Family Practice Advance Access published online on October 20, 2008
Family Practice, doi:10.1093/fampra/cmn073
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What is needed for coordinated action for health?
a Communication Science
b Public Health and Society, Wageningen University, Wageningen, The Netherlands
Correspondence to Lenneke Vaandrager, Group Public Health and Society, Department of Social Sciences, Wageningen University, Hollandseweg 1, 6706 KN Wageningen, The Netherlands; Email: lenneke.vaandrager{at}wur.nl
Received 16 May 2008; Revised 5 September 2008; Accepted 19 September 2008.
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Abstract |
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 Top Abstract IntroductionCoordinated actionFactors influencing the success...The added value of...Discussion and conclusionDeclarationReferences |
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Background. Due to the multidimensionality of emerging health and societal issues, there is an increased necessity for coordinated action, that is, action in which organizations and clients in two or more sectors work together to jointly achieve an outcome. Coordinated action creates opportunities for exchanging activities, expertise, skills and resources. However, the different disciplines are not used to working together.
Objectives. Coordinated action includes getting involved with working in a new area or setting, with new people and with different backgrounds, knowledge domains, interests and perspectives. In this paper, the challenges of coordinated action are discussed. The objective is to identify factors that are important in achieving and sustaining coordinated action for health.
Method. Identification of these factors is based on the authors’ experiences with coordinated action in community health promotion and on a review of literature.
Results. Six factors are identified which are important in achieving and sustaining coordinated action: representation of relevant societal sectors including clients, discussing aims and objectives, discussing roles and responsibilities, communication infrastructure, visibility and management.
Conclusions. The success of coordinated action depends on a well-structured process to support involvement, to nurture the collaboration process and to stimulate communication and the growth of positive relationships. Coordinated action can improve both health and social outcomes, and it has the potential for synergy. It is a challenge into which it is worthwhile investing time and energy.
Keywords. Client involvement, coordinated action, participation.
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Introduction |
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TopAbstractIntroductionCoordinated actionFactors influencing the success...The added value of...Discussion and conclusionDeclarationReferences |
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For many centuries, care for and the improvement of population health were a major responsibility of the biomedical sector. Together with sanitary reforms, advances in scientific medicine have been of enormous benefit to public health. However, since the middle of the 20th century chronic diseases increasingly became the leading cause of morbidity and mortality. Overweight and obesity are increasing worldwide. Trends indicate that these health problems are likely to become even more important over the next decade1–4 because of the rapid ageing of the population and the greater longevity of people with many chronic conditions.
Causes of chronic diseases are often multidimensional. Determinants of health include biological factors, lifestyle (e.g. alcohol abuse, smoking, poor diet and lack of physical exercise) and factors in the physical (e.g. food, hygiene and environmental pollution) and social environment (e.g. family, community and workplace), and the organization of health care.5
The changing patterns in health problems and in the determinants of health urge us to consider health from a multilevel perspective, beyond clinical and behavioural interventions. Because no one agency alone has the resources, access and trust relationships to address the wide range of determinants of public health problems,6,7 (inter)national and local policy makers as well as professional practice increasingly call to optimize population health through coordinated action between a variety of health and other societal sectors. This also was one of the guiding principles adopted at the International Conference on Primary Health Care for achieving health goals8 and is expressed in the Charter of Ottawa and in the Bangkok Charter of Health Promotion.1,2 Coordinated action can mean that partners in primary and secondary care make referrals to each other, for example in networks for integrated care provision. These networks speed up the referral process and facilitate communicative pathways between the partners.9 It can also mean that the cure sector (e.g. GPs) works together with other sectors, such as health promotion, social welfare and local grass root organizations to promote health at community or population level.
Coordinated action for health is more easily said than done. It is not a self-generating autonomous phenomenon, but on the contrary, it involves a learning process. In this paper, we critically scrutinize the opportunities and the challenges of coordinated action. We discuss the factors that are important in achieving and sustaining coordinated action, based on the lessons we learned in community health promotion projects10–14 and on the experiences described in literature.
