Public Health Partnerships:
Enthusiasm and Evidence
CPHA Conference 2014
• Ross Graham
– Manager of Strategic Projects, Middlesex-London Health Unit
• Shannon Sibbald
– Assistant Professor, Faculty of Health Sciences & Schulich Interfaculty
Program in Public Health, Western University
• Anita Kothari
– Associate Professor, Faculty of Health Sciences, Western University
Learning Objectives
• Describe the conflicting evidence and
enthusiasm for public health partnerships
• Explore tools to support effective decisionmaking regarding partnerships
• Define strategies to optimize knowledge
translation and service delivery via partnerships
Hands up Questions
Questions and discussion throughout
Questions at the end
Time for panel questions at the end
Public Health Partnerships:
Enthusiasm & Evidence
Ross Graham MSc CHE
Manager, Strategic Projects
Middlesex-London Health Unit
[email protected]
“collaboration in public health… is not an
option – it is necessary for success”(Wise, 2008)
PHPs in your Organization?
What areas of your organization commonly use PHPs?
1. Not commonly used
2. Commonly used, but mostly in health promotion areas
3. Commonly used, but mostly in protection/prevention areas
4. Commonly used across all areas
Roughly, how many PHPs is your organization involved with?
1. 0 to 50
2. 51 to 100
3. 100 to 200
4. >200
Not Optional
• A Core Competencies Canadian Public Health
Practitioners (#4)
• A Foundation of the Ontario PH Standards
– And Mentioned ~10,000 times in the OPHS
• A Requirement for Ontario Health Organizations (#5.2)
And Internationally,
• A core/essential/foundational PH practice (US, UK,
• A top PHSSR priority (in Canada too!)
Partnerships are “perhaps the greatest
challenge of the field” given public health’s
“non-hierarchal structure involving seemingly
limitless numbers of stakeholders”(Koh, 2009)
“the sheer variety of partnerships can be
bewildering… possibly nowhere more so than
in public health”(Hunter & Perkins, 2012)
What does the evidence say?
Not Quite As Enthusiastic…
• “many studies, perhaps wrongly in some cases, equate the presence of
collaboration with the success of a program without adequate empirical
verification.”(McGuire, 2006)
• “despite a common belief that multisector collaboration can improve
population health, researchers seldom study the effect of such
collaboration on population health outcomes.”(Woulfe et al., 2010)
• partnerships still driven by ‘conventional wisdom’ rather than
evidence. (Woulfe et al., 2010)
• only 30% of PHPs demonstrated “improved population-level outcomes
that might be attributed to collaboration activities.”(Roussos & Fawcett,
Not Quite As Enthusiastic…
“little evidence of the direct health effects of public health
partnerships”(Smith et al., 2009)
“where successes relating to public health outcomes were observed, it was
extremely difficult to assess the extent to which these were directly
attributable to partnership working.”(Smith et al., 2009)
From the incl. review (Smith et al.) “the impacts of intersectoral action on
health equity are mixed and limited” (NCCMT, 2012)
“Collaboration between local health and local government is commonly
considered best practice. However, the review did not identify any
reliable evidence that inter-agency collaboration, compared to
standard services, leads to health improvement” (Cochrane Review,
PHPs can be
effective & necessary
PHPs Appear most effective at
• fostering knowledge exchange (between
practitioners and organizations)
• facilitating community-based research
• achieving moderate behaviour-change in targeted
• supporting provision of PH services when PH
agencies have minimal resources
But Remember:
Effective PHPs are the exception, not the rule
The Bottom Line
• Mismatched enthusiasm & evidence
– Well-documented romance of collaboration
• Tough scenario for PH practitioners
• Need to
– Discuss partnerships realistically
– View partnerships as tool in PH toolbox
– Build the evidence base
1. Use evidence-based criteria to assess probability of
2. Consider PHPs as one of many possible strategies
to achieve a PH goal
3. Determine the optimal degree of involvement and
4. Insist on outcome measurements and publication
of results
5. Devise an exit strategy that minimizes risks to
stakeholder relations
How does your agency decide whether
or not to dedicate time/energy toward
a PHP?
How do you monitor PHP
Tools for Partnering in
Public Health
Shannon L Sibbald
Assistant Professor, Faculty of Health Sciences & Schulich Interfaculty
Program in Public Health, Western University
Why Partner?
Public Health Agency of Canada
• To promote and protect the health of
Canadians through leadership, partnership,
innovation and action in public health.
