ARCHIVED - Chronic Diseases in Canada

 

Volume 29, no. 4, October 2009

An intersectoral network for chronic disease prevention: the case of the Alberta Healthy Living Network

R. Geneau, PhD (1); B. Legowski, MHSc (1); S. Stachenko, MD (1)


Author References

  1. World Health Organization (WHO) Collaborating Centre on Chronic Non-Communicable Disease Policy, Public Health Agency of Canada, Ottawa, Ontario, Canada.

Correspondence: Robert Geneau, PhD, WHO Collaborating Centre on Chronic Non-Communicable Disease Policy, 785 Carling Avenue, Room 1003A2, Ottawa, Ontario,  K1A 0K9, Tel.: 613-946-6360; Email: robert.geneau@phac-aspc.gc.ca

 

Abstract

Chronic Diseases (CDs) are the leading causes of death and disability worldwide. CD experts have long promoted the use of integrated and intersectoral approaches to strengthen CD prevention efforts. This qualitative case study examined the perceived benefits and challenges associated with implementing an intersectoral network dedicated to CD prevention. Through interviewing key members of the Alberta Healthy Living Network (AHLN, or the Network), two overarching themes emerged from the data. The first relates to contrasting views on the role of the AHLN in relation to its actions and outcomes, especially concerning policy advocacy. The second focuses on the benefits and contributions of the AHLN and the challenge of demonstrating non-quantifiable outcomes. While the respondents agreed that the AHLN has contributed to intersectoral work in CD prevention in Alberta and to collaboration among Network members, several did not view this achievement as an end in itself and appealed to the Network to engage more in change-oriented activities. Managing contrasting expectations has had a significant impact on the functioning of the Network.

Key words: chronic diseases, intersectoral network, qualitative research, Alberta Healthy Living Network

Background

Chronic diseases (CDs) are associated with 60% of all deaths and 46% of the burden of disease worldwide.1 Recent reports and studies describe CDs as threatening health systems and economic stability around the world,2 partly because the human and economic toll associated with CDs is expected to increase substantially in the next two decades.3 In Canada, the total cost of illness, disability and death due to CDs was estimated to be over $45 billion in 2004.4a The societal cost for several CDs (heart disease, chronic obstructive pulmonary disease, diabetes and lung cancer) for people over 20 years of age was $1.07 billion in Alberta in 2000, with hospital and physician costs accounting for about 80% of the total. Lost income from premature death in that one year was estimated at $13.3 million and, if extrapolated over the average working life to age 65, would amount to $184 million.5

Chronic disease experts have long maintained that dealing effectively with CDs, individually or collectively, requires multifaceted approaches involving multiple strategies and sectors. The World Health Organization (WHO) calls for comprehensive, integrated and strategic approaches in dealing with CDs.4b,6,7 A comprehensive approach involves 1) simultaneously supporting population-level health promotion and disease prevention programs; 2) actively targeting groups and individuals at high risk; 3) maximizing population coverage with effective treatment and care; and 4) systematically reducing inequalities in health. An integrated approach on the largest scale means simultaneously targeting risk factors, underlying determinants of health and opportunities for disease prevention common to major CDs. The approach is strategic in that it has an impact on more than one disease.8

A comprehensive and integrated approach can also be applied to single diseases or risk factors. In Canada, an integrated approach to a single disease was first realized through the Canadian Heart Health Initiative (CHHI), which implemented community-based cardiovascular disease (CVD) prevention programs for 20 years from 1986 with funds matched by the federal government.

In Alberta, the response to the CHHI was the Alberta Heart Health Project, designed to explore the process of capacity building for heart health promotion within regional health authorities.9a While the project helped several authorities start CVD prevention initiatives, it has not led to sustainable investments in health promotion.10 Its legacy is that several key Alberta Heart Health Project members and promoters used its momentum to launch the Alberta Healthy Living Network (AHLN, or the Network) in 2002.9b

The AHLN is supporting leadership for integrated, collaborative action to promote health and prevent CDs in Alberta.11a Network members define an “integrated approach” as being multisectoral, multistrategic, multi-disease and multi–risk factor, while simultaneously engaging a variety of instruments (appropriate legislation, health system reform) and players (local communities, health authority and government policy makers, nongovernmental organizations, the private sector). The initial focus of the AHLN was on three risk factors common to CDs—unhealthy eating practices, tobacco use and physical inactivity—and their underlying determinants of health.12a

In February 2008, the AHLN consisted of 93 diverse member organizations, some of which were outside of the health sector. Federal and provincial governments, regional health authorities, non-profit organizations, professional organizations, the research community, Aboriginal groups and other regional relevant networks were represented.12b With this composition and mandate, the AHLN provides an opportunity to better understand how to apply an integrated approach to CD prevention using a network mechanism.

