Barriers to partnership working in public health: a qualitative study

"You just can't do that in dementia care": Barriers to partnership working within dementia services for people from south Asian communities

Background: People from South Asian communities are under-represented at all levels of dementia services. Consequently, there is pressure for the statutory sector to deliver services in partnership with Voluntary, Community, Faith and Social Enterprises (VCFSEs). This study set out to explore the constraints to effective partnership working which prevent dementia care from being delivered in an equitable way.Methods: Data collection consisted of two phases. First, we interviewed seven people with experience of partnership working and developed three fictional vignettes that were representative of the challenges they faced. We then used these vignettes to stimulate discussion in focus groups and interviews with 13 VCFSE and 16 statutory sector participants. Data was analysed using deductive thematic analysis.Findings: Three themes were developed during the analysis. First, White British-centric services focused on the challenges for statutory services in meeting the needs of South Asians, developing flexible, responsive services and making inclusive partnership working truly meaningful. Second, VCFSE participants (but not statutory service participants) associated a failure to deliver effective partnership working with unconscious bias operating within systems, leading to the devaluing of their expertise and to their views being ignored. Finally, participants emphasised the need to prioritise relationships if they were to meet the challenges of developing partnership working.Conclusion: We identified three constraints acting to prevent effective partnership working. First, the different meanings that statutory and VCFSE participants attach to challenges threatens their ability to develop a shared understanding of the needs of communities. Second, a reluctance to explicitly address service deficiencies can mean that stereotypes remain unaddressed. Finally, while both parties lacked power to change the fundamentals of service delivery, power and resources were also unbalanced with VCSFE services being more reliant on the statutory sector.

'Staying in the lane' of public health? Boundary-work in the roles of state health officials and experts in COVID-19 policymaking

The state-level COVID-19 response in the United States necessitated collaboration between governor' offices, health departments and numerous other departments and outside experts. To gain insight into how health officials and experts contributed to advising on COVID-19 policies, we conducted semi-structured interviews with 25 individuals with a health specialisation who were involved in COVID-19 policymaking, taking place between February and December 2022. We found two diverging understandings of the role of health officials and experts in COVID-19 policymaking: the role of 'staying in the lane' of public health in terms of the information that they collected, their advocacy for policies and their area of expertise and the role of engaging in the balancing of multiple considerations, such as public health, feasibility and competing objectives (such as the economy) in the crafting of pandemic policy. We draw on the concept of boundary-work to examine how these roles were constructed. We conclude by considering the appropriateness as well as the ethical implications of these two approaches to public health policymaking.

Mechanisms of Intersectoral Collaboration in the Health System: A Scoping Review

Background

The implementation of health interventions requires the collaboration of various sectors outside health due to the multidimensional nature of healthcare. Building effective partnerships demands the use of intersectoral mechanisms that facilitate the leadership and implementation of these programs. In this review, the mechanisms of intersectoral collaboration (ISC) and their results were identified.

Methods

This scoping review was conducted in 2020. Using relevant keywords, all documents related to ISC in the health system were identified by searching four databases (PubMed, Scopus, Science Direct, and Web of Science), Google, and Google scholar search engines. In the initial search, 2911 documents were extracted. Based on the selection criteria 52 documents were selected for content analysis.

Results

Five areas of ISC were identified, including funding (collection, pooling, and distribution of funds), governance and leadership (political commitment, rules and regulations, control and evaluation, and stakeholder engagement), structural mechanisms (interorganizational, government-based, and program-based structures), process tools (information tools, support tools, and resource and service sharing), and models and frameworks (general, national, and program-specific models).

Conclusion

An intersectoral framework or model be developed that considers the financial, structural, and leadership aspects as well as the necessary process tools required for each program. Moreover, it should be considered communication and human resources empowerment in each intervention.

Effect of a telecare-based intervention on stress levels in informal caregivers of older adults: protocol for a randomized controlled trial

Significance

Due to caregiving commitments, caregivers of older adults may not have the time to make use of the onsite community services available to them during the day. With the support of advanced technology, telecare could be a convenient and easily accessible channel for providing individualized caregiving advice to caregivers.

Objective

The aim of the study is to describe a research protocol that highlights the development of a telecare-based intervention program for reducing stress levels in informal caregivers of community-dwelling older adults.

Methods

It is a randomized controlled trial. The study is supported by two community centers. The study participants will be randomly assigned to either the telecare-based intervention group or the control group. The former will receive a 3-month program comprised of three components: online nurse case management supported by a health and social care team, an online resource center, and a discussion forum. The latter will receive the usual services that provided by the community centers. Data will be collected at two time points - pre-intervention (T1) and post-intervention (T2). The primary outcome is stress levels, while secondary outcomes include self-efficacy, depression levels, quality of life, and caregiving burden.

Discussion

Besides taking care of one or more older adults, informal caregivers have to deal with work, chores, and take care of their children. This study will add valuable information to the knowledge gap on whether telecare-based interventions with the support of an integrated health-social team can alleviate the stress levels of informal caregivers of community-dwelling older adults. If successful, policymakers and healthcare professionals should consider incorporating telecare modalities in a primary health setting for informal caregivers to correspond with them, to relieve their caregiving stress and promote a healthy life.

Clinical trial registration

https://www.clinicaltrials.gov/, NCT05636982.

Building engagement to support adoption of community-based substance use prevention initiatives

BACKGROUND

System-level approaches that target social determinants of health are promising strategies to support substance use prevention, holistic youth development and wellbeing. Yet, the youth services system is largely based on individual-focused programs that do not adequately account for social determinants of health and place the responsibility for wellness on the individual. There is a need to understand how to enhance adoption of complex system-level approaches that support comprehensive youth development. The Icelandic Prevention Model (IPM) represents a collaborative initiative that takes an ecological, system-level approach to prevent substance use and promote wellness in youth. This research was designed to examine key stakeholder perceptions to better understand social motivations and contextual complexities that influence stakeholder support to garner community-level adoption of the IPM in a rural Canadian community.

METHODS

This research applies a case study approach using qualitative interviews to explore strategies to support uptake in the early stages of IPM adoption associated with developing community buy-in and acceptance. A thematic analysis was applied using QSR NVivo.

RESULTS

Nine interviews were conducted with community partners leading the implementation of the IPM. Three over-arching themes emerged from the data: 1) Motivating influences 2) Strategies to develop buy-in, and 3) Resistance to the adoption of the IPM. Findings reflect issues that affect behaviour change in system transformation in general as well as upstream prevention and the IPM, in particular.