• Section Four: Partnerships, Collaboration and
• Partnership and collaboration optimizes
performance through shared resources and
Why Partner?
• strong values of partnership, citizenship, and
• Ethical obligation to do partnerships
• public health/community partnership
– defining community health problems,
– collecting and interpreting data,
– designing appropriate interventions
– jointly developing policies, regulations, and laws
• What are some of the practical challenges you
face in starting, maintaining, nurturing,
sustaining partnerships?
• What do you do about it?
• What can be done to improve your
experiences, outcomes and sustainability of
Partnership ‘Tools’
• Prescriptive > how ought a partnership form
and function
• Descriptive > how a partnership is functioning
• Prescriptive > how to improve partnerships
• six “R’s” of participation: recognition, respect,
role, relationship, reward, and results
Steps to Successful Partnership
• Stage 1: Initial Development
• 1. Vision; 2. Goals; 3. Understanding the Situation;
4. Commitment; 5. Implications
• Stage 2: Making It Happen
• 1. Action Plans; 2. Resources; 3. Roles and
Responsibilities; 4. Capacity Building
• Stage 3: Accountability and Future Directions
1. Evaluation;
2. Future Directions; 3. Revision, Renewal and
Frank &Smith. 2000. The Partnership Handbook
The Partnership Analysis Tool
• VicHealth, Australia (2011)
• Goals: Maximize effectiveness
of partnership through
continuous assessment and
monitoring in order to identify
that need improvement
• Use: to promote discussion
between agencies that will
clarify roles(takes time to do
this); completed by both
partners together; to reflect on
The Partnership Analysis Tool
Tool is divided into 3
1. Assess the purpose
2. Map the partnership
3. Provide feedback
Available at:
Social Network Analysis
• Mapping
• describe interactions
– Snapshot
• Individual or org level
• Intervention
– longitudinal
Partnership Self-Assessment Tool
• Center For The Advancement Of Collaborative Strategies In Health
• Eleven sections that are measured using a Likert scale and/or yes or
no questions:
administration and management
non-financial resources
financial and other capital resources
decision making
benefits of participation
drawbacks of participation
benefits and drawbacks of participating in the partnership
satisfaction with participation
Available through NCCMT:
• Examine: i) quality and ii) initial impacts of the
• 9 Domains:
– communication, collaborative research,
dissemination of research, research findings,
negotiation, partnership enhancement,
information needs, rapport, and commitment
• Common, early and mature indicators
Kothari A, MacLean L, Edwards N, Hobbs A: Indicators at the interface: managing
policymaker-researcher collaboration. Knowledge Manage Res Pract 2011, 9:203–214.
Successful partnership
• Things commonly found in successfully
– Partnership is doing what it was set to do
– Partnership is having impact beyond its immediate
stakeholder group
– Partnership is sustainable and self managing
– The partnership has had ‘added value’ leading to
significant benefits for both partners
Ross, T. 2011. The partnering toolbook
Recommendations for strengthening
collaborative partnership for health:
• Establish monitoring systems to detect progress in
achieving population health and health equity
• Develop and use action plans that assign responsibility
for changing communities and systems
• Facilitate natural reinforcement for people working
together across sectors
• Assure adequate base funding for collaborative efforts
that is sufficient to improve population-level outcomes
• Provide training and technical support for those
working in collaborative partnerships
Recommendations for strengthening
collaborative partnership for health:
• Establish participatory evaluation systems for
documenting and reviewing progress and
making adjustments.
• Arrange group contingencies to ensure
accountability for progress and improvement.
Integrated Knowledge Translation
Partnerships (IKTP)
Anita Kothari
Since we are talking about cross-sector…what sector are you
Public Health/Community Education/Research
Community-based (nonhealth) organization
Private Industry
Long Term Care
Have you been involved in conducting research with your
community/regional/provincial/federal partner?
• No
• Yes
Characteristics of IKT partnerships
What is being discussed in this area that
helps us think about all collaborations?
Implications for public health
Characteristics: Type 1 & 2 Knowledge
•Type 2: Integrated Knowledge
•Type 1: End of Grant Knowledge
•“Researcher – knowledge-user
partnerships in health research”
(Dennis and Lomas, 2003).
•Grant is done – get the word out:
•Getting researchers and decision
makers to come together in health
and health-related research.