There exists a growing body of sociological literature about organizational networks. According to Scott,13 a wide range of motives exists to power the development of network forms. One of the main motives is the desire to enhance organizational learning. This is especially true in the case of strategic alliances, or “partnerships,” a network form that is growing in popularity among knowledge-based organizations. However, Huerta et al.14 note that, in the case of health care networks, we still have little empirical information to understand what networks are, what they do and whether they achieve their stated goals—in this case, truly making a difference in the delivery of care and the maintenance of health. The authors conclude that there is a need for more empirical research to demonstrate how networks generate both challenges and opportunities for the participating organizations. A similar conclusion applies to networks and alliances in the field of health promotion. A number of papers have proposed conceptual models (e.g. coalition theory) and/or tools (e.g. surveys based on the Diagnosis of Sustainable Collaboration model) for understanding interorganizational relationships and collaboration,15,16 but there are still few empirical demonstrations.17-20 Overall, the conviction that partnership is a superior way of working in health promotion is still not clearly supported or refuted by the empirical literature.20a

So far, only one peer-reviewed paper about the AHLN has been published. That study examined whether partnership ties among the Network members influenced organizational perceptions of financial support.21 The authors argue that such perceptions are affected not only by organizational characteristics but also by a group’s position in a network. They conclude that network contexts can influence the way that organizations perceive their environment and the actions they may take in light of such perceptions.

In this qualitative study, our objective was to better understand the perceived benefits and challenges associated with the implementation of the AHLN. This article will not systematically report on all of the AHLN’s activities but rather will focus on the experiences of key Network members.

Methods

Data collection

We conducted 15 semi-structured interviews with key Network members in 2007 and 2008. The participants supported or directly contributed to the work of the AHLN and actively participated in one of the Network’s committees or working groups.* The interviews lasted an average of 75 minutes and were audio-recorded. The initial interview guide included open-ended questions about the role of the AHLN, the functioning of the Network (committees and working groups) and the perceived benefits and challenges associated with the implementation of the AHLN. (Please see Appendix for the interview questions.) Further clarifying and probing questions were added during the study process based on an iterative analysis of the collected material. Ethical approval was obtained from Health Canada’s Research Ethics Board, and all participants provided informed consent before the interview.

Data analysis

The interviews were transcribed verbatim, and then coded and analyzed with the support of NVivo 8 software. The coding tree was developed through an iterative open-coding process.22 Subsequent analysis involved axial and selected coding to explore interconnections between existing categories and subcategories. Finally, an immersion/crystallization approach23 was used to identify and articulate the themes and patterns emerging from the empirical dataset. All references to opportunities and challenges associated with the development and implementation of the AHLN were identified, coded, and aggregated into themes. These themes were given tentative titles and grouped with demonstrative quotes from the interviews along with preliminary interpretations. The initial categories and patterns were tested and revised during the data collection process until saturation.

Results

Two overarching themes emerged from the data. The first theme relates to the perceived role of the AHLN; the second focuses on the perceived contributions of the AHLN and how to measure them. When discussing the role of the AHLN, respondents offered contrasting views about the extent to which the Network should be action- or advocacy-oriented and about what that would actually mean in practice. All respondents shared the same concerns about the challenge of defining and agreeing on the role of the Network and about the necessity of measuring its impact. Demonstrating the added value of the AHLN was seen as a key challenge.

Developing a common vision about the role of the AHLN

The publication in 2003 of the Alberta Healthy Living Framework11b (updated in 2005), was seen by all respondents as a key achievement of the Network. The AHLN Framework11c describes the objectives and mission of the AHLN and its areas of focus and priority strategies (Table 1). Yet, several respondents feel that in “real life” (e.g. in meetings) the purpose and role of the Network is still unclear, whether it is to create “new” work or only support members’ existing work:

[I]t is … hard … managing the expectations. There are the ones that say, “It is strictly a network and [a] network is all it’s ever been and should be. It’s an opportunity to get together and share ideas and know what each other is doing [sic].” And there are others who say, “No, we should be accomplishing things.” … somewhere in between, that is where we probably need to be, but right now we seem to have expectations that sort of cover the whole spectrum.

Table 1
Areas of focus and priority strategies of the AHLN
Areas of focus

Priority strategies for integrated action

Healthy eating Partnership development and community linkages
Active living Awareness and education
Tobacco-free environment Healthy public policies
Surveillance
Best practices
Research and evaluation
Health disparities

 

The areas of mental health and injury prevention have been progressively added to the original priority areas of tobacco use, nutrition and physical activity. Most respondents saw the broadening scope of the AHLN as bringing both new opportunities and new challenges:

[W]hen we started out it was very clear it was nutrition, physical activity and tobacco. And then it became very broad and it became very wellness-oriented, so I think that has been good in a lot of ways … but it also dilutes things a bit … you have too many different perspectives about how things should move forward … [T]he good side of it, though, is that it does bring more players to the table as well. And, ultimately, I hope it would give you a greater impact if you have more partners involved in a broader approach to things.