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Coordinated action |
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Coordinated action for health is also referred to as intersectoral collaboration, which is defined as ‘a recognized relationship between (parts of) different sectors of society which has been formed to take action on an issue to achieve health outcomes in a way which is more effective, efficient or sustainable than might be achieved by the health sector acting alone’.14,15 Participants work together in needs assessment, priority setting and in the development, implementation and evaluation of actions aiming at the enhancement of health. The added value of coordinated action is generally acknowledged. It creates opportunities for linking or sharing information, activities, expertise, skills and resources between sectors to jointly achieve a defined outcome. Coordinated action is expected to bring about changes in at least two directions. Firstly, it should lead to the improvement of determinants of health and thereby the health of individuals and populations. Secondly, it is expected to increase the awareness of the health consequences involved in policy decisions and organizational practice, within and among different sectors.1,2,6
Generally, it is accepted that coordinated action can succeed if participants agree on the problem that has to be solved, on the aims and objectives, the roles and responsibilities and on strategies and procedures to address the problem. However simple and acceptable this may seem, it are exactly these aspects that make coordinated action such a challenge. Coordinated action includes getting involved with working in a new area or setting, with new people and with different backgrounds, knowledge domains, interests and perspectives. Each sector brings in specific knowledge and experience, its own general aims and its own horizons.16
Organizations are designed for specifically described aims and objectives. For example, primary care focuses on individual patients and aims to provide the patient with a broad spectrum of curative and preventive care. Public health and health promotion, on the other hand, focus on the promotion of health of populations and aim to fulfil society’s interest in assuring conditions in which people can be healthy. Organizations and societal sectors develop their own philosophy, their own culture, their own value and norm system and their own rituals. Also, they differently define concepts like health and quality of life.
Getting involved in coordinated action for health therefore may be quite unfamiliar. Studies by, for example, Wallerstein17 and Wagemakers et al.13 show that serious conflicts may arise between the collaborating parties because after a while these differences come to the fore. This strongly hampers the collaboration process. Based on the authors’ experiences in community health promotion10–14 and based on reported experiences in literature,6,7,9,17–22 we identify six factors that are important in achieving and sustaining coordinated action. These are representation of relevant societal sectors, including clients; discussing aims and objectives; discussing roles and responsibilities; communication infrastructure; visibility and management. Although these factors are relevant throughout the process of working together, factors 1–3 are especially important for achieving coordinated action and factors 4–6 are of special relevance for sustaining it. For each identified factor, the value, challenges and suggested strategies are discussed. This is summarized in Table 1.
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Factors influencing the success and sustainability of coordinated action |
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Representation of relevant societal sectors, including clients
Coordinated action for health is necessary because one sector has a limited perspective6 and a limited reach across the population. It should involve representatives from a variety of societal sectors and from both formal and informal organizations. To get these different sectors involved in practice often appears to be quite difficult. Usually, there is no history of working together. For example, GPs are not used to work with the public health sector and professionals are not used to work together with clients and vice versa. Moreover, some organizations find it difficult giving up their autonomy and control.6 In our coordinated action programme in Eindhoven for example, the intention was to involve various sectors, including public health, care, cure (GPs), welfare and clients.13 The welfare sector initially was very reluctant to participate because in their opinion, health promotion was no part of their job. By clearly explicating the relation between welfare and health, the contribution they could make and by involving them in the needs assessment, this sector became motivated to join the programme.
In our community programmes, we experienced that the main challenge in this respect is the under-representation of clients. Simply approaching clients and asking them to participate in needs assessment, planning and implementation of health promotion programmes is inappropriate and not successful.10,12–14 We learned that involving clients in needs assessment and asking them to comment on research results is a stimulating strategy to get and keep clients involved. Moreover, clients must experience that they have a voice in decision making. To achieve and sustain a satisfactory level of client involvement, it is important that activities are consistent with clients’ needs. This may mean that you have to start with other issues then the ones seen as priority by other participants (e.g. professionals). It makes clear to clients that their opinions are taken serious.