•Tailored reports, presentations,
Characteristics: IKT is about collaborative
knowledge/research generation
• Two-Communities Thesis (Caplan, 1979)
– Researchers and policy makers have different
– Have different reward systems
– Have different values
– Have different timelines (for decisions)
• Do you and your community/provincial/federal
partners have different reward systems, values,
From KT to Engaged Scholarship: Promoting Research Relevance and
Utilization. Bowen and Graham. 2013
Characteristics: IKT is similar to the
partnerships we are talking about
today in terms of process
Frequent meetings
Working together
Finding common ground
Finding resources
Collaborating to achieve something that
couldn’t be done independently
IKT Concepts to think about for
PH partnerships
1)Open System of Knowledge Production
Collective narratives of expertise
The Agora
3) Trans-disciplinarity
Science’s new social contract
with society. Gibbons. 1999
IKT Concepts to think about for
PH partnerships
Transformation among the team
New identity
Joint sensemaking
Common language
“partnerships move within and across different
professional worlds, and they can have a
multifaceted grasp of the programs [or research]
and work to help others make sense of them”
IKT Concepts to think about for
PH partnerships
Understanding is not just about knowing but
encompasses ways of being and relating
Common way to see the world
Common understandings of problems and
IKT Concepts to think about for
PH partnerships
• Low impact/Expect actionable outcomes
from research (positivity bias)
• Researcher dominance
• Policymaker dominance, integrity of the
research process and content
• What is knowledge? Worldviews, Theories,
• A Critical Second Look at IKT. Kothari and Wathen. 2013.
• Mode 2 Revisited: the New Production of Knowledge.
Nowotny et al. 2003
Implications for PH partnerships
IKT for research
• Expect positive
• Dominance by one side
• Common understanding
of problems and
PH partnerships (let’s discuss)
• Resource intensive –
determine if it is worth
it (evaluate!)
• Why is PH the steward
of these partnerships?
• How can we use this
Implications for PH partnerships
IKT for research
PH partnerships (let’s discuss)
• The team is transformed
– relational capital is
• ??
• Collective expertise
Multiple accountabilities
• Open system for
knowledge contribution:
private sector?
• ??
• ??
Final Thoughts
Denis & Lomas (2003, p. S2:4 ):
“collaborative research clearly has multiple objectives and
meaning in the eyes of those engaged in such partnership” but
the overriding aim of IKT is the use of research findings in practice
or policy decisions.
Collaborative program planning &
implementation has multiple objectives
and meaning in the eyes of those
engaged in such partnerships but the
overriding aim is improving population
health and decreasing health inequities.
Questions for the PANEL?
Complexity of Partnerships
Public Health Partnerships:
Enthusiasm and Evidence
Key References
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on public health outcomes in England between 1997 and 2008. J Public Health 2009;31(2):210–221.
Mitchell SM & Shortell SM. The governance and management of effective community health partnerships: a typology for research, policy, and practice.
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Hunter D & Perkins N. Partnership working in public health: the implications for governance of a systems approach. J Health Serv Res Policy 2012;17(suppl
McGuire M. Collaborative Public Management: Assessing What We Know and How We Know It. Publ Admin Rev 2006;66:33–43.
Andrews R & Entwistle T. Does Cross-Sectoral Partnership Deliver? An Empirical Exploration of Public Service Effectiveness, Efficiency, and Equity. J Public
Admin Res Theory 2010;20(3):679–701.
Woulfe J, Oliver TR, Siemering KQ & Zahner SJ. Multisector Partnerships in Population Health Improvement. Prev Chronic Dis 2010;7(6).
Assessing the impact and effectiveness of intersectoral action on the social determinants of health and health equity: An expedited systematic review
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Roussos ST & Fawcett SB. A review of collaborative partnerships as a strategy for improving community health. Annu Rev Public Health 2000;21:369–402.
Zakocs RC & Edwards EM. What explains community coalition effectiveness?: a review of the literature. Am J Prev Med 2006;30(4):351–361.
Hunter DJ, Perkins NS, Bambra C, Marks L, Blackman T, Hopkins T, et al. Partnership Working and the Implications for Governance: issues affecting public
health partnerships. Final report [Internet]. NIHR Service Delivery and Organisation programme; 2010 [cited 2013 Aug 11]. Available from:
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Hayes SL, Mann MK, Morgan FM, Kitcher H, Kelly MJ, Weightman AL. Collaboration between local health and local government agencies for health
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Presentation - Canadian Public Health Association