Discussions about the role of the AHLN have attempted to clarify whether or not it is an “action-oriented” network and what “action” means. Respondents agreed that, so far, the Network has played more of a role in communication and coordination than in “action.” A frequently cited example was the development of “common and integrated health messages”:

[T]he issue of common messaging—I think that’s a role that the AHLN can [play]. If we can come up with some common messages that all the different sectors and all the different organizations agree to [sic], then we can use those to inform professionals—health professionals and non–health professionals as well …

While all the respondents agreed that developing “common health messages” was very valuable, many had expected that the AHLN would also be active in supporting community-based initiatives:

I think we have to get down at [sic] the grass roots [level] and, you know, help community networks develop … that has to come from the bottom up … but the Network can support that work … And we are not doing that. And in my opinion, unless we do that, the Network is never going to survive. You have to create the demand throughout the whole province for the need for that kind of thing to continue. … That’s where our gap is …

The necessity to “create things” and to be “visible” also stems partly from the fear that members from the nongovernmental sector will lose interest in the AHLN if the work remains focused solely on coordination and communication:

I think that the grass roots organizations that are dedicated to socio-economic determinants of health may well lose interest around that. Well, we may lose them if we don’t figure it out pretty soon.

According to some of the respondents, the challenges associated with identifying tangible deliverables may explain why at least two of the seven working groups are considered mostly “inactive”. Several interviewees associate the (growing) lack of engagement within the Network to the challenges of defining what actions are expected from the AHLN.

Some of the respondents also identified policy change as another type of action that should be part of the Network’s mandate and mission, especially since the AHLN has a Healthy Public Policies Working Group:

I believe in the Network. … I do think we have been and can be an effective voice in the future. I do think we are going to have to look at … the whole true health promotion model and that means influencing policies, looking at the social determinants of health, the whole disparity issue.

The prospect of influencing policies has been linked to “policy advocacy,” a controversial subject among respondents. Should advocacy be part of the AHLN’s mission? Some respondents were adamantly in favour: “Advocacy for political change … is needed the most. And I really think that that should be a strong role for the AHLN.” However, for others “advocacy” is too strongly associated with letter-writing campaigns and “in-your-face strategies.” Most respondents promoted the use of more subtle forms of advocacy that can be done within government. The diverse perspectives within the AHLN on policy advocacy partly reflect the fact that “some members of the AHLN have advocacy as part of their mission, but most don’t.” For some respondents working in government, the sensitivities around a policy advocacy role stem from the perception of a conflict of interest since they are paid by government for the time they dedicate to the AHLN.

I think that [advocacy] needs to happen outside of the Network. I think if you get into real advocacy initiatives, the Network is not the place … I think it needs to link [sic] and know what is going on—you know, pass information back and forth—but the Network is not in a good position to really do the advocacy. That needs to be something quite independent.

Many respondents also considered the political and social context in Alberta as a factor influencing the role of the AHLN in regard to policy advocacy. On the one hand, many made it clear that doing more health promotion is easier than it was five years ago (though one respondent suggested that the province is “simply recouping some of the losses from 15 years ago”). On the other hand, there is relative consensus that the given context is generating real sensitivities and challenges regarding the reach of health promotion policies and those policies that address social and economic determinants of health:

It is pretty delicate—it is a pretty delicate issue … because issues around poverty are so huge. And it is not just one ministry. In fact, most of that kind of stuff [is] outside the Ministry of Health, yet it is always Health that seems to be—I don’t know if “implicated” is the right word—but [sic] “connected.”

Discussions about a policy advocacy role for the AHLN led to the development of a screening tool used by an Advocacy Review Panel created in 2007 to help the Network decide which calls to action it would support. For example, AHLN documents produced in 2008 indicate that the Network will support the development of evidence-based position papers by AHLN experts, but not letter-writing campaigns. While the screening tool has brought a sense of resolution to the discussions on advocacy, it is “too little, too late” for those AHLN members who had disengaged themselves from the Network as a consequence.

Several respondents acknowledged that the challenges associated with defining the role of the AHLN is partly due to a lack of stable leadership. However, finding such leadership is a challenge, considering that most members have little time to dedicate to the AHLN and “do this work on the corner of [their] desk.” A leadership transition affected the work of the AHLN during the period 2005 to 2006:

I think right now we’ve gone—I don’t want to say backwards, but we’ve stalled a bit. And partly we stalled because we lost the Executive Director of AHLN for a long time and so there was a big gap … [W]hen there is a gap in time in terms of leadership, things just don’t move forward.