CONCLUSIONS

The findings from this research describe critical insight derived from implementing community-driven initiatives that are designed to support health promotion. It contributes new scientific knowledge related to implementation of complex system-level innovations and practical information that is useful for communities interested in implementing the IPM or following similar approaches to prevent substance use.

Advancing community-engaged research during the COVID-19 pandemic: Insights from a social network analysis of the trans-LINK Network

Collaboration across sectors is critical to address complex health problems, particularly during the current COVID-19 pandemic. We examined the ability to collaborate during the pandemic as part of a baseline evaluation of an intersectoral network of healthcare and community organizations established to improve the collective response to transgender (trans) persons who have been sexually assaulted (the trans-LINK Network). A validated social network analysis survey was sent to 119 member organizations in Ontario, Canada. Survey respondents were asked, ‘Has COVID-19 negatively affected your organization’s ability to collaborate with other organizations on the support of trans survivors of sexual assault?’ and ‘How has COVID-19 negatively affected your organization’s ability to collaborate within the trans-LINK Network?’. Data were analyzed using descriptive statistics. Seventy-eight member organizations participated in the survey (response rate = 66%). Most organizations (79%) indicated that the pandemic had affected their ability to collaborate with others in the network, citing most commonly, increased workload (77%), increased demand for services (57%), and technical and digital challenges (50%). Survey findings were shared in a stakeholder consultation with 22 representatives of 21 network member organizations. Stakeholders provided suggestions to prevent and address the challenges, barriers, and disruptions in serving trans survivors experienced during the pandemic, which were organized into themes. Seven themes were generated and used as a scaffold for the development of recommendations to advance the network, including: increase communication and knowledge exchange among member organizations through the establishment of a network discussion forum and capacity building group workshops; enhance awareness of network organizations by developing a member-facing directory of member services, their contributions, and ability to provide specific supports; strengthen capacity to provide virtual and in-person services and programs through enhanced IT support and increased opportunities for knowledge sharing and skill development; and adopt a network wide syndemic approach that addresses co-occurring epidemics (COVID-19 + racism, housing insecurity, transphobia, xenophobia) that impact trans survivors of sexual assault.

Preventive health resource allocation decision-making processes and the use of economic evidence in an Australian state government—A mixed methods study

Context

Recommended best practice for resource allocation decisions by governments include a stepwise process guided by economic evidence. However, the use of economic evidence in preventive health decision-making, which often impacts on multiple sectors of government, is under-researched. This study aimed to explore the resource allocation decision-making processes for preventive health interventions in the New South Wales (NSW) Government in Australia, and specifically examined the barriers and facilitators to the use of economic evidence from the perspective of multiple government departments.

Methods

This mixed methods study was conducted using semi-structured interviews with NSW Treasury representatives (n = 4), a focus group of NSW Ministry of Health representatives (n = 9), and a quantitative questionnaire of all participants. The schedule for the interviews and focus group was based on resource allocation guidance documents from Australian government agencies. Deductive content analysis was undertaken, guided by the Multiple Streams Framework.

Findings

NSW Treasury participants believed that decision-making processes where economic efficiency was the key guiding principle was the ideal approach. However, the NSW Ministry of Health participants identified that for preventive health decision-making, economic evidence was not used to inform their own choices but was typically only used to convince other agencies of the merits of proposed initiatives when seeking approval. The key barriers to the use of economic evidence were the lack of capacity within the NSW Ministry of Health to understand and undertake economic evaluations; a lack of collaboration between NSW Treasury and preventive health decision-makers within the NSW Ministry of Health; and deficient processes and governance mechanisms that do not facilitate or incentivise effective inter-sectoral decision-making.

Conclusions

Institutional structures for resource allocation decision-making regarding preventive health result in processes that contrast with best practice recommendations. The multiple challenges to collaborative decision-making across agencies require organisational change to promote a whole-of-government approach.

Using systems science methods to enhance the work of national and local walking partnerships: practical insights from Ireland

Background

Physical activity (PA) literature is dominated by individual-level descriptive studies, which are known to have limited impact on population PA levels. Leveraging systems science methods offers opportunities to approach PA in a manner which embraces its inherent complexity. This study describes how participatory systems mapping and social network analysis (SNA) were used to understand the work of local and national level walking systems in Ireland.

Methods

Two adapted participatory action research workshops with multisectoral stakeholders were used to develop a systems map for walking in Cork, Ireland. The Global Action Plan for Physical Activity 2018–2030 (GAPPA) map was used as a framework to categorize workshop outcomes. Secondly, SNA methods were used to analyse the communication network between partners of Get Ireland Walking, a national walking promotion initiative, as defined within their strategic plan and the actual communication network as experienced by the partners.

Results

The systems mapping process allowed stakeholders to identify 19 suggested actions for the Cork walking system. The SNA found that there were considerably fewer communication ties between partners in the actual communication network than in the strategy defined network.

Conclusion

The systems mapping process was a useful catalyst for engaging stakeholders in cross-sectoral communication and the GAPPA was a practical way to organize workshop outcomes. Social network analysis methods highlighted that the communication network of a national level walking promotion partnership is not working as planned. Overall, the use of systems science methods can provide practical insights for local and national level walking systems.

Theory-based capacity building intervention for intersectoral action for health at local governments: An exploratory pilot study

Aim

To design, implement and evaluate a nurse‐led capacity building intervention (PromoGOB) for intersectoral action for health at local governments.

Design

The programme was based on theories of the policy process and organizational change and facilitated by a nurse developing a health broker role. A complex intervention perspective was adopted in carrying out the study. The intervention was evaluated using a mixed method embedded design.

Methods

Quantitative component relied on a specific questionnaire. This tool, designed and piloted ad hoc, measured the capacity in terms of knowledge, awareness, resources, skills, and commitment, both at sectoral and government levels. For the qualitative component, semi‐structured interviews were conducted. These explored the perceived capacity and feasibility and acceptability issues. The programme was initiated at the end of October 2019, and it lasted a total of 5 weeks. Nineteen individuals representing various sectors at a local government in northern Spain participated in the study. The data analysis was concluded by the end of March 2020.

Findings

PromoGOB positively influenced participants' capacity for addressing health promotion. Awareness component, intersectoral work and the nurse as health broker were essential in the programme. The necessity of political participation was identified as an issue to be prioritized in future studies.

