Identifying characteristics of intersectoral health interventions between the primary care and community settings for people living with obesity: an environmental scan protocol
================================================================================================================================================================================

* Géraldine Layani
* Anne Schweitzer
* Sopie Marielle Yapi
* Thameya Balasingam
* Laurence Berthelet
* Megane Pierre
* Alexandre Tremblay
* Nadia Sourial
* Antoine Boivin
* Maxime Sasseville
* Jean-Baptiste Gartner
* André Côté
* Frédéric Bergeron
* Lily Lessard
* Brigitte Vachon

## Abstract

**Introduction** Obesity, a complex chronic disease, is on the rise, leading to increased mortality, morbidity and societal challenges. This study explores intersectoral interventions focusing on the needs of people living with obesity (PLO).

**Methods and analysis** An environmental scan of the published and unpublished literature will be conducted using Medline, Embase, Cumulated Index in Nursing and Allied Health Literature and specialised websites. To be included, citations must describe or evaluate an intersectoral intervention for PLO developed in primary care or community settings. Title and abstract, full-text screening and extraction will be completed by two independent reviewers. Discrepancies will be resolved through consensus. Data such as study and intervention characteristics will be extracted using a customised extraction template on Covidence and synthesised in a table. Findings from this study will guide intervention design and enhance intersectoral collaboration in primary care and community settings. A multidisciplinary group, including clinicians and two patient partners, will be consulted throughout the process. Despite the challenges of defining intersectoral collaboration and limited data on obesity as a chronic disease, this study is foundational for developing effective intersectoral interventions for PLO.

**Ethics and dissemination** Ethics approval is not required. Findings will be disseminated through presentations at relevant conferences and other knowledge translation activities and will be published in a peer-reviewed journal.

*   Chronic Disease
*   Obesity
*   Community-Based Participatory Research
*   Primary healthcare
*   Primary Care

### STRENGTHS AND LIMITATIONS OF THIS STUDY

*   While there are currently no systematic methods for conducting environmental scans, we follow an established methodology to conduct literature reviews.

*   A multidisciplinary stakeholder group, including clinicians, managers and patient partners will be consulted throughout the environmental scan process.

*   Although there is a comprehensive search strategy, the variety of terms used to define intersectoral collaboration may limit the assessment of other relevant studies.

*   The recent recognition of obesity as a chronic disease may limit available data on intersectoral interventions, prompting our search strategy to encompass a broad range of literature.

## Introduction

Obesity is a complex and multifactorial chronic disease with a gradually increasing prevalence.1–3 In Canada, the prevalence has tripled since 1985, affecting 26.8% of Canadian adults (7.3 million), surpassing diabetes (9.4%) and hypertension (22.6%).4–6 Obesity is defined as an excess and/or dysfunctional adiposity in the body.1 Body mass index7 and the Edmonton Obesity Staging System (staging tools)8 are the main parameters used to estimate the risks associated with obesity. However, these parameters are increasingly controversial in the literature, since they do not consider a person’s total or regional adiposity.9 10 Abdominal and visceral adiposity are terms introduced into the literature to assess the health risks of the distribution of adiposity in the body.1 11 People living with obesity (PLO) have increased mortality risk, higher morbidity, reduced life expectancy and diminished quality of life.12–15 For instance, obesity puts individuals at risk for conditions such as hypertension, coronary artery disease, obstructive sleep apnoea, type 2 diabetes, osteoarthritis and certain cancers among others.1 16 In addition to comorbidities, many PLO experience weight-related prejudices, stigmatisation and discrimination, impacting their health and leading them to avoid healthcare and receive inequitable treatment.17 18

Despite the recognition of obesity as a chronic disease, healthcare is still often medicocentric.17 Indeed, different factors, such as genetics, metabolism, behaviour, sociocultural influences, environment and ethnicity, can contribute to obesity.1 19 The healthcare system only contributes to 20% of a person’s health, and it alone is insufficient to support PLO.20 Considering different aetiological factors, an integrated and systemic versus a problem-focused approach is needed. This approach supports interventions across the care continuum that can range from lifestyle interventions (such as access to healthy food, green spaces and community networks) to bariatric surgery.21–23 Thus, intersectoral interventions accounting for all determinants of a person’s health (socioeconomic, genetic, environmental and biomedical) would reduce the health inequities experienced by PLO.24 25