The financing of Network operations also affects how some respondents see the Network’s role evolving with time. in 2006, when a contribution from the Alberta Cancer Board tripled the Network budget (from $50,000 to $150,000), most respondents welcomed the stronger secretarial support that the funds allowed. However, some also expressed the concern that funding from an organization that focused on a disease could hamper the push toward integrated action to address multiple diseases, with one respondent commenting, “To be totally frank, I think that money has not necessarily done the Network a favour … we get away from integration just from that right there.”

Defining the added value of the AHLN: measuring intangibles

Demonstrating the added value of the AHLN is another key challenge critical to its sustainability. Several respondents reflected on the past key outputs of the AHLN, often citing knowledge dissemination, the publication of the AHLN Framework11d and the production of common and integrated messages about risk factors:

This [AHLN Framework11e] was a model that other provinces and territories followed, so I think this is a very good framework for [the Alberta] Healthy Living [Network] generally … I think it made some real achievements in terms of education and awareness and bringing people together, and we did a lot of work around common messages and put common messages on our website so people have one point of reference … I think it is something that we feel quite proud of—a lot of hard work.

A significant part of the Network’s added value is difficult to measure. Respondents spoke of raising awareness, adopting a different “mindset,” developing trust among Network members and the process of “mainstreaming health promotion”:

One of the added values of the AHLN was to bring certain issues into the mainstream … I think that the work the AHLN has done is creating an awareness of the social determinants of health and their impact on all types of diseases, and that’s probably the most valuable component that I have seen from the AHLN.

I feel that what very tangibly has changed is that there is a very strong level of trust that was not there before the AHLN.

Several respondents also spoke of the Network’s consensus-based approach to making decisions, a factor that facilitates AHLN activities and promotes trust:

[O]ne thing that has been a real strength in our Network is [that] it is very consensus-based … And I don’t always agree with the decisions but I support them. I don’t know better than anyone else, we are all there together, so if that’s where the group wants to move, then that is fine, and I will continue to evaluate and assess whether it is meaningful and important for me or not.

Since all of these outcomes are difficult to assess, several of the respondents expressed concerns about the lack of sound process indicators to measure the success of the AHLN:

Another one of the really frustrating challenges: we don’t have really good measures or [ways of showing] that we are making a difference in … strengthening the system, strengthening the voice for health promotion. I see just a lot more levels of activity, strength of activity, ability to work together on shared issues and connect externally and learn from each other but I am stymied about how to get that on to something that looks like a graph.

The Evaluation Framework,§ a companion document to the AHLN Framework,11f was developed in response to early recognition of the need to evaluate the AHLN’s activities. However, there was no consensus among the respondents about its usefulness and applicability, some calling it “too big, too complex and too daunting.” In summary, developing means to assess complex outcomes attributable to the AHLN remains a constant preoccupation.

Another challenge for measurement is that there is still limited evidence demonstrating or refuting the benefits of using an “integrated approach” for health promotion: “… maybe I am wrong, but we don’t really know if integration is better … You know, we know anecdotally that it is better, and that was one of the things that was our commitment to look at … .”

Sectoral and intersectoral collaboration

Intra- and intersectoral collaboration within government and the resultant increased awareness about the different roles in the field of CD prevention are perceived as very strong contributions to date: “By working together with other sectors—and I mean that’s the bottom line—I guess I see less and less turf protection … first off we need to understand what we are all doing in order to move the agenda.”

However, improved collaboration is an achievement that is hard to quantify, and thus it remains one of the most significant challenges facing the Network. While several respondents felt that the Network is allowing members to better “connect the dots,” concerns remain about the mix of sectors represented and how the demography of the Network (i.e. characteristics of its members) may affect the knowledge-to-action process:

I think it has been a real strength of our Network to have the provincial and federal government reps there; I think that has been … key to moving some things forward and getting funding and being well connected. But to me personally, right now, there are kind of too many government sectors, so you can’t really action a lot of things … we need intersectoral action in government, but it needs to be something different from this.

Collaboration with the private sector is another key challenge for the Network. While partnership-building and intersectoral collaboration are the cornerstones of the Network, respondents agree that just inviting people from industry to the Network table will not result in partnerships with the private sector. What remains elusive is how to compel the private sector to join the Network and coordinate its activities with those of other Network members: “I really struggled: ‘How do you engage industry in promoting health?’ I think we have no choice but to work with industry, but how can we do it and do it right?”

There is an oil company that might be interested in participating. But to just sit at a Coordinating Committee—nobody’s got time for that unless it’s an integral part of their work … most players and partners out there [in the private sector] have only an indirect connection. So we have to figure out what … things that are of importance to them if we want to involve them?

Discussion

This study explored some of the key perceived benefits and challenges associated with activating and coordinating a network of 93 organizations to work collaboratively to prevent CDs and promote health in Alberta. The AHLN is still in its early years, but a deeper understanding of some of the aspects highlighted in this study may benefit similar intersectoral networks working in the field of CD prevention in particular and health promotion in general.