Conclusion

This study highlights the relevance of capacity building at local governments and the role that nurses can play in it. Further work should be undertaken to continue developing Health in All Policies approach at local level.

Impact

This study offers a starting point for nurses to get involved in the policy process of health promotion, performing a specific role as health brokers, building capacity at local governments for addressing social determinants of health, and delving into theories and concepts of the Health in All Policies field.

Improving health through multisectoral collaboration: enablers and barriers

OBJECTIVE

Multisectoral partnerships (MPs) are increasingly viewed as an excellent strategy for promoting population health, although the Canadian evidence on MPs remains scant. The objective of this research was to identify enablers and barriers to multisectoral collaboration across three MPs (focused on food systems, urban development, and active transportation) in a Canadian urban centre.

METHODS

This study is part of a pan-Canadian research program-MUSE (Multisectoral Urban Systems for health and Equity in Canadian cities). A qualitative case study methodology was used to explore enablers and barriers to collaboration among three MPs in a mid-sized Canadian city. Key strategy documents of the MPs and 13 in-depth, semi-structured interviews were conducted with stakeholders from each MP. Interview data were transcribed and subjected to thematic analysis using NVivo 12 software, with rigour ensured through member checking.

RESULTS

Enablers to collaboration included agenda and goal alignment among partners, quality of relationships in MPs, and external enabling factors. Barriers to multisectoral collaboration included agenda and priority differences, factors related to partnership structure, constitution and processes, and external barriers. Based on these factors, we developed a multisectoral collaboration matrix that dichotomizes enablers and barriers into intrinsic/internal and extrinsic/external to increase understanding of health-promoting MPs in Canada.

CONCLUSION

Various enablers and barriers promote or inhibit multisectoral partnerships. By casting these factors into a matrix, members of ongoing or emerging MPs could take advantage of the factors that promote their work and are in their control (intrinsic enablers) or outside their control (extrinsic enablers) while working to overcome challenges presented by collaboration barriers.

An evaluation of the Victorian Salt Reduction Partnership's advocacy strategy for policy change

BACKGROUND

Public health advocacy strategies facilitate policy change by bringing key health issues to the forefront of public and political discourse, influencing decision-makers and public opinion, and increasing policy demand. The Victorian Salt Reduction Partnership (VSRP) was established in 2014 in response to inadequate government action to improve population diets in Australia. This study aimed to evaluate the success of the VSRP's advocacy strategy in achieving policy change.

METHODS

Documentation of VSRP activities and outputs were collected, and semi-structured interviews conducted as part of a comprehensive process evaluation. For this study, the Kotter Plus 10-step public health advocacy evaluation framework was used to guide data extraction, analysis, and synthesis.

RESULTS

A sense of urgency for salt reduction was generated by producing evidence and outlining the potential impact of a state-based salt reduction programme. This enabled the creation of a coalition with diverse skills and expertise, which facilitated the development of an innovative and collaborative advocacy action plan. A clear change vision was established, but communication of the vision to decision-makers was lacking, which reduced the impact of the programme as decision-makers were not provided with a clear incentive for policy change. As a result, while programme outputs were achieved, these did not translate to achieving broader strategic goals during a limited-term intervention in a political climate unconcerned with salt.

CONCLUSIONS

The Kotter Plus 10-step framework was a useful tool for evaluating the success of the VSRP advocacy strategy. The framework enabled the identification of key strengths, including the creation of the guiding coalition, and areas where efforts could be improved in future similar strategies, such as effective communication within partnerships and to decision-makers, to better influence policy and improve public health impact.

Exploring the local policy context for reducing health inequalities in children and young people: an in depth qualitative case study of one local authority in the North of England, UK

Background

Improving children and young people’s (CYP) health and addressing health inequalities are international priorities. Reducing inequalities is particularly pertinent in light of the Covid-19 outbreak which has exacerbated already widening inequalities in health. This study aimed to explore understandings of inequality, the anticipated pathways for reducing inequalities among CYP and key factors affecting the development and implementation of policy to reduce inequalities among CYP at a local level.

Methods

We carried out a qualitative case study of one local government region in the North of England (UK), comprising semi structured interviews (n = 16) with service providers with a responsibility for child health, non-participant observations of key meetings (n = 6 with 43 participants) where decisions around child health are made, and a local policy documentation review (n = 11). We employed a novel theoretical framework, drawing together different approaches to understanding policy, to guide our design and analysis.

Results

Participants in our study understood inequalities in CYP health almost exclusively as socioeconomically patterned inequalities in health practices and outcomes. Strategies which participants perceived to reduce inequalities included: preventive support and early intervention, an early years/whole family focus, targeted working in local areas of high deprivation, organisational integration and whole system/place-based approaches. Despite demonstrating a commitment to a social determinants of health approach, efforts to reduce inequalities were described as thwarted by the prevalence of poverty and budget cuts which hindered the ability of local organisations to work together. Participants critiqued national policy which aimed to reduce inequalities in CYP health for failing to recognise local economic disparities and the interrelated nature of the determinants of health.

Conclusions

Despite increased calls for a ‘whole systems’ approach to reducing inequalities in health, significant barriers to implementation remain. National governments need to work towards more joined up policy making, which takes into consideration regional disparities, allows for flexibility in interpretation and addresses the different and interrelated social determinants of health. Our findings have particular significance in light of Covid-19 and indicate the need for systems level policy responses and a health in all policies approach.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10782-0.

Stakeholder perspectives on the effectiveness of the Victorian Salt Reduction Partnership: a qualitative study

BACKGROUND

Interventions to reduce population salt intake are feasible and cost-effective. The Victorian Salt Reduction Partnership implemented a complex, multi-faceted salt reduction intervention between 2014 and 2020 in the Australian state of Victoria. This study aimed to understand stakeholder perspectives on the effectiveness of the Victorian Salt Reduction Partnership.

METHODS

Semi-structured interviews were conducted with Partnership and food industry stakeholders. The Consolidated Framework for Implementation Research was adapted for the Partnership intervention and used to guide the qualitative analysis.