The WHO introduced the concept of intersectoral action for health in 1997 as ‘a recognised relationship between one or more parts of the health sector and parts of another sector that has been formed to address an issue to achieve health outcomes (or intermediate health outcomes) more efficiently, effectively or sustainably than could be achieved by the health sector alone’.26 The literature emphasises the importance of developing intersectoral interventions for PLOs, but few health interventions encompass specific strategies to engage stakeholders such as clinicians, managers, policy makers, community members, and patients from different sectors actively.17

To effectively leverage available resources and expertise to improve health outcomes of PLO in Quebec, the OBESITY-INTER-COLLAB project was created. The OBESITY-INTER-COLLAB project is a participatory research project conducted in cogovernance with a citizen partner (LB) and a primary care researcher clinician (GL) to propose an innovative organisational approach to the healthcare and services currently offered to PLO in Quebec (Canada). The aim of this project is to coconstruct an intersectoral learning community dedicated to PLO, using a participatory research approach focused on their needs. The first step in achieving this goal is to conduct an environmental scan to model human and organisational resources for and with PLO. This will allow us to understand the models of intersectoral interventions that exist for and with PLOs in the literature, and how the resources and participants involved in these interventions are mobilised to create tangible effects on all the health determinants of PLOs. The results from the environmental scan will inform participants in the community of practice about interventions currently in place to support PLO and help them implement innovative interventions in their territories.

## Methods

Environmental scans are a structured information-gathering methodology around a subject used in the healthcare sector to synthesise evidence for programme information, policy development and identifying service gaps.27 28 While environmental scans are increasingly recognised in research for investigating health issues, there is currently no universally accepted standard methodology for conducting this method.29 30 The methodological framework for environmental scans usually encompasses gathering information from multiple sources, which improves the validity of the conclusions by lowering biases. This environmental scan will use data collection by reviewing the published and grey literature regarding intersectoral health interventions targeting PLO. Thus, the scan will follow four steps based on Arksey and O’Malley’s methodological framework: (1) search strategies and data sources, (2) selection process, (3) data extraction and (4) data synthesis.

The environmental scan centres on the following question:

‘What intersectoral health interventions have been developed within the community and primary care settings for people living with obesity?’

### Search strategies and data sources

#### Academic literature

An experienced research librarian (BN) designed the academic literature search strategy using medical subject headings and keywords. The different search terms cover the themes of intersectoral intervention and obesity. The following electronic databases will be searched: Medline (Ovid), Cumulated Index in Nursing and Allied Health Literature (CINAHL) (EBSCOhost) and Web of Science. The search in bibliographic databases will be limited to adults. Only the literature published in English or French between 01 January 2006 and 15 April 2024 will be considered, given that obesity was recognised as a chronic disease in the 2006 Canadian clinical practice guidelines on managing and preventing obesity.31 In CINAHL, we will use the limits ‘exclude Medline records’ and ‘peer-reviewed’. Another senior information specialist, using the Peer Review of Electronic Search Strategies checklist, will peer-review the Medline search strategy before execution. If required, the authors of the identified studies and reports will be contacted to acquire any missing information. The search strategy is reported in the online supplemental material appendix 1.

### Supplementary data

[[bmjopen-2024-091610supp001.pdf]](pending:yes)

#### Grey literature

The grey literature search aims to gather all relevant documents, webpages, blogs, news sites and other online resources that may not be included in the published literature. It will include search engines and preselected specific websites. The search strategy for this grey literature review will be discussed with an experienced research librarian (FB) and will be based on a grey literature guideline.32

The grey literature search will use the following keywords: intervention/action/approach, intersectoral/collaborative/community/participative, obesity and citizens/user. Searches will be carried out on sites in English and French. As per the librarian’s suggestion, only the first 50 results will be considered to ensure a comprehensive search and reach a saturation point.33

Indeed, since the relevance algorithm diminishes beyond the first few results and preliminary tests indicated that beyond the first 50, nothing relevant seemed to emerge, the limit of 50 will be applied.33 First, the metasearch engine eTools.ch will be used for a unique search on Google (Google.com, Mountain View, California, USA) and Qwant (Qwant.com, France). It will also be used to search government websites (eg, .org, .qc, .ca) in all the commonwealth countries. Specialised public health grey literature resources such as Tagpacker and all relevant webpages from the organisations listed in the online supplemental material appendix 2 will be consulted. The preselected website comprises a list of relevant websites encountered during discussions, research and knowledge gathering within the team. The process will be recorded in tables.