Discussing aims and objectives
Participants in coordinated action need to recognize a common mission for the issue on which they are working. This first of all means that they have to agree on the problem definition and on the aims and objectives of the programme they are working on. It is also necessary to ‘agree to disagree’ on other things. This is, for example, an important precondition for working with health insurers, pharmaceutical industry or for collaboration between organizations with clear differences in mission.
Our studies show that participants in a programme initially assume agreement about the aims and objectives. Consequently, discussions about the nature of the problem, about the meaning of concepts such as ‘health’ and ‘quality of life’ almost never take place and expectations about the outcomes of a programme remain unspoken. The programme in Eindhoven is a good example. Initially, it seemed that all participants were working in the same direction, but after a while it appeared that researchers were mainly concerned about lifestyle issues, whereas clients were more concerned about safety, stress and support of raising children. This caused serious conflicts.13 Our experience also shows that discussions about the underlying differences that induced the conflict can clear the air, after which the collaboration processes run smoothly.
Hence, it is especially important, particularly in the start-up phase of coordinated action programmes, to start with open communication and explicit discussion to find agreement about the ‘mission’ of the collaboration initiatives and to find acceptance of the differences that exist between the participants. A clear plan, outlining the goals of each activity, and a timetable for activities help to structure the process.
Discussing roles and responsibilities
Coordinated action per definition involves a variety of skills and expertise, and the idea is that participants together can achieve more than each participant could achieve alone. It is a challenge, however, to find clear definitions of roles and responsibilities for each of the participants in the programme. This has to be consensually developed. Participants have to move to areas that are complementary to their main tasks. For example, most GPs are educated in and expected to provide curative care. From research,23 it is known that GPs do not feel very confident about their health-promoting capacities, due to lack of knowledge, skills and time. Moreover, they experience a lack of patient motivation. It can be a condition that participants in a programme acquire competence in a certain area and that they (both clients and professionals) have to be trained in the new roles they have to play.24 Open discussion about the potential roles and responsibilities and about the mutual expectations of the contribution provided by all participants is pivotal.
Coordinated action depends on involvement and trust.25 Developing trust is a learning process in which participants have to find a balance between working together and getting the freedom to fulfil their part of the job in their own way. It has to be developed through positive experiences and successes. For example, in Eindhoven, one of the activities was a smoking cessation course, carried out by the municipal health service. Previous experiences showed that it is hard to stimulate clients to take part in such a course. The participating GP took the responsibility to refer clients to the course during consults. This was a successful strategy, which resulted in a satisfactory number of motivated clients who took part in the course. Hence, actually doing things together (e.g. rapid implementation of small activities) is important for it makes clear how the possible roles and responsibilities work out in practice and it gives insight in how to adjust or to change roles and responsibilities.
Our research clearly shows that an overriding aspect influencing the success of coordinated action is the nature of the relationship between the participants. Getting along well facilitates the willingness to compromise, to share knowledge and expertise and to share work.10–14 Shared commitment and planning to ensure the resources, mandate, reach and credibility contribute to the achievement and sustainability of the collaboration process.6,7,13,14
Communication infrastructure
Coordinated action is an ongoing process of decision making that requires a flow of regular input of information from and about the participants. It requires a regular assessment of needs, open channels to receive signals from the participants and discussion with clients. This means that it is important to create a communication infrastructure that facilitates the sharing of information, ideas and experience. Formal and informal meetings are important in this respect. For example, in the Amsterdam programmme, clear and regular communication was crucial in establishing and maintaining the relationship with the clients: migrant women.14
It should be noted, however, that developing communication infrastructures is time consuming. Moreover, especially in the start-up phase of a programme, there might be substantial differences in knowledge about specific topics and in communication capabilities. It therefore is important to place emphasis on building people’s capacities to access information when they need it, on developing their ability to experiment and draw conclusions and on their individual and collective ability to take sound decisions (health literacy). It is also important to put emphasis on participants’ self-activity. Telephone, e-mail, databases, teletext or Internet are suitable for supplying participants information at times when they are actively searching for it.