RESULTS

Fourteen Partnership and seven food industry stakeholders were interviewed. The Partnership was viewed as essential for intervention planning and decision-making and an enabler for intervention delivery. The goals of capacity building and collaborative action were perceived to have been achieved. The implementation team executed intended intervention activities and outputs, with some adaptations to strategy. Barriers and enablers to implementation were identified by interviewees, such as compatibility of individual, organisational and Partnership values and building positive relationships between the Partnership and food industry, respectively. Legal, political, social, environmental, technological and economic factors affecting intervention design, delivery and outcomes were identified.

CONCLUSIONS

Establishing a Partnership with diverse skills and experience facilitated collaborative action, capacity building and execution of the intervention. Monitoring and evaluating implementation informed strategy adaptations, which allowed optimisation of Partnership strategy. The importance of developing strong communication networks between strategic and implementation-levels was a key lesson.

Community aquatic therapy for Parkinson's disease: an international qualitative study

PURPOSE

To explore the opinions of people living with Parkinson's disease about access to and participation in community aquatic therapy.

METHODS

Focus groups and individual interviews were conducted with people living with Parkinson's disease in Ireland (n = 24) and Australia (n = 10). All discussions were audio-recorded, transcribed verbatim, and thematically analysed.

RESULTS

Four main themes were identified. Primarily, participants were optimistic about their reasons for choosing aquatic therapy and found it beneficial to their health and well-being. Optimal components of aquatic therapy identified were access to individually tailored aquatic programs, completed as a minimum once a week, at a moderate to high-intensity level, and guided by a credentialed instructor. Fear was a significant barrier for a small proportion of participants and was linked to water competence, past experiences, and fall risk associated with the aquatic environment. Participants identified a strong need for education and increased awareness about aquatic therapy benefits to promote greater engagement.

CONCLUSION

Aquatic therapy is a popular exercise choice for people with Parkinson's disease, especially in the early to middle disease stages. Considering the views of people living with Parkinson's disease can aid the design and implementation of interventions and future aquatic research internationally.Implications for RehabilitationAquatic therapy is emerging as an effective physiotherapy approach for managing motor and non-motor symptoms in Parkinson's disease.Little is known regarding community-based aquatic therapy programs from the perspectives of people living with Parkinson's disease internationally.People with Parkinson's disease may benefit from timely information about the unique benefits, prerequisites, and local aquatic therapy facilities to promote greater uptake of aquatic programs.Tailored aquatic therapy interventions delivered within a group setting by a credentialed healthcare professional may increase long-term adherence.

Understanding the dynamics of obesity prevention policy decision-making using a systems perspective: A case study of Healthy Together Victoria

INTRODUCTION

Despite global recommendations for governments to implement a comprehensive suite of policies to address obesity, policy adoption has been deficient globally. This paper utilised political science theory and systems thinking methods to examine the dynamics underlying decisions regarding obesity prevention policy adoption within the context of the Australian state government initiative, Healthy Together Victoria (HTV) (2011-2016). The aim was to understand key influences on policy processes, and to identify potential opportunities to increase the adoption of recommended policies.

METHODS

Data describing government processes in relation to the adoption of six policy interventions considered as part of HTV were collected using interviews (n = 57), document analyses (n = 568) and field note observations. The data were analysed using multiple political science theories. A systematic method was then used to develop a Causal Loop Diagram (CLD) for each policy intervention. A simplified meta-CLD was generated from synthesis of common elements across each of the six policy interventions.

RESULTS

The dynamics of policy change could be explained using a series of feedback loops. Five interconnected balancing loops served to reduce the propensity for policy change. These pertained to an organisational norm of risk aversion, and the complexity resulting from a whole-of-government policy approach and in-depth stakeholder consultation. However, seven virtuous reinforcing loops helped overcome policy resistance through policy actor capabilities that were improved over time as policy actors gained experience in advocating for change.

CONCLUSION

Policy processes for obesity prevention are complex and resistant to change. In order to increase adoption of recommended policies, several capabilities of policy actors, including policy skills, political astuteness, negotiation skills and consensus building, should be fostered and strengthened. Strategies to facilitate effective and broad-based consultation, both across and external to government, need to be implemented in ways that do not result in substantial delays in the policy process.

Community Action Package in Iran's Comprehensive Mental and Social Health Services (the SERAJ Program)

Objective: The social component of health plays a significant role in improving the mental health of the people of a district. A national program on providing comprehensive social and mental health services, entitled ‎‎"SERAJ", was developed and piloted in three districts of Iran. The present study aims to determine its model for improving the indicators of the social component of mental health. Method : This study is a system design for which a literature review, interviews with experts, and focused group discussions with stakeholders were used. Results: Community action in promoting the mental health of the districts has three main components: strengthening intersectoral collaboration through the memorandum of understandings (MoU), increasing people's participation by establishing People's Participation House (PPH) with the presence of the representative of current People's network, and social protection of people suffering from mental disorders by establishing the Social Support Unit (SSU) for self-reliance activity. All three components are controlled by the governor and with supervision and technical consult of the health network of the district and stakeholder participation. Conclusion: The model uses the inner capacities of the city instead of creating new structures. The prerequisites for the effective function of the main three components are educating departments, educating members of the PPH, and hiring a social worker at the SSU. The effective measures taken by the departments to reduce the risk factors for mental disorders are dependent on the technical and financial support of relevant organizations at the provincial and national levels.

How to improve recruitment, sustainability and scalability in physical activity programmes for adults aged 50 years and older: A qualitative study of key stakeholder perspectives

INTRODUCTION

Physical inactivity among adults aged 50 years and over is a worldwide health concern. The objectives of the study were to investigate the perspectives of those involved with existing physical activity programmes on optimising recruitment, sustainability and scalability of physical activity programmes for adults aged 50 years and over.

METHODS

The study was conducted in Ireland's Midwest region, where community-based physical activity programmes are delivered to groups by state-funded Local Sports Partnerships. Programme attendees, physical activity professionals and community advocates were recruited. One-to-one interviews and focus groups were conducted in 2018, recorded, transcribed and analysed by an interdisciplinary team experienced in qualitative research. Over a series of meetings, a thematic approach was used to code and analyse the transcripts, categorising data into higher order codes, themes and overarching themes with the purpose of making meaning of the data. Twenty-nine people participated in four focus groups and 18 participated in one-to-one interviews.

FINDINGS

Data analysis produced three overarching themes. "Age appropriate" explains how communication and the environment should be adapted to the needs of adults aged 50 years and older. "Culture and connection" refer to the interplay of individual and social factors that influence participation, including individual fears and insecurities, group cohesion and added value beyond the physical gains in these programmes. "Roles and partnerships" outlines how key collaborations may be identified and managed and how local ownership is key to success and scalability.

