmountable problem (e.g., providing accurate, engaging information that can be shared across multiple platforms) (Caulfield 2020, Office of the U.S. Surgeon General 2021). However, this requires substantial resources among already resource-scarce local organizations and government. Exploring the role of local thought leaders and organizations intervening in public opinion is an area for future research.

There are some limitations to our study. Our results reflect the perspectives and experiences of municipal officials in a selection of US municipalities with high rates of obesity or related health disparities, some of which were randomly sampled, while other officials were selected purposively. Participants from the latter group may have been more receptive to community health issues. Our study does not represent all settings (e.g., urban, rural) and populations (e.g., racial/ethnic minority groups, low-income populations) across the US.

There is a growing number and range of EBP for addressing obesity disparities in communities in the US and globally (the “what” that needs to be put in place) (Kristensen et al 2014, Kumanyika 2019, Lyn et al 2013, McKinnon et al 2016). There is far less information on how to implement EBP within a particular context, including the process of policy adaptation (Brownson et al 2022). In addressing the “how,” policymakers typically make decisions across a wide array of issues and may lack a broad understanding of the relationship of obesity-relevant policies or their potential impact across sectors (e.g., transportation, housing, and health). They may lack skills on ways to collaborate with other policymakers to make comprehensive and systematic policy decisions to positively impact community health and health equity. Community organizations have a key role as intermediaries influencing local policymaking. Findings from our study provide leads on how to inform and accelerate local-level policy development, implementation, and evaluation.