Visibility
Visibility is important for coordinated action. It functions as an incentive for involvement, action and continuation. Visibility refers to three aspects.
Firstly, it refers to ‘visibility of activities’. Being present at local events, for example, increases visibility. Also specific materials can be helpful, as are national and local media attention.
Secondly, it refers to ‘visibility of outcomes’. In practice, expected outcomes in terms of changes in behaviour and lifestyle, changes in conditions that affect health status and changes in the health status of a population itself often appear to be unrealistic within the timespan and reach of the programme. Such changes often can only be reached in the long term, perhaps in 10–20 years. Unrealistic outcome expectations will discourage the sustainability of efforts since the visibility of results is one of the major stimulating and driving forces for participants to stay on track. Short-term outcomes and intermediate outcomes should be defined in a measurable way to contribute to the visibility of the results of coordinated action. It is therefore important not just to focus on long-term health outcomes (e.g. lower body mass index) but also on short-term outcomes (e.g. reach of a programme) and intermediate outcomes (e.g. increased knowledge and awareness of a certain problem; reduced number of people making use of individual care and changes in the environment). This requires regular evaluation of activities and active feedback of results to the coordinated action team, followed by discussion, making action for change possible. Visible outcomes function not only as an incentive for the participants in the process but also as a means of getting political and financial support from decision makers.
Finally, ‘visibility of the individual contributions’ is productive and keeps participants motivated. It must therefore be clear what the individual participants are contributing.
Management
The management process of coordinated action needs special attention to structure the collaboration process. The main problem may not be to identify ‘what to do’ but to find out ‘how to get it done’. In practice, coordinated action programmes tend to focus on achieving a goal rather than to nurture the collaboration process. Managing the process requires leadership and a supporting framework.
A manager or so-called system integrator13,16 fulfils a crucial role and needs to have the following characteristics:
- acceptable to the partners
- flexible and reliable
- practical, using available resources
- good at following up on decisions
- enthusiastic and motivated, also a good motivator
- visionary and a good listener
- committed to the programme and have enough time available.
The manager has to maintain a good communication network infrastructure and has to encourage sharing of ideas, experience and information. This also means that the manager has to avoid an overkill of formal meetings. Management includes initiating debates and making realistic plans that reflect the wishes and possibilities of those involved in the programme.
The supportive framework refers to a clear structure, outlining the goals of each activity, the roles and responsibilities. A timetable for activities helps to structure the process. The outline should have some flexibility, in order to respond to changes and to incorporate learning experiences into programme planning.
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The added value of coordinated action |
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TopAbstractIntroductionCoordinated actionFactors influencing the success...The added value of...Discussion and conclusionDeclarationReferences |
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Evaluations of community health programmes6–22 clearly show the added value of coordinated action. Our research shows that coordinated action is a learning process: participants learn from each other and appreciate this and it increases their capacity and self-confidence. This is true for both professional and ‘lay’ participants.
Working ‘together’ rather than ‘alongside’ can energize people and results in new ways of tackling old problems. What characterizes successful collaboration is the recognition that it is not what people have in common but their differences in view of their expertise, knowledge, capacity and the organization they work for that make coordinated action more powerful than working separately. In addition, the enthusiasm of the partners in action strongly stimulates and provides motivation for continued participation in coordinated action. The principle of synergy seems to be very strong.26
Successful coordinated action leads to an active exchange of knowledge and information between sectors. It leads to actions which are consistent with clients’ needs and agreed upon by all participants and it leads to changes in the environment (e.g. accessibility of sport facilities). Hence, coordinated action leads to the improvement of determinants of health and thereby the health of individuals and populations.