CONCLUSION

Successful recruitment, sustainability and scalability require an understanding that the target population has unique needs that must be catered for when planning interventions, communicating messages and choosing personnel. The findings of this study can inform the development of community-based programmes to increase physical activity in adults aged 50 years and older.

Cross-Sector Collaboration for a Healthy Living Environment-Which Strategies to Implement, Why, and in Which Context?

BACKGROUND

Working toward a healthy living environment requires organizations from different policy domains and nongovernment partners involved in public health and the living environment to collaborate across sectors. The aim of this study is to understand how this cross-sector collaboration for a healthy living environment can be achieved.

METHODS

The realist evaluation approach was used to investigate what strategies can be used in which contexts to achieve cross-sector collaboration. The "Collaborative Adaptive Health Networks" framework was used as a theoretical framework. Seventeen partners of three Dutch projects collaborating for a healthy living environment in different regions were interviewed about their experiences during the initiating phase of their projects.

RESULTS

Seven themes for achieving cross-sector collaboration were identified, namely creating a feeling of equivalence, building trust, bridging different perspectives, providing clarity regarding roles and tasks, creating commitment, creating active engagement, and understanding whom to engage and when. For each theme, the strategies that were used, and why, were specified.

CONCLUSION

This study provides new insights in how cross-sector collaboration for a healthy living environment can be achieved in different contexts. Whether the start of a cross-sectoral collaboration is successful is largely influenced by the choice of leadership and the interorganizational relations.

The use of future scenario thinking for child public health in a local authority

BACKGROUND

Socioeconomic, cultural, technological, environment and ecological changes are rapidly transforming how children and young people (CYP) grow up, yet their impacts on CYP are difficult to predict. The traditional ways that Public Health practitioners work may not capture such complex and dynamic change. To address this, Lambeth Council used future scenario thinking.

METHODS

A literature review looked at political, socioeconomic and other 'transitions' in the borough. Interviews, focus groups and workshops were held with CYP, parents, carers, local statutory and non-statutory stakeholders about the future for Lambeth CYP in the decade ahead. Themes were analysed to identify which had the potential for the biggest impact or the most uncertainty.

RESULTS

The main transitions were described, 100 stakeholders interviewed, and five 'drivers' of the future were identified: protracted austerity, technological explosion, demographic shift, 'democratic shake-up' and planetary health. From all these data, four future scenarios were developed: 'communities care for themselves', 'collaborating to care for all', 'nobody cares' and 'who cares?'

CONCLUSIONS

New insights were gained about promoting more responsibility for, and active participation of CYP. This led to Lambeth's CYP Plan and the 'Made in Lambeth' campaign aiming to enlist the community and business in creating a child-friendly borough.

Stakeholders' experiences of the public health research process: time to change the system?

BACKGROUND

The importance of engaging stakeholders in the research process is well recognised. Whilst engagement is important, guidelines and practices vary for how stakeholders should be involved in research and how to facilitate effective collaborative relationships.

METHODS

This study aimed to explore the perspectives and experiences of stakeholders involved in the policy and practice area of outdoor space and non-communicable disease prevention. Stakeholders interviewed included academics, practitioners, policy-makers, knowledge brokers and a funder.

RESULTS

The findings suggest that stakeholders had positive experiences when engaged meaningfully in the research process, where research projects were carefully planned and managed with attention to context and culture, and where the research team was effective, respectful and communicative. These factors help to facilitate the translation of research into policy and practice. However, multiple challenges of collaborative research were identified which related to structural and systemic challenges, building and maintaining relationships, use and collection of data and information, cultural perceptions of research and research generation, and getting evidence into action. Participants felt that changing the funding system, exploring more collaborative research methodologies, improved research translation, and more effective collaborative relationships at all stages of the research process could address some of these challenges.

CONCLUSIONS

The findings highlight that, whilst stakeholder engagement in research was considered important, structural, cultural and individual practices impacted how this worked in practice. Identifying and testing solutions to address these challenges could improve synergies between research, policy, and practice and lead to the production of impactful research that reduces wastage of public funding, improves implementation of findings and ultimately improves public health outcomes.

Partnering to address rural health workforce challenges in Western NSW

Purpose

While one-third of Australians live outside major cities, there are ongoing challenges in providing accessible, sustainable, and appropriate primary health care services in rural and remote communities. The purpose of this paper is to explore a partnership approach to understanding and addressing complex primary health workforce issues in the western region of New South Wales (NSW), Australia.

Design/methodology/approach

The authors describe how a collaboration of five organisations worked together to engage a broader group of stakeholders and secure commitment and resources for a regional approach to address workforce challenges in Western NSW. A literature review and formal interviews with stakeholders gathered knowledge, identified issues and informed the overarching approach, including the development of the Western NSW Partnership Model and Primary Health Workforce Planning Framework. A stakeholder forum tested the proposed approach and gained endorsement for a collaborative priority action plan.

Findings

The Western NSW Partnership Model successfully engaged regional stakeholders and guided the development of a collaborative approach to building a sustainable primary health workforce for the future.

Originality/value

Given the scarcity of literature about effective partnerships approaches to address rural health workforce challenges, this paper contributes to an understanding of how to build sustainable partnerships to positively impact on the rural health workforce. This approach is replicable and potentially valuable elsewhere in NSW, other parts of Australia and internationally.

Role of the nurse in identifying and addressing health inequalities

This article aims to improve nurses' knowledge and understanding of health inequalities. Health inequalities are responsible for variation in health outcomes observed across different population groups. Therefore, it is essential that nurses have an understanding of the health inequalities that can occur, and their causes. This knowledge will enable nurses to address the challenges that health inequalities can create in nursing practice. This article raises awareness of this important aspect of care, so that nurses can successfully identify and address the health inequalities that they encounter in their practice, thus enabling a holistic approach to patient care.