We believe that two major interrelated themes highlighted in this study of AHLN partnerships are highly relevant nationally and internationally: 1) the challenge, given the size of the organization, of managing contrasting expectations about the roles, actions and outputs or outcomes of the Network as a whole; and 2) the challenge of demonstrating the value of the AHLN given that such networks often lead to intangible outcomes related, for example, to interorganizational learning. These themes, in turn, may contribute to another key challenge highlighted in this study—how to keep such diverse members engaged in a network for the longer term.

With regard to the Network’s purpose and actions, AHLN members held contrasting views about its priorities—actions at the community level versus influencing provincial government policy. While a true health promotion approach combines both perspectives,24 respondents who worked for the provincial government were in favour of strengthening capacity at the community level but were less likely to want the Network to influence policy change. Although the creation of an Advocacy Review Panel in 2008 demonstrates a willingness on the part of AHLN members to tackle this point of debate, the fact remains that some respondents hold deeply rooted values and concepts about the role of public servants and the code of conduct that they are to follow (i.e. that they refrain from publicly expressing their policy preferences and play “behind the scenes”). A positive example of public-servant influence on policy development comes from the province of Quebec. There, civil servants helped tobacco-control activists improve their arguments in response to the claims of the tobacco industry and, in doing so, contributed to the adoption of new provincial tobacco-control measures.25 However, there are examples of health promotion partnerships that very purposefully excluded government representatives because of the perception that their presence would prevent the use of effective advocacy mechanisms,26 and there is an international push for the creation of health promotion foundations that are at arm’s length from government in order to maintain accountability and transparency.27 Partnerships and alliances involving both government representatives and representatives of civil-society organizations thus pose challenges if the end result is perceived to be government action.

Studies focusing on intersectoral partnerships commonly feature the problems of role definition and contrasting expectations among participants. A qualitative study of the Global Programme for Health Promotion Effectiveness highlights the critical importance of inputs, processes and outputs on partnership functioning.20b The study findings led to the development of the Bergen Model of Collaborative Functioning (BMCF), which includes traditional elements in terms of inputs (e.g. leadership), processes (formal versus informal structures) and innovates by presenting a partnership’s mission as a type of input. It also proposes three different categories of outputs that can affect partnership functioning: 1) additive outputs, i.e. outputs that have not been affected by the interaction of the partnership; 2) synergistic outputs, i.e. outputs that could not have been achieved by one partner alone, with the partnership better able to be creative, holistic and realistic, attract new members and take action; and 3) antagonistic outputs, i.e. unwanted or disturbing outputs, or a lack of outputs, leading to the perception that the partnership is a waste of time and/or resources. Interestingly, the terms “outputs” and “outcomes” are used interchangeably in the BMCF, both referring to the expected and/or desired changes associated with the establishment of a partnership.

While the three categories of outputs presented in the BMCF are useful, they can be challenged by the empirical material presented in this paper. For example, it appears unrealistic to expect that all partners would share the same view about what is to be considered an additive, synergistic or antagonistic output. This is especially true if the concept of synergistic output is defined, as done by the authors, very broadly. Some members in a partnership may judge that some specific outputs are additive, i.e. that they would have happened even without the partnership, while others may argue that the partnership indirectly influenced the organization’s processes and outputs through interorganizational learning (e.g. influencing the ability of the partner to think more holistically, etc.). With this variety of perspectives, there cannot be absolute definitions of the three types of outputs; the partners will have to collectively determine if the partnership is worth pursuing.

In the case of the AHLN, respondents varied considerably in their views on the outputs of the Network. Some viewed the recruitment of new members as an accomplishment since it is a source of interorganizational learning, while others emphasized the potential impact of the AHLN on future programs and policies, with the view that the “learning organization” approach is never an end in itself but a route to improved performance. One of the outputs most desired by Network members was to increase capacity for CD prevention in the province of Alberta by building trust among members and increasing their capacity to work collaboratively.

But a key question remains: how can we best define the scope of influence of a network or partnership? Some networks limit their mission to knowledge exchange and interorganizational learning, while others would like to be associated with more “action-oriented” synergistic outcomes.28 This study shows that members of the AHLN are divided. If knowledge and learning alone are accepted as a legitimate type of output or outcome, the Network can be seen to be more successful, but this may discourage the more action-oriented members. If the Network wishes to be action-oriented, it requires a long-term perspective; however, some members may disengage from the partnership because of the perceived lack of early successes if the action output is considered alone. In either case, there is a significant evaluation challenge.