### Supplementary data

[[bmjopen-2024-091610supp002.pdf]](pending:yes)

### Selection process

Following the search, the results from the academic search will be imported into EndNote, a software for managing bibliographic references, to remove duplicates. The database will then be transferred to the Covidence web application for the screening process.34 The eligible literature will be screened using titles and abstracts, followed by a full-text review of selected sources. Eligible sites identified from the grey literature search will be exported to an Excel sheet. Two reviewers will independently assess all sources for inclusion according to predetermined criteria outlined in table 1. It will be categorised as included or excluded at each analysis stage. Any discrepancies between reviewers will be resolved through discussion with a third reviewer. Inter-rater reliability will be assessed to evaluate the validity of the selection process. Before the initial review, a sample of 50 study abstracts will be used to test the inclusion and exclusion criteria. This process aims to confirm the robustness and specificity of our selection criteria in identifying the relevant literature. Reasons for exclusion during full-text review will be documented.35

View this table:
[Table 1](http://bmjopen.bmj.com/content/15/3/e091610/T1)

Table 1 
Eligibility criteria

The Commonwealth fund’s international health policy surveys were used to select countries, ensuring the inclusion of countries with healthcare systems comparable to the Canadian system.36 37

### Data extraction

Data extraction will be performed on included citations and reports after the selection process. Information to be extracted encompasses source details and intervention characteristics, including the level of action, target population and involved actors. A comprehensive list of characteristics is outlined in table 2. Two reviewers will independently extract data from all included citations, with any discrepancies resolved through discussion within the research team. To ensure the precision of the process, the data extraction form will be piloted on a sample of 10 citations and adjusted as needed.

View this table:
[Table 2](http://bmjopen.bmj.com/content/15/3/e091610/T2)

Table 2 
Data extraction form

### Data synthesis

The results will be reported using a Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 flow diagram, presenting the screening process, including the number of citations identified, duplicates removed, studies screened, excluded texts and full texts included with reasons for exclusion.38 The characteristics of the included interventions will be summarised in a table and classified according to four social determinants of health in the County Health Rankings’ model of health: socioeconomic factors, physical environment, healthcare and health behaviours.19

Furthermore, the environmental scan results will be used to explore how to implement a health intervention involving the community and the health system (ie, the how?) for and with PLO to facilitate the implementation of the intersectoral obesity community of practice. Finally, findings will be synthesised as a report to inform participants in the community of practice about existing interventions comprehensively and synthetically for key data. A knowledge broker will be called to help find the right format to engage all participants in this process. The review started in May 2024 and is projected to be completed by March 2025.

## Ethics and dissemination

Ethics approval is unnecessary for this review, as it involves reviewing and collecting data from published and/or publicly available sources. Dissemination of the results is planned through peer-reviewed publications and presentations to key stakeholders.

## Discussion/conclusion

The environmental scan will identify potential intersectoral interventions for PLO. It aims to explore the characteristics of these types of interventions, including factors that contribute to their implementation and delivery, as well as knowledge gaps. The results of this scan may inform us on the actors needed to create an intersectoral collaboration and give information on their potential interaction, communes’ values and definitions. Therefore, it will help us design an intervention that responds to the needs of PLO. Environmental scan is a methodological approach from the business sectors to inform strategic decision-making, which has been widely adopted in the healthcare sector.39 However, it still lacks a consistent definition and a methodological guide to conduct this type of research in the literature.40 Thus, the environmental scan will include both the published and unpublished literature to ensure comprehensiveness but will be limited to publications in French and English. Challenges encountered with the grey literature, such as the difficulty accessing the information in a reproducible way, doing its inventory and evaluating the information, will be mitigated with double screening. However, the information collected in the grey literature search is complementary to that collected from traditional databases. Intersectorality is a relatively new approach that can be defined in various ways. Although there was a comprehensive search strategy, the various terms used to define intersectoral collaboration may limit the assessment of relevant citations. Additionally, obesity has only recently been acknowledged as a chronic disease, which may potentially limit the scope of available data.

Nevertheless, this study is the first step in establishing a practical base to help the project team develop an intervention for and with PLO that supports their overall health and well-being.

## Patient and public involvement

Our team includes two patient-partners, LB and MT, who will be involved throughout the review process and will be consulted from protocol development to dissemination. LB will also contribute as a reviewer.