Creating a Collaborative Platform for the Development of Community Interventions to Prevent Non-Communicable Diseases

Chronic diseases, also known as non-communicable diseases (NCD) are one of the most important public health problems of our time. Many of these diseases can be reduced by achieving healthy lifestyles. Community interventions are very useful in reducing these types of diseases since they have a direct impact over daily conditions and are adjustable to the complex situations that they carry. This article describes the process of the creation of a collaborative platform for the design and implementation of community interventions to prevent NCDs. This platform includes six non-governmental organizations who have aligned their prevention and health promotion objectives to develop joint community interventions. The intervention levels approach, based on the socio-ecological model has been the basic model to structure the working groups of the platform. Dealing with institutional differences, complexity and variability of contexts, defining the roles and responsibilities and managing the resources are key elements to have in mind to achieve good relations and functional partnerships to design and implement effective community interventions at different levels. Institutional recognition, support and planning based on local priorities are also key elements for these kinds of platforms to be successful, sustainable and, therefore, have an impact on people's health.

Is partnership the answer? Delivering the national immunisation programme in the new English health system: a mixed methods study

Background

The English national health system experienced a major reorganisation in April 2013. This mixed methods study examined how staff managed to deliver the national immunisation programme within a new health infrastructure and explored the role and contribution of ‘partnership working’ to programme implementation.

Methods

A cross-sectional online questionnaire survey and a qualitative evaluation of an urban immunisation board were conducted in 2016. The questionnaire included 38 questions about immunisation responsibilities, collaboration, service evaluation and programme support. It was completed by 199 immunisation providers and 70 people involved in the management of the immunisation programme. The evaluation involved 12 semi-structured interviews, 3 observations of forum meetings and the review of forum meeting minutes. Descriptive statistical analysis of the survey data was performed using SPSS version 23 and qualitative data from both study components were uploaded to NVivo 11 and analysed thematically.

Results

Screening and Immunisation Teams were cited as responsible for programme leadership by 56% of survey respondents, but concerns were raised about their capacity to oversee larger geographies and a case made for decentralised accountability mechanisms. Only 44% of immunisation managers stated that poor performance was addressed adequately, and half of respondents thought that support given to providers was inadequate. Managers reported that partnership working improved the organisation (83%) and performance (78%) of immunisation, but stated it was more beneficial for information-sharing than implementation. A preference for a “locality working approach” with committees covering smaller health economies rather than larger commissioning areas was voiced. The immunisation board examined in the qualitative evaluation sought to achieve this by forging links with locally based steering committees, but also had to address internal challenges related to the role of the board and contribution of members to programmatic decision-making.

Conclusions

Key challenges in delivering the immunisation programme were rooted in the new health infrastructure, which had created greater distance between commissioners and providers and resulted in the fragmentation of programme responsibilities. Partnership working bridged gaps but more needs to be done to strengthen accountability mechanisms and ensure that collaborative activities are outcome oriented and sustainable in the shifting environment of reorganisation.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6400-6) contains supplementary material, which is available to authorized users.

Intersectoral collaboration for the prevention and control of vector borne diseases to support the implementation of a global strategy: A systematic review

Introduction

Vector Borne Diseases (VBDs) have a major impact on public health and socio-economic development. Inter-sectoral collaboration was recommended as one of the key elements of Integrated Vector Management (IVM), however limited evidence measures the effect and contribution of intersectoral approaches including but not only IVM. This systematic review aims to assess the existing evidence on all forms of inter-sectoral collaboration in VBD control and prevention, identify any gaps and develop a framework from a global perspective.

Methods

Articles were identified through a search of PUBMED, Science of Direct, Web of Knowledge, Google Scholar and WHO archives using key words and excluded duplications (n = 2,034). The exclusion of non-VBDs control and prevention interventions resulted in 194 eligible titles/abstract/keywords for full text assessment. Further exclusion of non-peer reviewed articles, non-declaration of ethical clearance, reviews and expert opinion articles resulted in 50 articles finally being included for analysis with the extraction of data on outcome, factor/s influencing the effectiveness, indicators of collaboration and sustainability.

Results

Of the 50 articles included in the analysis, 19 articles were categorized as of moderate-strong quality. All articles compared pre- and post-intervention outcomes against disease or vector variables. Three papers included outcome variables on intersectoral collaboration and participation indicator. However, no paper undertook component analysis by different sectors or different activities. Only one paper compared cost data for community-intersectoral intervention for IRS and traditional “vertical” IRS. Six factors were identified as influencing the effectiveness of inter-sectoral collaboration. Five of six factors are the main ones, namely the approach (37/47), resources (34/47), relationships (33/47), management (29/47) and shared vision (20/47) factors. A conceptual framework has been developed based on this review.

Conclusion

This review shows the importance of inter-sectoral collaboration to reduce VBDs or vector densities. However, very few studies measured how much inter-sectoral collaboration contributes to the impact. Further high-quality studies using inter-sectoral collaboration indicators are recommended to be undertaken.

Using local authority entrance charges to tackle inequalities in physical activity? A qualitative study of leisure and public health perspectives

Background

Reducing or eliminating entrance charges for the public use of leisure facilities is one potential tool that local authorities (LA) have to reduce inequalities in physical activity (PA). Facility charges are likely to be a greater barrier to access for those who have lower incomes.

Methods

Semi-structured 1-to-1 and group interviews were conducted with 33 leisure and public health professionals in seven LAs in north-west England. We investigated how approaches to pricing varied in these settings and rationales influencing decision making.

Results

Welfare orientated (e.g. affordability) and commercial drivers (e.g. income generation) featured most prominently across areas. Pricing policies placed less direct focus on public health goals, although tackling inactivity was articulated as part of leisure's role more generally. Local targeting of free/concessionary offers was also defined and implemented differently. Decision makers described navigating competing pressures of providing services for the public 'good' yet remaining financially viable.

Conclusion

Many LAs are reviewing the extent of subsidy for facilities or are considering whether to invest public health budgets in leisure. The findings offer evidence of how pricing decisions are made and the approaches adopted in practice as well as the conflicting priorities for decision makers within an austerity context.

Service Integration Across Sectors in Europe: Literature and Practice

Introduction:

To meet the needs of vulnerable people, the integration of services across different sectors is important. This paper presents a preliminary review of service integration across sectors in Europe. Examples of service integration between social services, health, employment and/or education were studied. A further aim of the study was to improve conceptual clarity regarding service integration across sectors, using Minkman’s Developmental Model for Integrated Care (DMIC) as an analytical framework.

Methods:

The study methods comprised a literature review (34 articles) and a survey of practice examples across Europe (44 practices). This paper is based on a more comprehensive study published in 2016.

Results:

The study demonstrates that although the focus of integration across sectors is often on social services and health care, other arrangements are also frequently in place. The review shows that integration may be either tailored to a particular target group or designed for communities in general. Although systems to monitor and evaluate social service integration are often present, they are not yet fully developed. The study also highlights the importance of good leadership and organizational support in integrated service delivery.

Discussion:

The study shows that the DMIC can work as a conceptual framework for the analysis of service integration across sectors. However, as this is an exploratory study, further in-depth case studies are required to deepen our understanding of the processes involved in service integration across sectors.

Falling through the gaps: exploring the role of integrated commissioning in improving transition from children's to adults' services for young people with long-term health conditions in England

Objectives To explore the role of integrated commissioning in improving the transition of young people with long-term conditions from child to adult services. We aimed to identify organizational and policy gaps around transition services and provide recommendations for integrated commissioning practice. Methods Semi-structured in-depth interviews were conducted with two groups of participants: (1) twenty-four stakeholders involved in the commissioning and provision of transition services for young people with long-term conditions in two regions in England; (2) five professionals with national roles in relation to planning for transition. Transcripts were interrogated using thematic analysis. Results There is little evidence of integrated commissioning for transitional care for young people with long-term conditions. Commissioners perceive there to be a lack of national and local policy to guide integrated commissioning for transitional care; and limited resources for transition. Furthermore, commissioning organizations responsible for transition have different cultures, funding arrangements and related practices which make inter- and intra-agency co-ordination and cross-boundary continuity of care difficult to achieve. Conclusions Integrated commissioning may be an effective way to achieve successful transitional care for young people with long-term health conditions. However, this innovative relational approach to commissioning requires a national steer together with recognition of common values and joint ownership between relevant stakeholders.

It's hard to play ball: A qualitative study of knowledge exchange and silo effects in public health

BACKGROUND

Partnerships in public health form an important component of commissioning and implementing services, in England and internationally. In this research, we examine the views of staff involved in a City-wide health improvement programme which ran from 2009 to 2013 in England. We examine the practicalities of partnership work in community settings, and we describe some of barriers faced when implementing a large, multi-organisation health improvement programme.

METHODS

Qualitative, semi-structured interviews were performed. Purposive sampling was used to identify potential participants in the programme: programme board of directors, programme and project managers and intervention managers. Interviews were conducted one-to-one. We conducted a thematic analysis using the 'one sheet of paper' technique. This involved analysing data deductively, moving from initial to axial coding, developing categories and then identifying emerging themes.

RESULTS

Fifteen interviews were completed. Three themes were identified. The first theme reflects how poor communication approaches hindered the ability of partnerships to deliver their aims and objectives in a range of ways and for a range of reasons. Our second theme reflects how a lack of appropriate knowledge exchange hindered decision-making, affected trust and contributed to protectionist approaches to working. This lack of shared, and communicated, understanding of what type of knowledge is most appropriate and in which circumstance made meaningful knowledge exchange challenging for decision-making and partnership-working in the City-wide health improvement programme. Theme three demonstrates how perceptions about silos in partnership-working could be problematic, but silos themselves were at times beneficial to partnerships. This revealed a mismatch between rhetoric and a realistic understanding of what components of the programme were functional and which were more hindrance than help.

DISCUSSION

There were high expectations placed on the concept of what partnership work was, or how it should be done. We found our themes to be interdependent, and reflective of the 'dynamic fluid process' discussed within the knowledge mobilisation literature. We contend that reframing normal and embedded processes of silos and silo-working already in use might ease resistance to some knowledge exchange processes and contribute to better long-term functioning of public health partnerships.

Beyond "Two Cultures": Guidance for Establishing Effective Researcher/Health System Partnerships

BACKGROUND

The current literature proposing criteria and guidelines for collaborative health system research often fails to differentiate between: (a) various types of partnerships, (b) collaborations formed for the specific purpose of developing a research proposal and those based on long-standing relationships, (c) researcher vs. decision-maker initiatives, and (d) the underlying drivers for the collaboration.

METHODS

Qualitative interviews were conducted with 16 decision-makers and researchers who partnered on a Canadian major peer-reviewed grant proposal in 2013. Objectives of this exploration of participants' experiences with health system research collaboration were to: (a) explore perspectives and experience with research collaboration in general; (b) identify characteristics and strategies associated with effective partnerships; and (c) provide guidance for development of effective research partnerships. Interviews were audio-recorded and transcribed: transcripts were qualitatively analyzed using a general inductive approach.

RESULTS

Findings suggest that the common "two cultures" approach to research/decision-maker collaboration provides an inadequate framework for understanding the complexity of research partnerships. Many commonly-identified challenges to researcher/knowledge user (KU) collaboration are experienced as manageable by experienced research teams. Additional challenges (past experience with research and researchers; issues arising from previous collaboration; and health system dynamics) may be experienced in partnerships based on existing collaborations, and interact with partnership demands of time and communication. Current research practice may discourage KUs from engaging in collaborative research, in spite of strong beliefs in its potential benefits. Practical suggestions for supporting collaborations designed to respond to real-time health system challenges were identified.

CONCLUSION

Participants' experience with previous research activities, factors related to the established collaboration, and interpersonal, intra- and inter-organizational dynamics may present additional challenges to research partnerships built on existing collaboration. Differences between researchers and KUs may pose no greater challenges than differences among KUs (at various levels, and representing diverse perspectives and organizations) themselves. Effective "relationship brokering" is essential for meaningful collaboration.

Institutional logic in self-management support: coexistence and diversity

The prevalence of chronic conditions in Europe has been the subject of health-political reforms that have increasingly targeted collaboration between public, private and voluntary organisations for the purpose of supporting self-management of long-term diseases. The international literature describes collaboration across sectors as challenging, which implies that their respective logics are conflicting or incompatible. In line with the European context, recent Norwegian health policy advocates inter-sectorial partnerships. The aim of this policy is to create networks supporting better self-management for people with chronic conditions. The purpose of our qualitative study was to map different understandings of self-management support in private for-profit, volunteer and public organisations. These organisations are seen as potential self-management support networks for individuals with chronic conditions in Norway. From December 2012 to April 2013, we conducted 50 semi-structured interviews with representatives from relevant health and well-being organisations in different parts of Norway. According to the theoretical framework of institutional logic, representatives' statements are embedded with organisational understandings. In the analysis, we systematically assessed the representatives' different understandings of self-management support. The institutional logic we identified revealed traits of organisational historical backgrounds, and transitions in understanding. We found that the merging of individualism and fellowship in contemporary health policy generates different types of logic in different organisational contexts. The private for-profit organisations were concerned with the logic of a healthy appearance and mindset, whereas the private non-profit organisations emphasised fellowship and moral responsibility. Finally, the public, illness-oriented organisations tended to highlight individual conditions for illness management. Different types of logic may attract different users, and simultaneously, a diversity of logic types may challenge collaboration at the user's expense. Moral implications embed institutional logic implying a change towards individual responsibility for disease. Policy makers ought to consider complexities of logic in order to tailor the different needs of users.