Most respondents expressed concerns about the lack of indicators that reflect what they see as the main outcomes of the AHLN. These concerns correspond to what has been highlighted in recent studies in Canada about the investments from the CHHI, namely the need to develop indicators for capacity-building results.29, 30 The literature indicates that factors such as mutual trust, leadership and interpersonal relationships are essential for facilitating interorganizational relationships in health promotion. However, there are still major conceptual and methodological challenges to be met in quantitatively studying these complex concepts.18, 31, 32 From that perspective, qualitative studies such as this one offer unique opportunities for documenting the contributions of intersectoral networks like the AHLN. Future monitoring and evaluation activities of the AHLN could benefit from using alternatives to logic model frameworks and indicator-based approaches. For example, Outcome Mapping (OM) focuses on changes in behaviour, relationships and activities in people, groups and organizations. OM puts people and learning at the focal point of attention and accepts unanticipated changes as potential for innovation.33 The use of such an approach is also an essential first step for those interested in documenting the contributions of partnerships and networks to more traditional outcomes (e.g. better services, better programs, better policies).

Conclusions

This study examined the perceived benefits and challenges associated with the early implementation of an intersectoral network dedicated to CD prevention in Alberta, namely the AHLN. Our findings highlighted two key challenges likely to confront other intersectoral networks in the field of health promotion in general and CD prevention in particular: 1) reaching consensus on what actions and outcomes can be expected from large intersectoral networks; and 2) demonstrating the contributions and added value of such networks, short of an ultimate impact on disease or risk-factor rates. The early qualitative findings presented in this study suggest that, despite contrasting views about the scope and role of the Network, establishing the AHLN has led, from the perspective of the respondents, to an increased capacity to work intersectorally and collaboratively to strengthen CD prevention activities in Alberta. However, several of the respondents do not view this achievement as an end in itself and appeal to the Network to engage more in change-oriented activities. Managing contrasting expectations has had a significant impact on the functioning of the Network.

The emergence of intersectoral networks involved in health promotion in Canada in recent years, such as the AHLN, the British Columbia Healthy Living Alliance and the Chronic Disease Prevention Alliance of Canada, offers new opportunities to learn more about 1) how such networks operate; 2) what could be realistically expected of them and 3) how to evaluate their contributions.

Acknowledgements

For her careful reading of and valuable comments on earlier drafts of this work, the authors are indebted to Ms Gayle Fraser. We also wish to thank the reviewers for the helpful comments and suggestions.

Appendix – Interview guide

During the semistructured interviews, we explored the following dimensions or themes: 1) the participants’ (or interviewees’) involvement with the AHLN; 2) the structure, description and evolution of the AHLN since its inception; 3) integration and partnerships; 4) the factors enabling or constraining the implementation of the AHLN; 5) the perceived impact of the AHLN; and 6) the future of the AHLN.

Note: A semistructured interview is flexible, allowing new questions to be brought up during the interview as a result of what the interviewee says. The questions below were asked of the interviewee, but several other questions, including probing questions, were improvised during the course of each interview. The interview guide also evolved during the course of the study.

Average duration: 90 minutes

1) Background information on the respondent

  • Could you please tell me how long you have been involved with the AHLN?
  • Could you please describe your main responsibilities and activities? How do you contribute to the work of the AHLN?

2) Structure, description and evolution of the AHLN

  • Could you please describe the governance structures of the AHLN (executive committee, coordinating committee, etc.)?
  • What changes have you witnessed/experienced within the AHLN since your initial involvement (in terms of vision, mission and organizational/governance structures)? How do you explain these changes?
  • What forms of communication/interaction exist between the different members/organizations? How often do you meet? How are decisions made?
  • Please describe the resource-allocation processes. What are the steps and challenges in negotiating financial support?
  • The AHLN framework is focusing on five areas (healthy eating, active living, tobacco free, mental health and injury prevention). Could you please discuss how and why these priorities were selected?
  • The AHLN framework has seven priority strategies: partnership development and community linkages; awareness and education; surveillance; best practices; research and evaluation; health disparities; and healthy public policies. Could you please discuss why these strategies were selected?
  • Could you please tell me, from your perspective, what are the benefits and challenges of having a working group addressing each of the seven priority strategies of the AHLN?

3) Integration & partnerships

  • What does the concept of integration means to you? How would you characterize the AHLN in terms of integration? In what ways is your approach integrated?
  • Could you please discuss the AHLN partnership model (membership, terms of reference, etc.)? What are the benefits and challenges?
    • Intersectoral collaboration (e.g. health-education-environment-media)
    • Intrasectoral collaboration (e.g. public health and primary care interface)
    • Community integration and partnerships
    • International collaboration (e.g. WHO)
  • What activities/programs focusing on the prevention and control of noncommunicable diseases are currently underway in Alberta outside of the AHLN? What institutions/organizations are involved? What forms of collaboration currently exist between these institutions/organizations?

4) Enabling and constraining factors

This is a transversal theme, and questions about the enabling/constraining factors will be asked when discussing “organizational structures” and especially “integration and partnerships.” Additional questions (below) will be asked to validate and synthesize the information.