## Ethics statements

### Patient consent for publication

Not applicable.

## Footnotes

*   Contributors GL conceived of the idea, developed the research question and study methods and contributed meaningfully to the drafting and editing; SMY and AS aided significantly in developing the study methods and contributed meaningfully to the drafting, editing and formatting of the manuscript; TB, LB, MP, AT, NS, AB, MS, J-BG, AC, FB, LL and BV aided in developing the research question and study methods and contributed meaningfully to the editing of the manuscript. GL is the guarantor of this manuscript. All authors approved the final manuscript.

*   Funding This work was supported by 'Fonds de recherche du Québec – Nature et technologies', grant number: 337137.

*   Competing interests None declared.

*   Patient and public involvement Patients and/or the public were involved in the design, conduct, reporting or dissemination plans of this research. Refer to the Methods section for further details.

*   Provenance and peer review Not commissioned; externally peer reviewed.

*   Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

[http://creativecommons.org/licenses/by-nc/4.0/](http://creativecommons.org/licenses/by-nc/4.0/)
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: [http://creativecommons.org/licenses/by-nc/4.0/](http://creativecommons.org/licenses/by-nc/4.0/).

## References

1.  Twells LK, Janssen I, Kuk JL. Canadian adult obesity clinical practice guidelines: epidemiology of adult obesity. n.d. Available: [https://obesitycanada.ca/guidelines/epidemiology/](https://obesitycanada.ca/guidelines/epidemiology/)
    
    

2.  Abarca-Gómez L, Abdeen ZA, Hamid ZA, et al. Worldwide trends in body-mass index, underweight, overweight, and obesity from 1975 to 2016: a pooled analysis of 2416 population-based measurement studies in 128·9 million children, adolescents, and adults. Lancet 2017;390:2627–42. [doi:10.1016/S0140-6736(17)32129-3](http://dx.doi.org/10.1016/S0140-6736(17)32129-3)
    
    [CrossRef](http://bmjopen.bmj.com/lookup/external-ref?access_num=doi:10.1016/S0140-6736(17)32129-3&link_type=DOI) 
    
    [PubMed](http://bmjopen.bmj.com/lookup/external-ref?access_num=29029897&link_type=MED&atom=%2Fbmjopen%2F15%2F3%2Fe091610.atom) 

3.  Luli M, Yeo G, Farrell E, et al. The implications of defining obesity as a disease: a report from the Association for the Study of Obesity 2021 annual conference. EClinicalMedicine 2023;58:101962. [doi:10.1016/j.eclinm.2023.101962](http://dx.doi.org/10.1016/j.eclinm.2023.101962)
    
    

4.  Padwal RS, Bienek A, McAlister FA, et al. Epidemiology of Hypertension in Canada: An Update. Can J Cardiol 2016;32:687–94. [doi:10.1016/j.cjca.2015.07.734](http://dx.doi.org/10.1016/j.cjca.2015.07.734)
    
    [CrossRef](http://bmjopen.bmj.com/lookup/external-ref?access_num=10.1016/j.cjca.2015.07.734&link_type=DOI) 
    
    [PubMed](http://bmjopen.bmj.com/lookup/external-ref?access_num=26711315&link_type=MED&atom=%2Fbmjopen%2F15%2F3%2Fe091610.atom) 

5.  Agence de la santé publique du Canada. L’obésité dans les régions rurales et les régions urbaines du Canada - Infobase de la santé publique. 2020 Available: [https://sante-infobase.canada.ca/labo-de-donnees/blogue-atlas-facteurs-risque-canada-obesite.html](https://sante-infobase.canada.ca/labo-de-donnees/blogue-atlas-facteurs-risque-canada-obesite.html)
    
    

6.  Agence de la santé publique duCanada. Diabète: Aperçu. 2008. Available: [https://www.canada.ca/fr/sante-publique/services/maladies-chroniques/diabete.html](https://www.canada.ca/fr/sante-publique/services/maladies-chroniques/diabete.html)
    
    

7.  Institut de la statistique du Québec. Comment se porte la santé de la population québécoise? Institut de la statistique du Québec; 2023. Available: [https://statistique.quebec.ca/fr/communique/comment-se-porte-sante-population-quebecoise](https://statistique.quebec.ca/fr/communique/comment-se-porte-sante-population-quebecoise)
    
    

8.  Sharma AM, Kushner RF. A proposed clinical staging system for obesity. Int J Obes 2009;33:289–95. [doi:10.1038/ijo.2009.2](http://dx.doi.org/10.1038/ijo.2009.2)
    
    [CrossRef](http://bmjopen.bmj.com/lookup/external-ref?access_num=10.1038/ijo.2009.2&link_type=DOI) 

9.  Jensen MD, Ryan DH, Apovian CM. 2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults. Circulation 2014;129:S102–38. [doi:10.1161/01.cir.0000437739.71477.ee](http://dx.doi.org/10.1161/01.cir.0000437739.71477.ee)
    
    [FREE Full Text](http://bmjopen.bmj.com/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6MTQ6ImNpcmN1bGF0aW9uYWhhIjtzOjU6InJlc2lkIjtzOjE5OiIxMjkvMjVfc3VwcGxfMi9TMTAyIjtzOjQ6ImF0b20iO3M6MjY6Ii9ibWpvcGVuLzE1LzMvZTA5MTYxMC5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

10. Prospective Studies Collaboration, Whitlock G, Lewington S, et al. Body-mass index and cause-specific mortality in 900 000 adults: collaborative analyses of 57 prospective studies. Lancet 2009;373:1083–96. [doi:10.1016/S0140-6736(09)60318-4](http://dx.doi.org/10.1016/S0140-6736(09)60318-4)
    
    [CrossRef](http://bmjopen.bmj.com/lookup/external-ref?access_num=10.1016/S0140-6736(09)60318-4&link_type=DOI) 
    
    [PubMed](http://bmjopen.bmj.com/lookup/external-ref?access_num=19299006&link_type=MED&atom=%2Fbmjopen%2F15%2F3%2Fe091610.atom) 
    
    [Web of Science](http://bmjopen.bmj.com/lookup/external-ref?access_num=000264773600029&link_type=ISI) 

11. Wharton S, Lau DCW, Vallis M, et al. Obesity in adults: a clinical practice guideline. CMAJ 2020;192:E875–91. [doi:10.1503/cmaj.191707](http://dx.doi.org/10.1503/cmaj.191707)
    
    [FREE Full Text](http://bmjopen.bmj.com/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czoxMToiMTkyLzMxL0U4NzUiO3M6NDoiYXRvbSI7czoyNjoiL2Jtam9wZW4vMTUvMy9lMDkxNjEwLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

12. Sutin AR, Stephan Y, Terracciano A. Weight Discrimination and Risk of Mortality. Psychol Sci 2015;26:1803–11. [doi:10.1177/0956797615601103](http://dx.doi.org/10.1177/0956797615601103)
    
    [CrossRef](http://bmjopen.bmj.com/lookup/external-ref?access_num=10.1177/0956797615601103&link_type=DOI) 
    
    [PubMed](http://bmjopen.bmj.com/lookup/external-ref?access_num=26420442&link_type=MED&atom=%2Fbmjopen%2F15%2F3%2Fe091610.atom) 

13. Guh DP, Zhang W, Bansback N, et al. The incidence of co-morbidities related to obesity and overweight: a systematic review and meta-analysis. BMC Public Health 2009;9:88. [doi:10.1186/1471-2458-9-88](http://dx.doi.org/10.1186/1471-2458-9-88)
    
    

14. Bastien M, Poirier P, Lemieux I, et al. Overview of epidemiology and contribution of obesity to cardiovascular disease. Prog Cardiovasc Dis 2014;56:369–81. [doi:10.1016/j.pcad.2013.10.016](http://dx.doi.org/10.1016/j.pcad.2013.10.016)
    
    [CrossRef](http://bmjopen.bmj.com/lookup/external-ref?access_num=10.1016/j.pcad.2013.10.016&link_type=DOI) 
    
    [PubMed](http://bmjopen.bmj.com/lookup/external-ref?access_num=24438728&link_type=MED&atom=%2Fbmjopen%2F15%2F3%2Fe091610.atom) 

15. Anis AH, Zhang W, Bansback N, et al. Obesity and overweight in Canada: an updated cost‐of‐illness study. Obes Rev 2010;11:31–40. [doi:10.1111/j.1467-789X.2009.00579.x](http://dx.doi.org/10.1111/j.1467-789X.2009.00579.x)
    
    [CrossRef](http://bmjopen.bmj.com/lookup/external-ref?access_num=10.1111/j.1467-789X.2009.00579.x&link_type=DOI) 
    
    [PubMed](http://bmjopen.bmj.com/lookup/external-ref?access_num=19413707&link_type=MED&atom=%2Fbmjopen%2F15%2F3%2Fe091610.atom) 
    
    [Web of Science](http://bmjopen.bmj.com/lookup/external-ref?access_num=000273022000005&link_type=ISI) 

16. Jehan S, Zizi F, Pandi-Perumal SR, et al. Energy imbalance: obesity, associated comorbidities, prevention, management and public health implications. Adv Obes Weight Manag Control 2020;10:146–61.
    
    [PubMed](http://bmjopen.bmj.com/lookup/external-ref?access_num=33305001&link_type=MED&atom=%2Fbmjopen%2F15%2F3%2Fe091610.atom) 

17. Salas XR, Forhan M, Caulfield T, et al. A critical analysis of obesity prevention policies and strategies. Can J Public Health 2017;108:e598–608. [doi:10.17269/CJPH.108.6044](http://dx.doi.org/10.17269/CJPH.108.6044)
    
    [PubMed](http://bmjopen.bmj.com/lookup/external-ref?access_num=31823280&link_type=MED&atom=%2Fbmjopen%2F15%2F3%2Fe091610.atom) 

18. Alberga AS, Edache IY, Forhan M, et al. Weight bias and health care utilization: a scoping review. Prim Health Care Res Dev 2019;20:e116. [doi:10.1017/S1463423619000227](http://dx.doi.org/10.1017/S1463423619000227)
    
    

19. University of Wisconsin Population Health Institute. Health factors | county health rankings & roadmaps. 2014 Available: [https://www.countyhealthrankings.org/health-data/health-factors](https://www.countyhealthrankings.org/health-data/health-factors)
    
    

20. Institute for Clinical Systems Improvement. Going beyond clinical walls: solving complex problems. 2014. Available: [https://www.icsi.org/wp-content/uploads/2019/08/1.SolvingComplexProblems\_BeyondClinicalWalls.pdf](https://www.icsi.org/wp-content/uploads/2019/08/1.SolvingComplexProblems_BeyondClinicalWalls.pdf)
    
    

21. Institut national de santé publique du Québec. L’obésité au Québec: ralentissement de l’augmentation, mais inégalités socio-économiques. Institut national de santé publique du Québec. 2019 Available: [https://www.inspq.qc.ca/santescope/analyses/obesite](https://www.inspq.qc.ca/santescope/analyses/obesite)
    
    

22. Organization WH. Framework on integrated, people-centred health services. 2016. Available: [https://apps.who.int/gb/ebwha/pdf\_files/wha69/a69\_39-en.pdf](https://apps.who.int/gb/ebwha/pdf_files/wha69/a69_39-en.pdf)
    
    

23. Pearce C, Rychetnik L, Wutzke S, et al. Obesity prevention and the role of hospital and community-based health services: a scoping review. BMC Health Serv Res 2019;19:453. [doi:10.1186/s12913-019-4262-3](http://dx.doi.org/10.1186/s12913-019-4262-3)
    
    

24. Ndumbe-Eyoh S, Moffatt H. Intersectoral action for health equity: a rapid systematic review. BMC Public Health 2013;13:1056. [doi:10.1186/1471-2458-13-1056](http://dx.doi.org/10.1186/1471-2458-13-1056)
    
    

25. Dubois A, St-Pierre L, Veras M. A scoping review of definitions and frameworks of intersectoral action. Ciênc Saúde Coletiva 2015;20:2933–42. [doi:10.1590/1413-812320152010.01222014](http://dx.doi.org/10.1590/1413-812320152010.01222014)
    
    

26. Organization WH. Intersectoral action for health: a cornerstone for health-for-all in the twenty-first century. In: Report on an International Conference Held in Halifax. 1997: 20–3.
    
    

27. Graham P, Evitts T, Thomas-MacLean R. Environmental scans: how useful are they for primary care research? Can Fam Physician 2008;54:1022–3.
    
    [FREE Full Text](http://bmjopen.bmj.com/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6MzoiY2ZwIjtzOjU6InJlc2lkIjtzOjk6IjU0LzcvMTAyMiI7czo0OiJhdG9tIjtzOjI2OiIvYm1qb3Blbi8xNS8zL2UwOTE2MTAuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

28. Charlton P, Kean T, Liu RH, et al. Use of environmental scans in health services delivery research: a scoping review. BMJ Open 2021;11:e050284. [doi:10.1136/bmjopen-2021-050284](http://dx.doi.org/10.1136/bmjopen-2021-050284)
    
    

29. Wilburn A, Vanderpool RC, Knight JR. Environmental Scanning as a Public Health Tool: Kentucky’s Human Papillomavirus Vaccination Project. Prev Chronic Dis 2016;13:E109. [doi:10.5888/pcd13.160165](http://dx.doi.org/10.5888/pcd13.160165)
    
    

30. Naumann D. An Environmental Scan of Programs Available to Residents of Eastern Ontario Affected by Fetal Alcohol Spectrum Disorder (FASD). J Dev Disabil 2013;19:29–50.
    
    

31. Lau DCW, Douketis JD, Morrison KM, et al. 2006 Canadian clinical practice guidelines on the management and prevention of obesity in adults and children [summary]. CMAJ 2007;176:S1–13. [doi:10.1503/cmaj.061409](http://dx.doi.org/10.1503/cmaj.061409)
    
    [Abstract/FREE Full Text](http://bmjopen.bmj.com/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czo4OiIxNzYvNi9TMSI7czo0OiJhdG9tIjtzOjI2OiIvYm1qb3Blbi8xNS8zL2UwOTE2MTAuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

32. Association des bibliothèques de la santé du Canada. Guides et outils: recherche - veille - services techniques [Biblio3S]. 2024 Available: [https://extranet.santecom.qc.ca/wiki/!biblio3s/materiel](https://extranet.santecom.qc.ca/wiki/!biblio3s/materiel)
    
    

33. Godin K, Stapleton J, Kirkpatrick SI, et al. Applying systematic review search methods to the grey literature: a case study examining guidelines for school-based breakfast programs in Canada. Syst Rev 2015;4:138. [doi:10.1186/s13643-015-0125-0](http://dx.doi.org/10.1186/s13643-015-0125-0)
    
    

34. Veritas Health Innovation M Australia. Covidence - better systematic review management. 2024 Available: [https://www.covidence.org/](https://www.covidence.org/)
    
    

35. Higgins JP, Green S. Cochrane handbook for systematic reviews of interventions: Cochrane book series.
    
    

36. Doty MM, Tikkanen R, Shah A, et al. Primary Care Physicians’ Role In Coordinating Medical And Health-Related Social Needs In Eleven Countries. Health Aff (Millwood) 2020;39:115–23. [doi:10.1377/hlthaff.2019.01088](http://dx.doi.org/10.1377/hlthaff.2019.01088)
    
    [CrossRef](http://bmjopen.bmj.com/lookup/external-ref?access_num=10.1377/hlthaff.2019.01088&link_type=DOI) 
    
    [PubMed](http://bmjopen.bmj.com/lookup/external-ref?access_num=31821045&link_type=MED&atom=%2Fbmjopen%2F15%2F3%2Fe091610.atom) 

37. Langton J, Wong S, Johnston S, et al. Primary Care Performance Measurement and Reporting at a Regional Level: Could a Matrix Approach Provide Actionable Information for Policy Makers and Clinicians? Hcpol 2016;12:33–51. [doi:10.12927/hcpol.2016.24942](http://dx.doi.org/10.12927/hcpol.2016.24942)
    
    

38. Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. [doi:10.1136/bmj.n71](http://dx.doi.org/10.1136/bmj.n71)
    
    

39. Robinson CV, Ahmad F, Simmons JEL. Consolidation and fragmentation in environmental scanning: A review and research agenda. Long Range Plann 2021;54:101997. [doi:10.1016/j.lrp.2020.101997](http://dx.doi.org/10.1016/j.lrp.2020.101997)
    
    

40. Graham P, Evitts T, Thomas-MacLean R. Environmental scans. Can Fam Physician Juill 2008;54:1022–3.
    
    

41. Himmelman A. Collaboration for a change: definitions, decision-making models, roles, and collaboration processguide. 2002. Available: [https://tennessee.edu/wp-content/uploads/2019/07/Himmelman-Collaboration-for-a-Change.pdf](https://tennessee.edu/wp-content/uploads/2019/07/Himmelman-Collaboration-for-a-Change.pdf)