Mapping Collaborative Relations among Canada's Chronic Disease Prevention Organizations

In the field of chronic disease prevention (CDP), collaborations between organizations provide a vital framework for intersectoral engagement and exchanges of knowledge, expertise and resources. However, little is known about how the structures of preventive health systems actually articulate with CDP capacity and outcomes. Drawing upon data from the Public Health Organizational Capacity Study - a repeat census of all public health organizations in Canada - we used social network analysis to map and examine interorganizational collaborative relationships in the Canadian preventive health system. The network of relationships obtained through our study shows that provincial boundaries remain a major factor influencing collaborative patterns. Not only are collaborations scarce on the interprovincial level but they are also mostly limited to links with federal and multi-provincial organizations. Given this finding, federal or multi-provincial organizations that occupy central bridging positions in the Canadian CDP collaborative structure should serve as key players for shaping CDP practices in the country.

Group affiliation in self-management: support or threat to identity?

BACKGROUND

Self-management is considered important in chronic illness, and contemporary health policy recommends participation in support groups for individuals with chronic conditions. Although withdrawal from or non-participation in support groups is an important problem, there is limited knowledge about individuals' own motivation for participation in or withdrawal from self-management support groups.

OBJECTIVES

To investigate how individuals with type 2 diabetes perceive participation in group-based self-management support.

DESIGN

This is a qualitative focus group study using a semi-structured interview guide.

SETTING AND PARTICIPANTS

Sixteen participants diagnosed with type 2 diabetes were included in the study. Individuals with and without group affiliations were mixed in three focus groups to trigger discussions. In the analysis, reoccurring themes of engagement and discussions between participants were focused within a theoretical frame of institutional logic. The focus groups are seen as social spaces where participants construct identity.

RESULTS

Both participation and non-participation in group-based self-management support are associated with dealing with the stigma of having type 2 diabetes. Negotiations contribute to constructing an illness dignity as a response to the logic of moral responsibility for the disease.

DISCUSSION AND CONCLUSION

Contemporary policy contributes to societal understandings of individuals with type 2 diabetes as morally inadequate. Our study shows that group-based self-management support may counteract blame and contribute in negotiations of identity for individuals with type 2 diabetes. This mechanism makes participation in groups beneficial for some but stigma inducing for others.

Association between organizational capacity and involvement in chronic disease prevention programming among Canadian public health organizations

In the context of the emerging field of public health services and systems research, this study (i) tested a model of the relationships between public health organizational capacity (OC) for chronic disease prevention, its determinants (organizational supports for evaluation, partnership effectiveness) and one possible outcome of OC (involvement in core chronic disease prevention practices) and (ii) examined differences in the nature of these relationships among organizations operating in more and less facilitating external environments. OC was conceptualized as skills and resources/supports for chronic disease prevention programming. Data were from a census of 210 Canadian public health organizations with mandates for chronic disease prevention. The hypothesized relationships were tested using structural equation modeling. Overall, the results supported the model. Organizational supports for evaluation accounted for 33% of the variance in skills. Skills and resources/supports were directly and strongly related to involvement. Organizations operating within facilitating external contexts for chronic disease prevention had more effective partnerships, more resources/supports, stronger skills and greater involvement in core chronic disease prevention practices. Results also suggested that organizations functioning in less facilitating environments may not benefit as expected from partnerships. Empirical testing of this conceptual model helps develop a better understanding of public health OC.

An Exploratory Analysis of Network Characteristics and Quality of Interactions among Public Health Collaboratives

ABSTRACT

While the benefits of collaboration have become widely accepted and the practice of collaboration is growing within the public health system, a paucity of research exists that examines factors and mechanisms related to effective collaboration between public health and their partner organizations. The purpose of this paper is to address this gap by exploring the structural and organizational characteristics of public health collaboratives. Design and Methods. Using both social network analysis and traditional statistical methods, we conduct an exploratory secondary data analysis of 11 public health collaboratives chosen from across the United States. All collaboratives are part of the PARTNER (www.partnertool.net) database. We analyze data to identify relational patterns by exploring the structure (the way that organizations connect and exchange relationships), in relation to perceptions of value and trust, explanations for varying reports of success, and factors related to outcomes. We describe the characteristics of the collaboratives, types of resource contributions, outcomes of the collaboratives, perceptions of success, and reasons for success. We found high variation and significant differences within and between these collaboratives including perceptions of success. There were significant relationships among various factors such as resource contributions, reasons cited for success, and trust and value perceived by organizations. We find that although the unique structure of each collaborative makes it challenging to identify a specific set of factors to determine when a collaborative will be successful, the organizational characteristics and interorganizational dynamics do appear to impact outcomes. We recommend a quality improvement process that suggests matching assessment to goals and developing action steps for performance improvement.

ACKNOWLEDGEMENTS

the authors would like to thank the Robert Wood Johnson Foundation's Public Health Program for funding for this research.

From policy to reality: clinical managers' views of the organizational challenges of primary care reform in Portugal

The primary healthcare reform in Portugal is based on the development of a new management model and clinical governance framework. The objective is to strengthen primary healthcare services to reduce the inappropriate utilization of secondary and emergency services and to make efficiency gains and to better control costs. New interventions include the introduction of a system of production-based incentives for family health units. This paper presents an initial assessment of the implementation of the new policies and tries to explain the gap between its expected results and what was observed in the field 5 years later. We used a Strengths, Weaknesses, Opportunities, and Threats analysis conducted in 12 regions, to collect the perceptions of members of Clinical Councils of Health Centers Groups, responsible for the implementation of the reform. The analysis looked at the dimensions of coverage, productivity, technical quality, and service quality. It identifies weaknesses in human resources management (shortages, incentives, team management) and lack of support from central and regional management. There is a perceived gap between the framework for reform as defined by law and the support made available for its implementation, leading to tensions between decision makers, managers, and health professionals.