  • From your perspective, what are the greatest strengths of the AHLN? What factors do you feel contributed the most to these strengths/successes?
  • From your perspective, what are the greatest challenges/obstacles associated with the implementation of the AHLN? What factors do you feel contributed the most to limit/constrain the implementation of the AHLN?
  • Could you please discuss again the factors that helped or limited community integration, intersectoral or international collaboration, or developing partnerships within the health sector?

5) The perceived impact of the AHLN

  • How would you describe the impact of the AHLN so far?
    • Explore – visibility of the Chronic Disease agenda and challenges within government, communities and the health sector in general
    • Explore – intergration and partnerships, (inter and intra sectoral collaboration)
    • Explore – programs and policies
  • How is the AHLN doing? What were the main findings of those evaluation studies?
  • What impact do you feel the AHLN had on capacity-building in the following fields: social marketing; program evaluation, monitoring and surveillance; partnerships and collaboration; professional education||?

6) Future of the AHLN

  • How would you characterize the future of the AHLN?
  • What characteristics of the AHLN do you consider unique and potentially useful for other jurisdictions?

Footnotes

 *^ Seven Working Groups were formed to address the seven priority strategies of the AHLN (see table 1) and accomplish specific actions (e.g. produce documents that can guide/facilitate integrated collaborative action) as directed by the Coordinating Committee.

 †^ A computer assisted qualitative data analysis software (CAQDAS) like NVivo 8 1) helps automate and thus speed up the coding process and 2) provides a more complex way of looking at the relationships in the data.

 ‡^ At the time of data collection, in 2007, the working group on “healthy public policies” and the working group on “research evaluation” were considered “inactive”.

 §^ The AHLN Evaluation Framework is available at: http://www.ahln.ca/modules.php ?name=Contentpub&pa=showpage&pid=4

 ||^ areas of focus of the CINDI programme – the AHLN is part of the CINDI network

 