Another interesting added value of coordinated action is that it increases the awareness of the health consequences of organizational policy and practice. In our studies for example, commercial organizations or welfare organizations, which initially did not see a task for them in the promotion of population health became induced to explicitly place health on their agenda and in their policy statements.10,12–14
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Discussion and conclusion |
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TopAbstractIntroductionCoordinated actionFactors influencing the success...The added value of...Discussion and conclusionDeclarationReferences |
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Improvement of population health cannot be achieved by the health sector alone. Organizations increasingly have to work together in order to achieve their own goals and to achieve goals at a higher level. It demands coordinated action from health and other societal sectors, from governmental and non-governmental organizations and from voluntary and grassroots organizations.1,2 All these organizations aim to produce their own goods or services. For example, schools provide education, hospitals provide treatment, the police provide safety and security and cultural organizations provide leisure activities. In coordinated action, organizations move to areas that are complementary to their main tasks—areas with which they are often not equipped to deal. In our experience, conflicts almost always occur due to initial differences in missions and working procedures, but if the differences are addressed in open discussions, coordinated action becomes successful and the achievements are far beyond what participants could have achieved on their own.
In this paper, we identified six factors which are crucial in achieving and sustaining coordinated action for health. The fact that we discussed them in this order (see Table 1) does not mean that coordinated action is a linear and stepwise process which starts with involving sectors, followed by discussing aims and objectives, etc. On the contrary, the six factors are strongly interrelated and intermingled.
Certainly, representation of relevant sectors, discussing aims and objectives and discussing roles and responsibilities are of major importance to get started. However, they are crucial for sustaining coordinated action as well. Where the overall mission of a coordinated action programme may stay the same (e.g. improve population health), the more specific aims and objectives may change throughout time, as a result of the achievements of the programme or as a result of actual occurrences and societal changes. When aims and objectives change, new roles and tasks are required, and it might also mean that new sectors need to become involved. This means that aims and objectives, representation and roles and responsibilities are subject to continuous scrutiny. Likewise, the three factors that we discussed in relation to sustaining coordinated action are important in the start-up phase as well.
Sustaining coordinated action requires nurturing of relationships and collaboration processes. Without such attention, coordinated action is likely to deteriorate. Therefore, a clear communication infrastructure, good management and visibility deserve continuous attention. Realistic outcome expectations, quick implementation of (small) activities, regular evaluations and feedback on the achievements and celebration of these achievements are helpful in sustaining enthusiasm.
We can conclude that there are many challenges to the success of coordinated action, but these challenges are outweighed by the many potential benefits, including a learning process and an infrastructure for continuation.6,10–14,17–22 Despite the endeavour in building networks for coordinated action and despite all the conditions necessary to make it into a successful enterprise, the added value over single actions of single institutions makes it worthwhile investing effort, time and energy. It increases capacity and self-confidence among all stakeholders, and it leads to empowerment at individual and community level.
GPs can contribute significantly to coordinated action for health initiatives. Today’s health challenges urge professionals from different sectors and clients to work together for better health and quality of life. The call for more and high-quality care is growing but there are limited financial options to meet this demand. Coordinated action is assumed to improve the efficiency of patient care.9 Only enhancing efficiency of care is not sufficient: efforts are needed to prevent the need and demand for care. When the health-care sector takes greater responsibility for health promotion and chronic disease prevention as an integral part of service delivery, this can also be an important contribution to the containment of rising health-care costs.26 Therefore, we invite GPs to participate in coordinated action for health: it enables them to take up their responsibilities in the field of health promotion and it provides them the advantages like getting enthusiastic and stimulated by others.
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Declaration |
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Funding: None.
Ethical approval: None.
Conflicts of interest: None.
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Notes |
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Koelen MA, Vaandrager L and Wagemakers A. What is needed for coordinated action for health? Family Practice 2008; Pages 1–7 of 7.
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References |
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