References

  1. ^ World Health Organization. Preventing chronic diseases: a vital investment: WHO global report [Internet]. Geneva: World Health Organization; 2005 [cited September 20, 2008]. Available from: http://www.who.int/chp/ chronic_disease_report/en/index.html
  2. ^ World Economic Forum, Working Towards Wellness Initiative. Working towards wellness: The business rationale [Internet]. Geneva: World Economic Forum; 2008. [cited September 20, 2008]. Available from: http://www.pwc.com/extweb/ pwcpublications.nsf/docid/ 6EE4249D9FCF6ADF85257415001A3EE8
  3. ^ World Health Organization. Gaining health: The European strategy for the prevention and control of noncommunicable diseases. Copenhagen: World Health Organization; 2006.
  4. ^ a,b World Health Organization; Government of Canada: WHO global forum IV on chronic disease prevention and control. Geneva: WHO/Health Canada; 2005.
  5. ^ Jacobs P, Klarenbach S, Ohinmaa A, Golmohammadi K, Demeter S, Schopflocher., D Chronic diseases in Alberta: cost of treatment and investment in prevention. Edmonton: Alberta Healthy Living Network; 2004. [cited September 20, 2008]. Available from: http://www.health-in-action.org/ library/pdf/AHLN/whatsnew/ Chronic_Diseases _in_AB.pdf.
  6. ^ Pan American Health Organization. Regional strategy and plan of action on an integrated approach to the prevention and control of chronic diseases including diet, physical activity, and health. Washington (DC): PAHO; 2007.
  7. ^ World Health Organization. Prevention and control of noncommunicable diseases: implementation of the global strategy. Geneva: World Health Organization; 2007.
  8. ^ World Health Organization. A strategy to prevent chronic disease in Europe: A focus on public health action: The CINDI vision. Copenhagen: World Health Organization; 2004.
  9. ^ a,b Wolbeck Minke S, Smith C, Plotnikoff RC, Khalema E, Raine K. The evolution of integrated chronic disease prevention in Alberta, Canada. Prev Chronic Dis. 2006; 3(3):A102.
  10. ^ Jacobs P, Ohinmaa A, Golmohammadi K, Demeter S, Schopflocher D, Klarenbach S. Public investment in providing information for chronic disease prevention for adults in Alberta. Can J Public Health. 2006;97(3):197-200.
  11. ^ a,b,c,d,e,f Alberta Healthy Living Network. The Alberta Healthy Living Framework: An Integrated Approach. Calgary: Alberta Healthy Living Network; 2005. [cited October 17, 2008]. Available from: http://www.ahln.ca/index.php
  12. ^ a,b Alberta Healthy Living Network. Welcome to the AHLN [homepage on the Internet]. Calgary (AB): AHLN; 2009. [cited October 18, 2008]. Available from: http://www.ahln.ca/index.php
  13. ^ Scott WR: Organizations: rational, natural, and open systems. 5th ed. Upper Saddle River: Prentice Hall; 2002.
  14. ^ Huerta TR, Casebeer A, Vanderplaat M. Using networks to enhance health services delivery: perspectives, paradoxes and propositions. Healthc Pap. 2006;7(2):10-26.
  15. ^ O’Neill M, Lemieux V, Groleau.G, Frotin F, Lamarche P: Coalition theory as a framework for understanding and implementing intersectoral health-related interventions. Health Promot Int. 1997;12(1):79-87.
  16. ^  Leurs MT, Mur-Veeman IM, van der Sar R, Schaalma HP, de Vries NK. Diagnosis of sustainable collaboration in health promotion—a case study. BMC Public Health. 2008;8:382.
  17. ^ Fear H, Barnett P. Holding fast: the experience of collaboration in a competitive environment. Health Promot Int. 2003;18(1):5-14.
  18. ^ Dunlop JM, Holosko MJ. The story behind the story of collaborative networks – relationships do matter! J Health Soc Policy. 2004;19(3):1-18.
  19. ^ Doncliff B. Collaboration is essential in health promotion. Nurs N Z. 2001;7(7):26-7.
  20. ^ a,b Corbin JH, Mittelmark MB. Partnership lessons from the Global Programme for Health Promotion Effectiveness: a case study. Health Promot Int. 2008;23(4):365-71.
  21. ^ Moore S, Smith C, Simpson T, Minke SW. The influence of partnership centrality on organizational perceptions of support: a case study of the AHLN structure. BMC Health Serv Res. 2006;6:141.
  22. ^ Miles MB, Huberman AM. Qualitative data analysis: an expanded sourcebook. 2nd ed. Thousand Oaks, CA: Sage Publications;1994.
  23. ^ Denzin NK, Lincoln YS. Handbook of qualitative research. Thousand Oaks, CA: Sage Publications; 2000.
  24. ^ O’Neil M, Pederson A, Dupéré S, Rootman I, editors. Health promotion in Canada: critical perspectives. 2nd ed. Ottawa, ON: Canadian Scholars’ Press; 2007.
  25. ^ Breton E, Richard L, Gagnon F, Jacques M, Bergeron P. Fighting a tobacco-tax rollback: a political analysis of the 1994 cigarette contraband crisis in Canada. J Public Health Policy. 2006;27(1):77-99.
  26. ^ Potts-Datema W, Smith BJ, Taras H, Lewallen TC, Bogden JF, Murray S. Successful strategies and lessons learned from development of large-scale partnerships of national non-governmental organisations. Promot Educ. 2005;12(3-4):131-137.
  27. ^ International Network of Health Promotion Foundations: Supporting the establishment of new Health Promotion Foundations: strategies for resource mobilization. Bangkok: International Foundation for Health Promotion; 2005 [cited March 6, 2009]. Available from: URL: http://74.125.95.132/ search?q=cache: dPDitVadS0wJ: www.hp-foundations.net/ Strategies%2520for% 2520resouce %2520mobilisation %2520(Kickbusch).pdf+ Kickbusch +AND+HEALTH+ PROMOTION+FOUNDATION& cd=6&hl=fr&ct= clnk&gl=ca
  28. ^ McCall DS, Rootman I, Bayley D. International School Health Network: an informal network for advocacy and knowledge exchange. Promot Educ. 2005;12(3-4):173-7.
  29. ^ Robinson K, Farmer T, Riley B, Elliott SJ, Eyles J; CHHDP Investigative Team, Strategic, and Research Advisory Groups. Realistic expectations: investing in organizational capacity building for chronic disease prevention. Am J Health Promot. 2007;21(5):430-8.
  30. ^ Robinson K, Elliott SJ, Driedger SM, Eyles J, O’Loughlin J, Riley B, Cameron R, Harvey D. CHHDP Strategic and Research Advisory Groups. Using linking systems to build capacity and enhance dissemination in heart health promotion: a Canadian multiple-case study. Health Educ Res. 2005;20(5):499-513.
  31. ^ Sepannen R, Blomqvist K, Sundqvist S. Measuring inter-organizational trust – a critical review of the empirical research in 1990-2003. Ind Market Manage. 2007;36(2):249-65.
  32. ^ Anderson D, Plotnikoff RC, Raine K, Barrett L. Development of measures of individual leadership for health promotion. Int J Health Care Qual Assur Inc Leadersh Health Serv. 2005;18(2-3):i-xii.
  33. ^ Earl S, Carden F, Smutylo T. Outcome Mapping: Building Learning and Reflection into Development Programs. Ottawa (ON): International Development Research Centre; 2001.

 

Only feature articles are peer reviewed. Authors retain responsibility for the content of their articles; the opinions expressed are not necessarily those of the CDIC editorial committee nor of the Public Health Agency of Canada.

 

Report a problem or mistake on this page
Please select all that apply:

Thank you for your help!

You will not receive a reply. For enquiries, contact us.

Date modified: