Background
Worldwide, health systems are revisiting the concept of primary health care (PHC) and trying to understand why the promise of ‘health for all’ has fallen short of the expectations it once inspired. The multiple, sometimes conflicted, meanings attached to PHC have been confusing, divisive and eroded its potential to improve health. Not only is PHC poorly integrated with the rest of the health system, there are challenges with integration between interventions offered by sectors within the field of PHC (Frenk, Reference Frenk2009). In this article, we focus on how collaboration between two sectors, primary care (PC) and public health (PH), might improve PHC.
We use the definition of PHC articulated in the Alma Ata Declaration; PHC is ‘essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self reliance and self-determination’ (World Health Organization [WHO], 1978: 1). We make a distinction between PHC and PC, not to resurrect old debates, but to make clear, as others have done (Muldoon et al., Reference Muldoon, Hogg and Levitt2006; Russell et al., Reference Russell, Geneau, Liddy, Hogg and Hogan2007) that PHC is a broad term conceptualizing an approach to health policy and services for individuals and populations that includes PC, PH and other services and sectors. As the first point of entry to a healthcare system, PC provides person-focused, integrated, coordinated care over time for all but the most uncommon conditions (Starfield, Reference Starfield1998). We define PH to be ‘an organized activity of society to promote, protect and improve, and when necessary, restore the health of individuals, specified groups, or the entire population. It is a combination of sciences, skills, and values that function through collective societal activities and involve programs, services, and institutions aimed at protecting and improving the health of all people’ (Public Health Agency of Canada, 2007: 13).
Collaboration between PC and PH is believed to enable the delivery of more effective clinical services, community screening and public education campaigns than what might be achieved by either of these sectors alone (Lasker, Reference Lasker2002; Weiss et al., Reference Weiss, Anderson and Lasker2002). According to Lasker, when the practice-based services for individuals offered by PC are combined with the population-based strategies offered by PH, health services can become more accessible and tailored to community needs, and better equipped to manage the origins of health problems. Lasker and The Committee on Medicine and Public Health's (Reference Lasker1997) framework for PC and PH collaboration includes: a shared goal; the full range of health and disease determinants; the people and organizations that can make an impact on these determinants; the diverse resources and skills of partners; and the types of interventions that can be mounted. The focus of the interventions in a PC and PH collaboration can be to increase service coordination, increase accessibility for the uninsured, enhance the quality and cost-effectiveness of care, identify and address community problems, strengthen health promotion and health protection and shape the health system through policy, training and research (Lasker and The Committee on Medicine and Public Health, Reference Lasker1997). We used the Public Health Agency of Canada (1997: 9) definition of collaboration, ‘a recognized relationship among different sectors or groups, which have been formed to take action on an issue in a way that is more effective or sustainable than might be achieved by the public health sector acting alone’.
Shifting patient population and health service trends, together with an increased focus on population health and health determinants, are some of the drivers propelling the exploration of collaboration between PC and PH. In the United States, the fiscal pressures associated with providing care for a growing uninsured patient population have influenced the leverage attributed to collaboration (Lasker and The Committee on Medicine and Public Health, Reference Lasker1997). In the United Kingdom, efforts to integrate PC and PH began in the 1990s with the establishment of Primary Care Groups, and later Primary Care Trusts, which have a requirement to engage in strategic planning, needs assessment and service evaluation (Gillam et al., Reference Gillam, Joffe, Miller, Gray, Epstein and Plamping1998; The Change Foundation, 2009). In Canada, after decades of little progress (Hutchison et al., Reference Hutchison, Abelson and Lavis2001), PHC renewal efforts have ramped up with an unprecedented momentum (Hutchison, Reference Hutchison2008) with growing recognition that stronger collaboration between PC and PH is needed (Dault et al., Reference Dault, Lomas and Barer2004; Ontario Ministry of Health and Long Term Care, 2006; Rachlis, Reference Rachlis2006; The Change Foundation, 2009). Concurrently, in the wake of disasters such as SARS, the tainted blood scandal (transfusions of blood contaminated with hepatitis C) and water contamination, calls to renew PH have led to improvements in human resource planning and management (Canadian Institutes of Health Research [CIHR], 2003; Naylor et al., Reference Naylor, Basrur, Bergeron, Brunham, Butler-Jones, Dafoe, Ferguson-Pare, Lussing, McGeer, Neufeld and Plummer2003; Joint Task Group on Public Health Human Resources, 2005).
In this article, we report on a scoping review of the literature that examines collaboration between PC and PH. The purpose of the review was to determine what was known from published quantitative and qualitative studies, evaluation research, systematic and other types of literature reviews as well as descriptive accounts without an explicit research design about structures and processes required to build successful collaborations between PH and PC, outcomes of these collaborations and markers of their success.
Methods
The study followed established scoping literature review methods (Arksey and O'Malley, Reference Arksey and O'Malley2005; Anderson et al., Reference Anderson, Sebaldt, Lohfeld, Karwalajtys, Ismaila, Goeree, Donald, Burgess and Kaczorowski2008; Rumrill et al., Reference Rumrill, Fitzgerald and Merchant2010) and was guided by a framework that identifies three determinants for collaboration (San Martin-Rodriguez et al., Reference San Martin-Rodriguez, Beaulieu, Amour and Ferrada Videla2005). Systemic determinants reside in the environment outside of the organization where the collaboration takes place. Organizational determinants are conditions within the organization, and interactional determinants refer to the interpersonal interactions between team members. This framework guided data extraction and coding of articles included in the review. A detailed description of our methods is published in another paper in this issue (Valaitis et al., in press); therefore, here, we report only key points.
Nine databases (MEDLINE, CINAHL, Cochrane, DARE, Dissertations International, EPOC, EMBASE, PsycINFO and Sociological Abstracts) were searched from 1988 (10 years following Alma Ata) to May 2008 using Mesh Headings and free text key words that were applicable to PH, PC and collaboration – in combinations using the Boolean operators ‘AND’ and ‘OR’ (Table 1). Two librarians developed a search strategy independently and, after comparing results, agreed on a single strategy. To update our review, the same databases were searched for systematic and other types of review articles in July 2011 yielding four relevant articles that we consider in our discussion of the review results. Additional strategies included a search of relevant websites, hand searching of relevant journals and the references in two review articles (Ciliska et al., Reference Ciliska, Ehrlich and DeGuzman2005; Stevenson Rowan et al., Reference Stevenson Rowan, Hogg and Huston2007) and contact with content experts (Valaitis et al., in press). To enable some comparability of heathcare systems, the review was restricted to articles about collaboration between PC and PH in Canada, United States, Western Europe, Australia and New Zealand. We included primary studies of all types, theses, literature reviews of all types, including systematic reviews, and descriptive accounts of collaboration without an explicit research design if they addressed either structures or processes to build collaboration between PC and PH, outcomes of collaboration or markers of success, and were published in English.
Table 1 Keywords for electronic database search
The title and abstract of each article was independently evaluated by two researchers, as were articles assessed as relevant. Disagreements were resolved by consensus by the co-principal investigators (R.M.M. and R.V.). Data were extracted using a specifically designed and pilot-tested form derived from detailed research questions. Consistent with a narrative approach (Arksey and O'Malley, Reference Arksey and O'Malley2005), extractors recorded details of structures and processes of programs or interventions to contextualize results. Data extracted included the purpose of the collaboration, participants in the collaboration, research methods used, if any, the site or context of where the collaboration occurred, theoretical framework applied, if any, what precipitated and or motivated the collaboration, activities of professionals and disciplines, barriers and facilitators to and results or outcomes of collaboration and indicators of a successful collaboration. A compendium containing the complete extraction forms, most of which are one page in length, for all 114 articles can be obtained by contacting the corresponding author. Each extraction form was imported separately as a ‘source’ into NVivo 8 (QSR International Pty Ltd, 2008). Guided by the research questions and the San Martin-Rodriguez et al. (Reference San Martin-Rodriguez, Beaulieu, Amour and Ferrada Videla2005) determinants of collaboration framework described previously, the first two authors developed the coding structure for analysis in consultation with the research team. Extractions were analyzed using content analysis with first-level coding followed by categorization into larger themes.
Results
The combined search strategy yielded 6125 articles. Of these, 114 articles met the inclusion criteria. In the interests of brevity, Table 2 lists the first author of these articles alphabetically. The majority of articles originated from the United Kingdom (38%) and the United States (34%; Valaitis et al., in press). Most articles described local collaborations in urban and rural settings often involving physicians and nurses and were reported at organizational and interactional levels. The results presented here are a high-level overview. Details about the aims of the interventions and collaborations and the activities of professionals and organizations involved in collaborations are identified in the compendium of extraction forms for each article available from the first author.
Table 2 Articles included in scoping review listed by first author
Types of collaboration
We used Lasker and The Committee on Medicine and Public Health's (Reference Lasker1997) synergies of medicine and PH collaboration to guide categorization of the types of collaboration found in our review. These include collaborations aimed at: improving health care by coordinating services for individuals; improving access to care by establishing frameworks to provide care for uninsured; improving the quality and cost-effectiveness of care by applying a population perspective to medical practice; using clinical practice to identify and address community health problems; strengthening health promotion and health protection by mobilizing community campaigns; and shaping the future direction of the health system by collaborating around policy, training and research (Lasker and The Committee on Medicine and Public Health, Reference Lasker1997: 51). The most commonly reported types of collaboration were those aimed at improving the quality and cost-effectiveness of care by applying a population perspective to PC (22%), and those that used clinical practice to identify and address community problems (17%). Other types, representing collaborations that focused on integration and/or quality improvement, primarily included numerous papers from the United Kingdom that reported on collaboration in efforts to achieve a model of an integrated health system (Wood et al., Reference Wood, Farrow and Elliott1994; Gerrish, Reference Gerrish1999; Headland et al., Reference Headland, Crown and Pringle2000; Banks-Smith et al., Reference Banks-Smith, Dowswell, Gillam and Shipman2001; Bindman et al., Reference Bindman, Weiner and Majeed2001; Hurst et al., Reference Hurst, Ford and Gleeson2002; Edmonstone et al., Reference Edmonstone, Hamer and Smith2003; Roff, Reference Roff2003; Heller and Goldwater, Reference Heller and Goldwater2004; Meyrick, Reference Meyrick2004; Hopayian et al., Reference Hopayian, Harvey, Howe and Horrocks2005; Marks and Hunter, Reference Marks and Hunter2005; Shaw et al., Reference Shaw, Ashcroft and Petchey2006; Brown et al., Reference Brown, Burns, Chapel, Cronin, Evans, Gray, Howard, Kendall, Lewendon, Mackenzie, Miles, Morgan, Orme, Tolley and Weil2007). Collaborations aiming to improve access to care by establishing frameworks to provide care for the uninsured were only reported in articles originating from the United States (Machala and Miner, Reference Machala and Miner1994; Lasker and The Committee on Medicine and Public Health, Reference Lasker1997; Wilson et al., Reference Wilson, Wold, Spencer and Pittman2000; Oros et al., Reference Oros, Johantgen, Antol, Heller and Ravella2001; McElmurry et al., Reference McElmurry, McCreary, Park, Ramos, Martinez, Parikh, Kozik and Fogelfeld2009). Another commonly reported type of collaboration was academic partnerships initiated to concurrently improve service delivery and broaden students’ educational experiences (Bennett et al., Reference Bennett, Lewis, Doniger, Bell, Kouides, LaForce and Barker1994; Lundeen et al., Reference Lundeen, Friedbacher, Thomas and Jackson1997; Williams et al., Reference Williams, Riegelman and Grossman1999; Wilson et al., Reference Wilson, Wold, Spencer and Pittman2000; Oros et al., Reference Oros, Johantgen, Antol, Heller and Ravella2001; Desai et al., Reference Desai, Solberg, Clark, Reger, Pearson, Bishop, Roberts, Sniegowski and O'Connor2003; Morgan and Kelly, Reference Morgan and Kelly2004; Ferrari and Rideout, Reference Ferrari and Rideout2005; Michener et al., Reference Michener, Champagne, Yaggy, Yaggy and Krause2005; Rothman et al., Reference Rothman, Lourie, Brian and Foley2005; Harrison et al., Reference Harrison, MacNab, Duffy and Benton2006).
Activities carried out in collaborations
Collaborations between PC and PH served a variety of client populations, and, as Figure 1 shows, involved a full range of activities. Community activities included community engagement and participation (Bennett et al., Reference Bennett, Lewis, Doniger, Bell, Kouides, LaForce and Barker1994; Alexy and Elnitsky, Reference Alexy and Elnitsky1996; Billingham and Perkins, Reference Billingham and Perkins1997; Lundeen et al., Reference Lundeen, Friedbacher, Thomas and Jackson1997; McDonald et al., Reference McDonald, Langford and Boldero1997; Ewles, Reference Ewles1999; Harper et al., Reference Harper, Baker and Reif2000; Margolis et al., Reference Margolis, Stevens, Bordley, Stuart, Harlan, Keyes-Elstein and Wisseh2001; Oros et al., Reference Oros, Johantgen, Antol, Heller and Ravella2001; Heller et al., Reference Heller, Edwards, Patterson and Elhassan2003; Carlisle et al., Reference Carlisle, Morris, Whittle, Hargreaves, Fryers and Lindley2004; Andrews, Reference Andrews2002; Fraser, Reference Fraser2005; Michener et al., Reference Michener, Champagne, Yaggy, Yaggy and Krause2005; Rothman et al., Reference Rothman, Lourie, Brian and Foley2005; Asaid and Riley, Reference Asaid and Riley2007), community development (Billingham and Perkins, Reference Billingham and Perkins1997; Heller and Goldwater, Reference Heller and Goldwater2004; Brown et al., Reference Brown, Burns, Chapel, Cronin, Evans, Gray, Howard, Kendall, Lewendon, Mackenzie, Miles, Morgan, Orme, Tolley and Weil2007) and multi-sectoral involvement (Billingham and Perkins, Reference Billingham and Perkins1997; Arora et al., Reference Arora, Davies and Thompson2000; Wilson et al., Reference Wilson, Wold, Spencer and Pittman2000). Various types of jointly offered health promotion (Fatchett, Reference Fatchett1990; Wiles and Robison, Reference Wiles and Robison1994; Wood et al., Reference Wood, Farrow and Elliott1994; Lasker and The Committee on Medicine and Public Health, Reference Lasker1997; Cook, Reference Cook2000; Bindman et al., Reference Bindman, Weiner and Majeed2001; Oros et al., Reference Oros, Johantgen, Antol, Heller and Ravella2001; Heller et al., Reference Heller, Edwards, Patterson and Elhassan2003; Riley et al., Reference Riley, Harding, Meads, Underwood and Carter2003; Dion, Reference Dion2004; Kearney et al., Reference Kearney, Bradbury, Ellahi, Hodgson and Thurston2005; Rothman et al., Reference Rothman, Lourie, Brian and Foley2005; Brown, Reference Brown2006; Sanders et al., Reference Sanders, Ralph, Sofronoff, Gardiner, Thompson, Dwyer and Bidwell2008), health education (Lambrew et al., Reference Lambrew, Ricketts and Morrissey1993; Bennett et al., Reference Bennett, Lewis, Doniger, Bell, Kouides, LaForce and Barker1994; Alexy and Elnitsky, Reference Alexy and Elnitsky1996; Harper et al., Reference Harper, Baker and Reif2000; Record et al., Reference Record, Harris, Record, Gilbert-Arcari, Desisto and Bunnell2000; Thackway et al., Reference Thackway, Delpech, Jorm, McAnulty and Visotina2000; Bourdages et al., Reference Bourdages, Sauvageau and Lepage2003; Harris et al., Reference Harris, Samples, Keenan, Fox, Melchiono and Woods2003; Heller and Goldwater, Reference Heller and Goldwater2004; Ferrari and Rideout, Reference Ferrari and Rideout2005; Kearney et al., Reference Kearney, Bradbury, Ellahi, Hodgson and Thurston2005; Mack et al., Reference Mack, Brantley and Bell2007; McElmurry et al., Reference McElmurry, McCreary, Park, Ramos, Martinez, Parikh, Kozik and Fogelfeld2009; Sanders et al., Reference Sanders, Ralph, Sofronoff, Gardiner, Thompson, Dwyer and Bidwell2008) and illness/injury prevention initiatives (Lasker and The Committee on Medicine and Public Health, Reference Lasker1997; Lundeen et al., Reference Lundeen, Friedbacher, Thomas and Jackson1997; Crump et al., Reference Crump, Gaston and Fergerson1999; Rogers et al., Reference Rogers, Veale and Weller1999; Lemelin et al., Reference Lemelin, Hogg and Baskerville2001; O'Neil and Clarkson, Reference O'Neil and Clarkson2002; Heller et al., Reference Heller, Edwards, Patterson and Elhassan2003; Heller and Goldwater, Reference Heller and Goldwater2004; Meyrick, Reference Meyrick2004; Chambers et al., Reference Chambers, Kaczorowski, Dolovich, Karwalajtys, Hall, McDonough, Hogg, Farrell, Hendriks and Levitt2005; Kearney et al., Reference Kearney, Bradbury, Ellahi, Hodgson and Thurston2005; Brown, Reference Brown2006; Harrison et al., Reference Harrison, MacNab, Duffy and Benton2006; PHRED, 2006; Stevenson Rowan et al., Reference Stevenson Rowan, Hogg and Huston2007) were reported. The most commonly offered health services were general PC services (Alexy and Elnitsky, Reference Alexy and Elnitsky1996; Lundeen et al., Reference Lundeen, Friedbacher, Thomas and Jackson1997; Poulton, Reference Poulton2000; Record et al., Reference Record, Harris, Record, Gilbert-Arcari, Desisto and Bunnell2000; Andrews, Reference Andrews2002; Heller and Goldwater, Reference Heller and Goldwater2004; Ferrari and Rideout, Reference Ferrari and Rideout2005; Brown, Reference Brown2006; Kaufman et al., Reference Kaufman, Derksen, Alfero, DeFelice, Sava, Tomedi, Baptiste, Jaeger and Powell2006; Shirin and Absher, Reference Shirin, Scotten and Absher2006; de Guzman, Reference DeGuzman2007; Jackson and Marley, Reference Jackson and Marley2007; Taylor et al., Reference Taylor, Stokes, Bajuscak, Serdula, Siegel, Griffin, Keiser, Agate, Kite-Powell, Roach, Humbert, Brusuelas and Shekar2007), chronic disease management including screening (Alexy and Elnitsky, Reference Alexy and Elnitsky1996; Rogers et al., Reference Rogers, Veale and Weller1999; Record et al., Reference Record, Harris, Record, Gilbert-Arcari, Desisto and Bunnell2000; CIHR, 2003; Chambers et al., Reference Chambers, Kaczorowski, Dolovich, Karwalajtys, Hall, McDonough, Hogg, Farrell, Hendriks and Levitt2005; Ferrari and Rideout, Reference Ferrari and Rideout2005; Brown, Reference Brown2006; PHRED, 2006; Mack et al., Reference Mack, Brantley and Bell2007; Wedel et al., Reference Wedel, Kalischuk and Patterson2007) and immunization and communicable disease control (Lambrew et al., Reference Lambrew, Ricketts and Morrissey1993; Bennett et al., Reference Bennett, Lewis, Doniger, Bell, Kouides, LaForce and Barker1994; Wood et al., Reference Wood, Farrow and Elliott1994; Alexy and Elnitsky, Reference Alexy and Elnitsky1996; Danila et al., Reference Danila, Lexau, Lynfield, Moore and Osterholm1997; Crump et al., Reference Crump, Gaston and Fergerson1999; Harper et al., Reference Harper, Baker and Reif2000; Russell et al., Reference Russell, Sutton, Reid, Beynon, Cohen and Huffman2003; Heller and Goldwater, Reference Heller and Goldwater2004; Ferrari and Rideout, Reference Ferrari and Rideout2005; Harris et al., Reference Harris, Pickering, Fasano, Fowler, Gangarosa and Gust2007). Several collaborations involved information systems activities such as developing or managing information systems (Voelker, Reference Voelker1994; Hripcsak et al., Reference Hripcsak, Knirsch, Jain, Stazesky, Pablos-Mendez and Fulmer1999; Renfrew et al., Reference Renfrew, Kempe, Lowery, Chandramouli, Steiner and Berman2001; Shandro, Reference Shandro2003; Heller and Goldwater, Reference Heller and Goldwater2004; Meyrick, Reference Meyrick2004; Mack et al., Reference Mack, Brantley and Bell2007) and sharing information (Shandro, Reference Shandro2003; Harris et al., Reference Harris, Pickering, Fasano, Fowler, Gangarosa and Gust2007). Development or implementation of best practice guidelines using a variety of strategies was reported (Lambrew et al., Reference Lambrew, Ricketts and Morrissey1993; Wood et al., Reference Wood, Farrow and Elliott1994; McDonald et al., Reference McDonald, Langford and Boldero1997; Crump et al., Reference Crump, Gaston and Fergerson1999; Cook, Reference Cook2000; Wilson et al., Reference Wilson, Wold, Spencer and Pittman2000; Shandro, Reference Shandro2003; Michener et al., Reference Michener, Champagne, Yaggy, Yaggy and Krause2005; Huston et al., Reference Huston, Hogg, Martin, Soto and Newbury2006; Larson et al., Reference Larson, Levy, Rome, Matte, Silver and Frieden2006) as well as a leadership role for PH in promoting such guidelines (Lasker and The Committee on Medicine and Public Health, Reference Lasker1997; Welton et al., Reference Welton, Kantner and Katz1997; Cornell, Reference Cornell1999; Hurst et al., Reference Hurst, Ford and Gleeson2002; Hopayian et al., Reference Hopayian, Harvey, Howe and Horrocks2005). Activities carried out by PH in collaborations with PC included conducting needs assessments (Billingham and Perkins, Reference Billingham and Perkins1997; Lasker and The Committee on Medicine and Public Health, Reference Lasker1997; Kilduff et al., Reference Kilduff, McKeown and Crowther1998; Poulton, Reference Poulton2000; Wilson et al., Reference Wilson, Wold, Spencer and Pittman2000; Bindman et al., Reference Bindman, Weiner and Majeed2001; Gillam and Schamroth, Reference Gillam and Schamroth2002; Heller et al., Reference Heller, Edwards, Patterson and Elhassan2003; Roff, Reference Roff2003; Dion, Reference Dion2004; Meyrick, Reference Meyrick2004; Brauer et al., Reference Brauer, Schneider, Preece, Northmore, West, Dietrich and Davidson2006; Brown, Reference Brown2006; de Guzman, Reference DeGuzman2007; Stevenson Rowan et al., Reference Stevenson Rowan, Hogg and Huston2007; Taylor et al., Reference Taylor, Stokes, Bajuscak, Serdula, Siegel, Griffin, Keiser, Agate, Kite-Powell, Roach, Humbert, Brusuelas and Shekar2007; Wedel et al., Reference Wedel, Kalischuk and Patterson2007), planning programs (Cornell, Reference Cornell1999; Cook, Reference Cook2000; Oros et al., 2001; Desai et al., Reference Desai, Solberg, Clark, Reger, Pearson, Bishop, Roberts, Sniegowski and O'Connor2003; Wedel et al., Reference Wedel, Kalischuk and Patterson2007) and carrying out quality assurance and evaluation (Bindman et al., Reference Bindman, Weiner and Majeed2001; Hurst et al., Reference Hurst, Ford and Gleeson2002; Bourdages et al., Reference Bourdages, Sauvageau and Lepage2003; Hogg et al., Reference Hogg, Huston, Martin, Saginur, Newbury, Vilis and Soto2006a; Brown et al., Reference Brown, Burns, Chapel, Cronin, Evans, Gray, Howard, Kendall, Lewendon, Mackenzie, Miles, Morgan, Orme, Tolley and Weil2007; de Guzman, Reference DeGuzman2007; Harris et al., Reference Harris, Pickering, Fasano, Fowler, Gangarosa and Gust2007). Teamwork and management activities tended to focus on supporting teams and measures to address client and service concerns or practice governance (Ciliska et al., Reference Ciliska, Woodcox and Isaacs1992; Wood et al., Reference Wood, Farrow and Elliott1994; Malcolm and Barnett, Reference Malcolm and Barnett1995; Gillam et al., Reference Gillam, Joffe, Miller, Gray, Epstein and Plamping1998; Cook, Reference Cook2000; Headland et al., Reference Headland, Crown and Pringle2000; Banks-Smith et al., Reference Banks-Smith, Dowswell, Gillam and Shipman2001; Bindman et al., Reference Bindman, Weiner and Majeed2001; Hurst et al., Reference Hurst, Ford and Gleeson2002; Bourdages et al., Reference Bourdages, Sauvageau and Lepage2003; Edmonstone et al., Reference Edmonstone, Hamer and Smith2003; Riley et al., Reference Riley, Harding, Meads, Underwood and Carter2003; Asaid and Riley, Reference Asaid and Riley2007). Professional education initiatives included academic programming (Mayo et al., Reference Mayo, White, Oates and Franklin1996; Harris et al., Reference Harris, Samples, Keenan, Fox, Melchiono and Woods2003; Heller and Goldwater, Reference Heller and Goldwater2004; Morgan and Kelly, Reference Morgan and Kelly2004; Lea et al., Reference Lea, Johnson, Ellingwood, Allan, Patel and Smith2005; Kaufman et al., Reference Kaufman, Derksen, Alfero, DeFelice, Sava, Tomedi, Baptiste, Jaeger and Powell2006) and informal training initiatives (Wood et al., Reference Wood, Farrow and Elliott1994; Thomas et al., Reference Thomas, Cashman and Fulmer1995; Welton et al., Reference Welton, Kantner and Katz1997; Gillam et al., Reference Gillam, Joffe, Miller, Gray, Epstein and Plamping1998; Cornell, Reference Cornell1999; Scott, Reference Scott1999; Bindman et al., Reference Bindman, Weiner and Majeed2001; Gillam and Schamroth, Reference Gillam and Schamroth2002; Harris et al., Reference Harris, Samples, Keenan, Fox, Melchiono and Woods2003; Huston et al., Reference Huston, Hogg, Martin, Soto and Newbury2006; Harris et al., Reference Harris, Pickering, Fasano, Fowler, Gangarosa and Gust2007; Hogg and Hanley, Reference Hogg and Hanley2008; McElmurry et al., Reference McElmurry, McCreary, Park, Ramos, Martinez, Parikh, Kozik and Fogelfeld2009). Advisory board and committee participation (Alexy and Elnitsky, Reference Alexy and Elnitsky1996; Kilduff et al., Reference Kilduff, McKeown and Crowther1998; Margolis et al., Reference Margolis, Stevens, Bordley, Stuart, Harlan, Keyes-Elstein and Wisseh2001; Iliffe et al., Reference Iliffe, Lenihan, Wallace, Drennan, Blanchard and Harris2002; Desai et al., Reference Desai, Solberg, Clark, Reger, Pearson, Bishop, Roberts, Sniegowski and O'Connor2003; Dion, Reference Dion2004; Rothman et al., Reference Rothman, Lourie, Brian and Foley2005) and social marketing and communication campaigns about health issues (Danila et al., Reference Danila, Lexau, Lynfield, Moore and Osterholm1997; Lasker and The Committee on Medicine and Public Health, Reference Lasker1997; Hripcsak et al., Reference Hripcsak, Knirsch, Jain, Stazesky, Pablos-Mendez and Fulmer1999; O'Neil and Clarkson, Reference O'Neil and Clarkson2002; Kearney et al., Reference Kearney, Bradbury, Ellahi, Hodgson and Thurston2005; Sanders et al., Reference Sanders, Ralph, Sofronoff, Gardiner, Thompson, Dwyer and Bidwell2008) were also reported.
Figure 1 Activities in Primary Care and Public Health Collaborations
The characteristics of successful collaboration between PC and PH as well as structural and process factors influencing collaboration are briefly discussed in the following section and summarized in Figure 2. Results are presented according to the three determinants for collaboration (systemic, organizational and interactional) as proposed in the framework by San Martin-Rodriguez et al. (Reference San Martin-Rodriguez, Beaulieu, Amour and Ferrada Videla2005).
Figure 2 Factors Influencing Collaboration between Primary Care and Public Health
Systemic factors influencing collaboration
Government involvement, policy and fit with local needs
Health reform and government mandates for development of teams and partnerships were important systemic factors enabling collaboration reported in UK articles (Wiles and Robison, Reference Wiles and Robison1994; Wood et al., Reference Wood, Farrow and Elliott1994; Gillam et al., Reference Gillam, Joffe, Miller, Gray, Epstein and Plamping1998; Arora et al., Reference Arora, Davies and Thompson2000; Poulton, Reference Poulton2000; Banks-Smith et al., Reference Banks-Smith, Dowswell, Gillam and Shipman2001; Cook et al., Reference Cook, Gerrish and Clarke2001; Jewell and Griffiths, Reference Jewell and Griffiths2001; Hurst et al., Reference Hurst, Ford and Gleeson2002; Iliffe and Lenihan, Reference Iliffe and Lenihan2003; Riley et al., Reference Riley, Harding, Meads, Underwood and Carter2003; Meyrick, Reference Meyrick2004; Shaw et al., Reference Shaw, Ashcroft and Petchey2006; Brown et al., Reference Brown, Burns, Chapel, Cronin, Evans, Gray, Howard, Kendall, Lewendon, Mackenzie, Miles, Morgan, Orme, Tolley and Weil2007), and to a lesser extent, in articles from Canada (Shandro, Reference Shandro2003; Butler-Jones, Reference Butler-Jones2004; Brauer et al., Reference Brauer, Schneider, Preece, Northmore, West, Dietrich and Davidson2006; Sanders et al., Reference Sanders, Ralph, Sofronoff, Gardiner, Thompson, Dwyer and Bidwell2008) and the United States (Jenkins and Sullivan-Marx, Reference Jenkins and Sullivan-Marx1994; Lasker and The Committee on Medicine and Public Health, Reference Lasker1997). Collaboration between PC and PH occurred more commonly where initiatives had common goals such as reducing health disparities and meeting the healthcare needs of disadvantaged populations (Lasker and The Committee on Medicine and Public Health, Reference Lasker1997; Wilson et al., Reference Wilson, Wold, Spencer and Pittman2000; Elster et al., Reference Elster and Callan2002; Harrison et al., Reference Harrison, MacNab, Duffy and Benton2006; PHRED, 2006; Wedel et al., Reference Wedel, Kalischuk and Patterson2007; McElmurry et al., Reference McElmurry, McCreary, Park, Ramos, Martinez, Parikh, Kozik and Fogelfeld2009), improving quality of care (Ferguson et al., Reference Ferguson, Berkeley, Fourcher, Guyton and Reiner1992; Alexy and Elnitsky, Reference Alexy and Elnitsky1996; Lundeen et al., Reference Lundeen, Friedbacher, Thomas and Jackson1997; Harris et al., Reference Harris, Samples, Keenan, Fox, Melchiono and Woods2003; Heller and Goldwater, Reference Heller and Goldwater2004), containing costs (Lambrew et al., Reference Lambrew, Ricketts and Morrissey1993; Voelker, Reference Voelker1994; Lasker and The Committee on Medicine and Public Health, Reference Lasker1997; Welton et al., Reference Welton, Kantner and Katz1997; Hripcsak et al., Reference Hripcsak, Knirsch, Jain, Stazesky, Pablos-Mendez and Fulmer1999; Williams et al., Reference Williams, Riegelman and Grossman1999), enhancing evidence-informed practice (Cornell, Reference Cornell1999; Jordan et al., Reference Jordan, Wright, Wilkinson and Williams1998; Gillam and Schamroth, Reference Gillam and Schamroth2002; Hopayian et al., Reference Hopayian, Harvey, Howe and Horrocks2005; Larson et al., Reference Larson, Levy, Rome, Matte, Silver and Frieden2006) and improving emergency planning and response (Hogg et al., Reference Hogg, Huston, Martin and Soto2006b; Harris et al., Reference Harris, Pickering, Fasano, Fowler, Gangarosa and Gust2007; Mack et al., Reference Mack, Brantley and Bell2007; Pierce et al., Reference Pierce, Pittard, West and Richardson2007; Taylor et al., Reference Taylor, Stokes, Bajuscak, Serdula, Siegel, Griffin, Keiser, Agate, Kite-Powell, Roach, Humbert, Brusuelas and Shekar2007). Collaboration was, however, also negatively impacted by the rapid and constant change created by healthcare reform (Welton et al., Reference Welton, Kantner and Katz1997; Hopayian et al., Reference Hopayian, Harvey, Howe and Horrocks2005). Newly created structures and governance processes could lead to uncertainty about the processes of PC and PH collaborations (Ciliska et al., Reference Ciliska, Ehrlich and DeGuzman2005). Healthcare reform became a barrier to collaboration when national priorities took precedence over community-level priorities (Ewles, Reference Ewles1999).
Government involvement, including the ‘fit’ of collaboration with a government's agenda and endorsement of the value of collaboration by government officials (Lambrew et al., Reference Lambrew, Ricketts and Morrissey1993; Shandro, Reference Shandro2003) were important facilitators (Harrison and Keen, Reference Harrison and Keen2002; Riley et al., Reference Riley, Harding, Meads, Underwood and Carter2003; Sanders et al., Reference Sanders, Ralph, Sofronoff, Gardiner, Thompson, Dwyer and Bidwell2008). The importance of collaboration between levels of government, for example, in an emergency (Taylor et al., Reference Taylor, Stokes, Bajuscak, Serdula, Siegel, Griffin, Keiser, Agate, Kite-Powell, Roach, Humbert, Brusuelas and Shekar2007), and coordination and priority setting to enhance collaboration were stressed (Ciliska et al., Reference Ciliska, Ehrlich and DeGuzman2005). Relevant policy development was especially emphasized, one example being the reorganization of fiscal and structural resources to create Primary Care Groups in the United Kingdom (Bindman et al., Reference Bindman, Weiner and Majeed2001).
Funding and resource factors
Collaborations were successful, for the most part, if they were adequately funded (Lambrew et al., Reference Lambrew, Ricketts and Morrissey1993; Poulton, Reference Poulton2000; Kaufman et al., Reference Kaufman, Derksen, Alfero, DeFelice, Sava, Tomedi, Baptiste, Jaeger and Powell2006; Olney and Yoon, Reference Olney and Yoon2007; Wedel et al., Reference Wedel, Kalischuk and Patterson2007). Interestingly, not all successful collaborations required additional investments (Lasker and The Committee on Medicine and Public Health, Reference Lasker1997); some pooled and shared resources (CIHR, 2003) and capitalized on volunteer and in-kind contributions (Lundeen et al., Reference Lundeen, Friedbacher, Thomas and Jackson1997; PHRED, 2006; Shaw et al., Reference Shaw, Ashcroft and Petchey2006).
Collaboration between PC and PH was impeded where a lack of resources for evaluation, health promotion activities and information infrastructure for reporting, sharing and comparing data, human resources and time occurred (Ciliska et al., Reference Ciliska, Woodcox and Isaacs1992; Billingham and Perkins, Reference Billingham and Perkins1997; McDonald et al., Reference McDonald, Langford and Boldero1997; Cornell, Reference Cornell1999; Gerrish, Reference Gerrish1999; Rogers et al., Reference Rogers, Veale and Weller1999; Bindman et al., Reference Bindman, Weiner and Majeed2001; Lemelin et al., Reference Lemelin, Hogg and Baskerville2001; Edmonstone et al., Reference Edmonstone, Hamer and Smith2003; Iliffe and Lenihan, Reference Iliffe and Lenihan2003; Hopayian et al., Reference Hopayian, Harvey, Howe and Horrocks2005; Kearney et al., Reference Kearney, Bradbury, Ellahi, Hodgson and Thurston2005; de Guzman, Reference DeGuzman2007; Stevenson Rowan et al., Reference Stevenson Rowan, Hogg and Huston2007; Xyrichis and Lowton, Reference Xyrichis and Lowton2008). Fee-for-service remuneration of physicians impeded collaboration while alternatives such as capitation, salary or blended funding models enabled them to delegate tasks, allowing more opportunity to provide community-based care (Wedel et al., Reference Wedel, Kalischuk and Patterson2007; The Network Towards Unity for Health, 2008). The intermittent or short-lived nature of some pilot or demonstration projects was another impediment (Arora et al., Reference Arora, Davies and Thompson2000; Hogg and Hanley, Reference Hogg and Hanley2008).
At a broader level, other challenges related to distribution of funds across health sectors and dominance of an illness rather than a health paradigm (Lemelin et al., Reference Lemelin, Hogg and Baskerville2001). Financial performance incentives were criticised for preferentially encouraging some health promotion activities in PC at the expense of those not incentivized (Hogg and Hanley, Reference Hogg and Hanley2008). The small size of PH departments and their capacity to respond to the imperative for more collaboration with PC was a concern (Cornell, Reference Cornell1999; CIHR, 2003), and there was apprehension that population expertise and programs could be diluted if absorbed into PC (CIHR, 2003).
Power and control issues
Many successful collaborations between PC and PH were driven by values and beliefs, most commonly a belief in the value of collaboration between sectors (Fatchett, Reference Fatchett1990; Ayres et al., Reference Ayres, Pollock, Wilson, Fox, Tabner and Hanney1996; Hripcsak et al., Reference Hripcsak, Knirsch, Jain, Stazesky, Pablos-Mendez and Fulmer1999; Williams et al., Reference Williams, Riegelman and Grossman1999; Elster et al., Reference Elster and Callan2002; Butler-Jones, Reference Butler-Jones2004; Dion, Reference Dion2004; Chambers et al., Reference Chambers, Kaczorowski, Dolovich, Karwalajtys, Hall, McDonough, Hogg, Farrell, Hendriks and Levitt2005; Fraser, Reference Fraser2005; Shaw et al., Reference Shaw, Ashcroft and Petchey2006; Harris et al., Reference Harris, Pickering, Fasano, Fowler, Gangarosa and Gust2007; Stevenson Rowan et al., Reference Stevenson Rowan, Hogg and Huston2007), the value of prevention, health promotion and population heath (Fatchett, Reference Fatchett1990; Jenkins and Sullivan-Marx, Reference Jenkins and Sullivan-Marx1994; Lasker and The Committee on Medicine and Public Health, Reference Lasker1997; Jordan et al., Reference Jordan, Wright, Wilkinson and Williams1998; Elster et al., Reference Elster and Callan2002; Desai et al., Reference Desai, Solberg, Clark, Reger, Pearson, Bishop, Roberts, Sniegowski and O'Connor2003; Brauer et al., Reference Brauer, Schneider, Preece, Northmore, West, Dietrich and Davidson2006; Olney and Yoon, Reference Olney and Yoon2007) and the importance of teamwork for enabling effective coordinated care (Cook et al., Reference Cook, Gerrish and Clarke2001; Xyrichis and Lowton, Reference Xyrichis and Lowton2008). Less-successful collaborations were characterized by separate and siloed bureaucracies of PC and PH (The Network Towards Unity for Health, 2008). Territorial ownership conflicts about programs and mandates were common concerns at the systems and organizational levels (Jenkins and Sullivan-Marx, Reference Jenkins and Sullivan-Marx1994; Wiles and Robison, Reference Wiles and Robison1994; Malcolm and Barnett, Reference Malcolm and Barnett1995; Lasker and The Committee on Medicine and Public Health, Reference Lasker1997; Bindman et al., Reference Bindman, Weiner and Majeed2001; Hopayian et al., Reference Hopayian, Harvey, Howe and Horrocks2005; Mack et al., Reference Mack, Brantley and Bell2007; Wedel et al., Reference Wedel, Kalischuk and Patterson2007).
Education and training
Interdisciplinary education (Ciliska et al., Reference Ciliska, Ehrlich and DeGuzman2005) emphasizing system-wide collaborative work practices (Welton et al., Reference Welton, Kantner and Katz1997; The Network Towards Unity for Health, 2008) and training in PH (Carlisle et al., Reference Carlisle, Morris, Whittle, Hargreaves, Fryers and Lindley2004) are needed. There were calls for education programs to bridge knowledge gaps and prepare graduates for practice in integrated systems (Carlisle et al., Reference Carlisle, Morris, Whittle, Hargreaves, Fryers and Lindley2004; Brown, Reference Brown2006) and training to expand managerial abilities in facilitating large diverse teams (Banks-Smith et al., Reference Banks-Smith, Dowswell, Gillam and Shipman2001; Harrison and Keen, Reference Harrison and Keen2002; Iliffe and Lenihan, Reference Iliffe and Lenihan2003; Hogg and Hanley, Reference Hogg and Hanley2008). Furthermore, evaluation skill development is needed in applying PH concepts in PC (Jordan et al., Reference Jordan, Wright, Wilkinson and Williams1998; Gillam and Schamroth, Reference Gillam and Schamroth2002; Iliffe and Lenihan, Reference Iliffe and Lenihan2003).
Organizational factors
Lack of a common agenda
Successful collaboration was most likely to occur with organizational support and resources. Lack of organizational support, which restricted collaboration, took many forms including lack of a common agenda (Kilduff et al., Reference Kilduff, McKeown and Crowther1998; Dion, Reference Dion2004; Brauer et al., Reference Brauer, Schneider, Preece, Northmore, West, Dietrich and Davidson2006; Brown, Reference Brown2006; Hogg and Hanley, Reference Hogg and Hanley2008) or vision (Arora et al., Reference Arora, Davies and Thompson2000; Shandro, Reference Shandro2003; Shaw et al., Reference Shaw, Ashcroft and Petchey2006; Wedel et al., Reference Wedel, Kalischuk and Patterson2007), as well as dominating (Harrison and Keen, Reference Harrison and Keen2002) and competing agendas (Welton et al., Reference Welton, Kantner and Katz1997; Heller et al., Reference Heller, Edwards, Patterson and Elhassan2003; Ciliska et al., Reference Ciliska, Ehrlich and DeGuzman2005; Hopayian et al., Reference Hopayian, Harvey, Howe and Horrocks2005; Hogg and Hanley, Reference Hogg and Hanley2008). Differences in organizational culture, such as PC's focus on individuals and short-term results, and PH's focus on populations and long-term view of health, limited their collaboration (Welton et al., Reference Welton, Kantner and Katz1997; Arora et al., Reference Arora, Davies and Thompson2000; Edmonstone et al., Reference Edmonstone, Hamer and Smith2003). Added to this, PC was reported to devalue aspects of PH activities such as prevention, population needs assessments, and community development (Ayres et al., Reference Ayres, Pollock, Wilson, Fox, Tabner and Hanney1996; Billingham and Perkins, Reference Billingham and Perkins1997; Jordan et al., Reference Jordan, Wright, Wilkinson and Williams1998; Kilduff et al., Reference Kilduff, McKeown and Crowther1998; Hurst et al., Reference Hurst, Ford and Gleeson2002; Bourdages et al., Reference Bourdages, Sauvageau and Lepage2003; Ciliska et al., Reference Ciliska, Ehrlich and DeGuzman2005; Shaw et al., Reference Shaw, Ashcroft and Petchey2006; Hogg and Hanley, Reference Hogg and Hanley2008). Physician workload issues, lack of joint planning and challenges associated with multiple-stakeholder engagement deterred buy-in to collaboration by the PC sector (Arora et al., Reference Arora, Davies and Thompson2000; Banks-Smith et al., Reference Banks-Smith, Dowswell, Gillam and Shipman2001; Gillam and Schamroth, Reference Gillam and Schamroth2002; Russell et al., Reference Russell, Sutton, Reid, Beynon, Cohen and Huffman2003; Meyrick, Reference Meyrick2004; Chambers et al., Reference Chambers, Kaczorowski, Dolovich, Karwalajtys, Hall, McDonough, Hogg, Farrell, Hendriks and Levitt2005; Rothman et al., Reference Rothman, Lourie, Brian and Foley2005). Finally, PH role confusion at the organizational level restricted collaboration, particularly with respect to the general lack of role clarity and variation in PH roles between sites (Meyrick, Reference Meyrick2004; Hopayian et al., Reference Hopayian, Harvey, Howe and Horrocks2005).
Knowledge and resource limitations
Resource limitations were the most commonly identified organizational barrier to collaboration and included deficits in human and financial resources, space, team building and change management capacity (Carlisle et al., Reference Carlisle, Morris, Whittle, Hargreaves, Fryers and Lindley2004; Chambers et al., Reference Chambers, Kaczorowski, Dolovich, Karwalajtys, Hall, McDonough, Hogg, Farrell, Hendriks and Levitt2005; Brauer et al., Reference Brauer, Schneider, Preece, Northmore, West, Dietrich and Davidson2006; de Guzman, Reference DeGuzman2007). Concerns about human resources pertained to the availability and performance capacity of personnel to manage collaborative teams (Harrison and Keen, Reference Harrison and Keen2002; Iliffe and Lenihan, Reference Iliffe and Lenihan2003; Hogg and Hanley, Reference Hogg and Hanley2008), knowledge of PH concepts in PC (Arora et al., Reference Arora, Davies and Thompson2000; Heller et al., Reference Heller, Edwards, Patterson and Elhassan2003; Hogg et al., Reference Hogg, Huston, Martin and Soto2006b) and skills required of PH to perform needs assessments (Jordan et al., Reference Jordan, Wright, Wilkinson and Williams1998). The time needed for collaboration, community mobilization and evaluation was another barrier (Gillam et al., Reference Gillam, Joffe, Miller, Gray, Epstein and Plamping1998; Harper et al., Reference Harper, Baker and Reif2000; Harrison and Keen, Reference Harrison and Keen2002; Bourdages et al., Reference Bourdages, Sauvageau and Lepage2003; Shandro, Reference Shandro2003). That said, many authors reported that health professionals facilitated collaboration (Jenkins and Sullivan-Marx, Reference Jenkins and Sullivan-Marx1994; Ayres et al., Reference Ayres, Pollock, Wilson, Fox, Tabner and Hanney1996; Mayo et al., Reference Mayo, White, Oates and Franklin1996; Jordan et al., Reference Jordan, Wright, Wilkinson and Williams1998; Margolis et al., Reference Margolis, Stevens, Bordley, Stuart, Harlan, Keyes-Elstein and Wisseh2001; Harrison and Keen, Reference Harrison and Keen2002; Ferrari and Rideout, Reference Ferrari and Rideout2005; Hogg and Hanley, Reference Hogg and Hanley2008) and partners brought resources to the table (Leeds et al., 2000; Wilson et al., Reference Wilson, Wold, Spencer and Pittman2000; Michener et al., Reference Michener, Champagne, Yaggy, Yaggy and Krause2005).
Leadership, management and accountability issues
Developing community-based committees with diverse membership mandated with an advisory or steering function was a key leadership approach to facilitate collaboration. Community engagement and representation on these committees were essential for collaborations to be responsive to community needs and facilitate joint planning (Machala and Miner, Reference Machala and Miner1994; Alexy and Elnitsky, Reference Alexy and Elnitsky1996; Billingham and Perkins, Reference Billingham and Perkins1997; Crump et al., Reference Crump, Gaston and Fergerson1999; Ewles, Reference Ewles1999; Harper et al., Reference Harper, Baker and Reif2000; Wilson et al., Reference Wilson, Wold, Spencer and Pittman2000; Bindman et al., Reference Bindman, Weiner and Majeed2001; Oros et al., Reference Oros, Johantgen, Antol, Heller and Ravella2001; Andrews, Reference Andrews2002; Michener et al., Reference Michener, Champagne, Yaggy, Yaggy and Krause2005; Rothman et al., Reference Rothman, Lourie, Brian and Foley2005; Kaufman et al., Reference Kaufman, Derksen, Alfero, DeFelice, Sava, Tomedi, Baptiste, Jaeger and Powell2006; Asaid and Riley, Reference Asaid and Riley2007; Sanders et al., Reference Sanders, Ralph, Sofronoff, Gardiner, Thompson, Dwyer and Bidwell2008). Involvement of multiple professionals was also important to develop buy-in (Lambrew et al., Reference Lambrew, Ricketts and Morrissey1993; Alexy and Elnitsky, Reference Alexy and Elnitsky1996; Margolis et al., Reference Margolis, Stevens, Bordley, Stuart, Harlan, Keyes-Elstein and Wisseh2001; Iliffe et al., Reference Iliffe, Lenihan, Wallace, Drennan, Blanchard and Harris2002; Shandro, Reference Shandro2003; Ciliska et al., Reference Ciliska, Ehrlich and DeGuzman2005). Specific strategies to enable collaboration included: contractual agreements between jurisdictions and organizations (Wood et al., Reference Wood, Farrow and Elliott1994; Lasker and The Committee on Medicine and Public Health, Reference Lasker1997; Cornell, Reference Cornell1999; Wilson et al., Reference Wilson, Wold, Spencer and Pittman2000; Porter et al., Reference Porter, Ross, Chapman, Kohatsu and Fox2007; Wedel et al., Reference Wedel, Kalischuk and Patterson2007); organizational structures such as personnel designated to enhance cooperation between PC and PH (Lambrew et al., Reference Lambrew, Ricketts and Morrissey1993; Gerrish, Reference Gerrish1999; Williams et al., Reference Williams, Riegelman and Grossman1999; Headland et al., Reference Headland, Crown and Pringle2000); mentorship programs for new employees (Scott, Reference Scott1999); involvement of someone able to bridge the sectors (Lasker and The Committee on Medicine and Public Health, Reference Lasker1997); physician and non-physician champions (Harper et al., Reference Harper, Baker and Reif2000); and job descriptions requiring collaboration (Russell et al., Reference Russell, Sutton, Reid, Beynon, Cohen and Huffman2003).
An important management process was to prepare the organization for changes associated with collaboration (The Network Towards Unity for Health, 2008) and ensure organizational structures and processes enabled healthcare providers to function optimally (Shandro, Reference Shandro2003; Ciliska et al., Reference Ciliska, Ehrlich and DeGuzman2005; de Guzman, Reference DeGuzman2007). Small, stable, diverse teams with a high proportion of full-time staff enabled better team participation with more impact on patient care (Shaw et al., Reference Shaw, Ashcroft and Petchey2006; Xyrichis and Lowton, Reference Xyrichis and Lowton2008). Obtaining adequate administrative support for managers (Lasker and The Committee on Medicine and Public Health, Reference Lasker1997; Kilduff et al., Reference Kilduff, McKeown and Crowther1998) and assisting them to develop knowledge and skills needed to support the work of collaborative teams (Banks-Smith et al., Reference Banks-Smith, Dowswell, Gillam and Shipman2001; Margolis et al., Reference Margolis, Stevens, Bordley, Stuart, Harlan, Keyes-Elstein and Wisseh2001) were stressed.
Geographic proximity of partners
Co-location of PH and PC organizations and team members was an important facilitator of collaboration. Geographic proximity of team members facilitated communication, information exchange, a sense of common purpose and high levels of trust between healthcare providers (Williams et al., Reference Williams, Riegelman and Grossman1999; Cook et al., Reference Cook, Gerrish and Clarke2001; Kaufman et al., Reference Kaufman, Derksen, Alfero, DeFelice, Sava, Tomedi, Baptiste, Jaeger and Powell2006; Wedel et al., Reference Wedel, Kalischuk and Patterson2007; Xyrichis and Lowton, Reference Xyrichis and Lowton2008). However, geographic separation of team members left some providers, especially in rural settings, feeling professionally isolated (Oros et al., Reference Oros, Johantgen, Antol, Heller and Ravella2001; Ciliska et al., Reference Ciliska, Ehrlich and DeGuzman2005; Brown, Reference Brown2006). Network formation is a strategy that created critical mass among geographically dispersed team members (Jewell and Griffiths, Reference Jewell and Griffiths2001).
Shared protocols, tools and information sharing
The use of a standardized shared system for collecting data and disseminating information enhanced access to quality medical information and supported effective interdisciplinary care (Voelker, Reference Voelker1994; Welton et al., Reference Welton, Kantner and Katz1997; Banks-Smith et al., Reference Banks-Smith, Dowswell, Gillam and Shipman2001; Kaufman et al., Reference Kaufman, Derksen, Alfero, DeFelice, Sava, Tomedi, Baptiste, Jaeger and Powell2006; Pierce et al., Reference Pierce, Pittard, West and Richardson2007; Stevenson Rowan et al., Reference Stevenson Rowan, Hogg and Huston2007; Wedel et al., Reference Wedel, Kalischuk and Patterson2007; The Network Towards Unity for Health, 2008). Shared protocols were useful for facilitating multi-disciplinary, evidence-based practice and quality assurance and for collecting data and disseminating information (Welton et al., Reference Welton, Kantner and Katz1997; Margolis et al., Reference Margolis, Stevens, Bordley, Stuart, Harlan, Keyes-Elstein and Wisseh2001; Hurst et al., Reference Hurst, Ford and Gleeson2002). Other facilitators of collaboration were evidence-based toolkits and decision-support tools (Rogers et al., Reference Rogers, Veale and Weller1999; Huston et al., Reference Huston, Hogg, Martin, Soto and Newbury2006; Larson et al., Reference Larson, Levy, Rome, Matte, Silver and Frieden2006; Wedel et al., Reference Wedel, Kalischuk and Patterson2007), as well as clear referral processes between partners (Crump et al., Reference Crump, Gaston and Fergerson1999), and linked records (Shandro, Reference Shandro2003).
Interactional factors
Shared purpose, philosophy and beliefs
Early successes in the collaboration between PC and PH maintained enthusiasm (Cornell, Reference Cornell1999; Arora et al., Reference Arora, Davies and Thompson2000) and collaborations were enhanced if partners shared similar philosophies of care (Wiles and Robison, Reference Wiles and Robison1994; de Guzman, Reference DeGuzman2007); believed in the value of the collaboration's impact on community health (Cornell, Reference Cornell1999); and acknowledged the importance of health improvement and health inequalities (Arora et al., Reference Arora, Davies and Thompson2000). When there was not a similar philosophy of care or a common goal to reach, attitudes and beliefs of team members became barriers to collaboration. Attitudes included negative stereotypical views of PC and PH roles and a lack of belief in the value of collaboration or activities such as prevention (Voelker, Reference Voelker1994; Rogers et al., Reference Rogers, Veale and Weller1999; Russell et al., Reference Russell, Sutton, Reid, Beynon, Cohen and Huffman2003; Porter et al., Reference Porter, Ross, Chapman, Kohatsu and Fox2007; The Network Towards Unity for Health, 2008). Other attitudinal issues included resistance to change (Kilduff et al., Reference Kilduff, McKeown and Crowther1998; Gerrish, Reference Gerrish1999; Leeds et al., 2000; Banks-Smith et al., Reference Banks-Smith, Dowswell, Gillam and Shipman2001; The Network Towards Unity for Health, 2008) and lack of interest in participating in planned activities (Bourdages et al., Reference Bourdages, Sauvageau and Lepage2003; Chambers et al., Reference Chambers, Kaczorowski, Dolovich, Karwalajtys, Hall, McDonough, Hogg, Farrell, Hendriks and Levitt2005). A lack of understanding of PH (Billingham and Perkins, Reference Billingham and Perkins1997; Dion, Reference Dion2004; Ciliska et al., Reference Ciliska, Ehrlich and DeGuzman2005; Brauer et al., Reference Brauer, Schneider, Preece, Northmore, West, Dietrich and Davidson2006; Xyrichis and Lowton, Reference Xyrichis and Lowton2008) and various community nursing roles (Wiles and Robison, Reference Wiles and Robison1994; Baptiste and Drennan, Reference Baptiste and Drennan1999) created interpersonal barriers to collaboration, as did philosophical differences in approaches to care (Wiles and Robison, Reference Wiles and Robison1994; Hurst et al., Reference Hurst, Ford and Gleeson2002) and competing priorities and agendas (Harrison and Keen, Reference Harrison and Keen2002; Iliffe and Lenihan, Reference Iliffe and Lenihan2003; Brauer et al., Reference Brauer, Schneider, Preece, Northmore, West, Dietrich and Davidson2006).
Clear roles and positive relationships
The quality of professional relationships (Riley et al., Reference Riley, Harding, Meads, Underwood and Carter2003; PHRED, 2006; Harris et al., Reference Harris, Pickering, Fasano, Fowler, Gangarosa and Gust2007; Jackson and Marley, Reference Jackson and Marley2007) was a vital facilitator for collaboration. Numerous authors reported on the importance of all partners having clear roles and responsibilities to enable effective teamwork (Wiles and Robison, Reference Wiles and Robison1994; Wood et al., Reference Wood, Farrow and Elliott1994; Mayo et al., Reference Mayo, White, Oates and Franklin1996; Billingham and Perkins, Reference Billingham and Perkins1997; Lasker and The Committee on Medicine and Public Health, Reference Lasker1997; Welton et al., Reference Welton, Kantner and Katz1997; Gillam et al., Reference Gillam, Joffe, Miller, Gray, Epstein and Plamping1998; Cook, Reference Cook2000; Cook et al., Reference Cook, Gerrish and Clarke2001; Shandro, Reference Shandro2003; Dion, Reference Dion2004; Ciliska et al., Reference Ciliska, Ehrlich and DeGuzman2005; Brauer et al., Reference Brauer, Schneider, Preece, Northmore, West, Dietrich and Davidson2006; Brown, Reference Brown2006; Stevenson Rowan et al., Reference Stevenson Rowan, Hogg and Huston2007; Xyrichis and Lowton, Reference Xyrichis and Lowton2008). Having better knowledge of one another's roles, skills and organizations enhanced the speed and nature of decision-making among teams.
Moreover, understanding of and capacity for interdisciplinary teamwork (Poulton, Reference Poulton2000; Heller et al., Reference Heller, Edwards, Patterson and Elhassan2003; Dion, Reference Dion2004; Xyrichis and Lowton, Reference Xyrichis and Lowton2008) having had previous positive relationships and developing new linkages among PC and PH personnel (Wood et al., Reference Wood, Farrow and Elliott1994; Ayres et al., Reference Ayres, Pollock, Wilson, Fox, Tabner and Hanney1996; Baptiste and Drennan, Reference Baptiste and Drennan1999; Margolis et al., Reference Margolis, Stevens, Bordley, Stuart, Harlan, Keyes-Elstein and Wisseh2001; Brown, Reference Brown2006; Shaw et al., Reference Shaw, Ashcroft and Petchey2006; Porter et al., Reference Porter, Ross, Chapman, Kohatsu and Fox2007) enabled collaborations. In contrast, various types of communication issues (Baptiste and Drennan, Reference Baptiste and Drennan1999; Hripcsak et al., Reference Hripcsak, Knirsch, Jain, Stazesky, Pablos-Mendez and Fulmer1999; Hurst et al., Reference Hurst, Ford and Gleeson2002; Ciliska et al., Reference Ciliska, Ehrlich and DeGuzman2005) and poor rapport impeded collaboration (Wiles and Robison, Reference Wiles and Robison1994; Alexy and Elnitsky, Reference Alexy and Elnitsky1996; Poulton, Reference Poulton2000; Harris et al., Reference Harris, Pickering, Fasano, Fowler, Gangarosa and Gust2007; Hopayian et al., Reference Hopayian, Harvey, Howe and Horrocks2005). Specific strategies to develop team relations included the following: providing partners with feedback; acquiring input often; having patience to nurture relationships; taking the time needed to build linkages (Ferguson et al., Reference Ferguson, Berkeley, Fourcher, Guyton and Reiner1992; Billingham and Perkins, Reference Billingham and Perkins1997; McDonald et al., Reference McDonald, Langford and Boldero1997; Mack et al., Reference Mack, Brantley and Bell2007); and education (Bennett et al., Reference Bennett, Lewis, Doniger, Bell, Kouides, LaForce and Barker1994; Scott, Reference Scott1999; Ciliska et al., Reference Ciliska, Ehrlich and DeGuzman2005).
Effective communication and decision-making strategies
Many authors discussed the importance of direct and open communication and decision-making to promote understanding, trust and respect between PH, PC and the community (Lasker and The Committee on Medicine and Public Health, Reference Lasker1997; Welton et al., Reference Welton, Kantner and Katz1997; Kilduff et al., Reference Kilduff, McKeown and Crowther1998; Cornell, Reference Cornell1999; Gerrish, Reference Gerrish1999; Scott, Reference Scott1999; Riley et al., Reference Riley, Harding, Meads, Underwood and Carter2003; Shirin and Absher, Reference Shirin, Scotten and Absher2006; Asaid and Riley, Reference Asaid and Riley2007; Harris et al., Reference Harris, Pickering, Fasano, Fowler, Gangarosa and Gust2007; Mack et al., Reference Mack, Brantley and Bell2007; Wedel et al., Reference Wedel, Kalischuk and Patterson2007). Brief, unscheduled visits were thought by some to overcome the frequently cited barriers of time and scheduling (Larson et al., Reference Larson, Levy, Rome, Matte, Silver and Frieden2006). Others identified the value of regular monthly meetings for promoting collaboration, enhancing communication and developing trust and mutual understanding (Margolis et al., Reference Margolis, Stevens, Bordley, Stuart, Harlan, Keyes-Elstein and Wisseh2001; Brown, Reference Brown2006; Mack et al., Reference Mack, Brantley and Bell2007). Facilitators included attention to process, open, upfront communication about competition and control issues and appreciation of collaborating partners’ various complementary resources, skills and expertise (Lasker and The Committee on Medicine and Public Health, Reference Lasker1997; Cornell, Reference Cornell1999; Michener et al., Reference Michener, Champagne, Yaggy, Yaggy and Krause2005). Involvement of the whole team was important to develop buy-in and a sense of ownership (Ferguson et al., Reference Ferguson, Berkeley, Fourcher, Guyton and Reiner1992; Lasker and The Committee on Medicine and Public Health, Reference Lasker1997; Cornell, Reference Cornell1999; Leeds et al., 2000), while consensus building (Cook et al., Reference Cook, Gerrish and Clarke2001; Huston et al., Reference Huston, Hogg, Martin, Soto and Newbury2006; Wedel et al., Reference Wedel, Kalischuk and Patterson2007) and joint planning (Oros et al., Reference Oros, Johantgen, Antol, Heller and Ravella2001) enabled teams to address various health-related activities. Specific strategies to improve communication and decision-making included: giving and receiving feedback (Billingham and Perkins, Reference Billingham and Perkins1997; Asaid and Riley, Reference Asaid and Riley2007; Jackson and Marley, Reference Jackson and Marley2007); responding to community-identified needs (Rothman et al., Reference Rothman, Lourie, Brian and Foley2005); being mindful of the PC context (Billingham and Perkins, Reference Billingham and Perkins1997; Cornell, Reference Cornell1999); empowering all team members (Scott, Reference Scott1999); and letting go of rigid professional boundaries to better meet community needs (Lasker and The Committee on Medicine and Public Health, Reference Lasker1997; Riley et al., Reference Riley, Harding, Meads, Underwood and Carter2003; Ciliska et al., Reference Ciliska, Ehrlich and DeGuzman2005).
Markers of successful collaboration
Overall, there was sparse evidence about what marks successful collaboration between PC and PH. Although authors did not specifically discuss indicators, some were surmized from the extractions. Successful collaboration was thought to have occurred when there was: a feeling of being part of the team (Wiles and Robison, Reference Wiles and Robison1994); full co-location of the team (Wedel et al., Reference Wedel, Kalischuk and Patterson2007); improvement in health-related outcomes (Porter et al., Reference Porter, Ross, Chapman, Kohatsu and Fox2007); reduction in health disparities (Porter et al., Reference Porter, Ross, Chapman, Kohatsu and Fox2007); improvement in access to health services (Porter et al., Reference Porter, Ross, Chapman, Kohatsu and Fox2007); improvement in health-related knowledge, attitudes and or behaviors (Porter et al., Reference Porter, Ross, Chapman, Kohatsu and Fox2007); increased capacity and expertise (Desai et al., Reference Desai, Solberg, Clark, Reger, Pearson, Bishop, Roberts, Sniegowski and O'Connor2003); implementation of new collaborative initiatives (Desai et al., Reference Desai, Solberg, Clark, Reger, Pearson, Bishop, Roberts, Sniegowski and O'Connor2003); sustained programs (Riley et al., Reference Riley, Harding, Meads, Underwood and Carter2003; Wedel et al., Reference Wedel, Kalischuk and Patterson2007); increased understanding of PC (Gillam and Schamroth, Reference Gillam and Schamroth2002); increased community assessment and data collection and analysis skills (Gillam and Schamroth, Reference Gillam and Schamroth2002); increased linkages with other agencies (Gillam and Schamroth, Reference Gillam and Schamroth2002); and improved support for multidisciplinary collaboration and teamwork (Gillam and Schamroth, Reference Gillam and Schamroth2002).
Positive outcomes of collaboration
Our review found that successful collaboration between PC and PH could have different benefits for each partner (Lasker and The Committee on Medicine and Public Health, Reference Lasker1997) and resulted in outcomes for individuals and populations, health professionals and healthcare systems.
Individuals and populations
Health outcomes for individuals and populations can be grouped into three main areas beginning with improvements in chronic disease management (Crump et al., Reference Crump, Gaston and Fergerson1999; Record et al., Reference Record, Harris, Record, Gilbert-Arcari, Desisto and Bunnell2000; Desai et al., Reference Desai, Solberg, Clark, Reger, Pearson, Bishop, Roberts, Sniegowski and O'Connor2003; Jackson and Marley, Reference Jackson and Marley2007; McElmurry et al., Reference McElmurry, McCreary, Park, Ramos, Martinez, Parikh, Kozik and Fogelfeld2009), including screening (Gillam et al., Reference Gillam, Joffe, Miller, Gray, Epstein and Plamping1998; Rothman et al., Reference Rothman, Lourie, Brian and Foley2005; Larson et al., Reference Larson, Levy, Rome, Matte, Silver and Frieden2006) and self-care (McElmurry et al., Reference McElmurry, McCreary, Park, Ramos, Martinez, Parikh, Kozik and Fogelfeld2009). Second, there were improvements in communicable disease control (Mayo et al., Reference Mayo, White, Oates and Franklin1996; Danila et al., Reference Danila, Lexau, Lynfield, Moore and Osterholm1997; Hripcsak et al., Reference Hripcsak, Knirsch, Jain, Stazesky, Pablos-Mendez and Fulmer1999; Hogg et al., Reference Hogg, Huston, Martin, Saginur, Newbury, Vilis and Soto2006a) and immunization rates (Bennett et al., Reference Bennett, Lewis, Doniger, Bell, Kouides, LaForce and Barker1994; Crump et al., Reference Crump, Gaston and Fergerson1999; Rothman et al., Reference Rothman, Lourie, Brian and Foley2005; Larson et al., Reference Larson, Levy, Rome, Matte, Silver and Frieden2006). Third, improvements were seen in maternal and child health including better birth outcomes (Machala and Miner, Reference Machala and Miner1994), reduced teen pregnancies (Rothman et al., Reference Rothman, Lourie, Brian and Foley2005), increased uptake of prenatal care (Rothman et al., Reference Rothman, Lourie, Brian and Foley2005), healthier maternal and child lifestyles (Margolis et al., Reference Margolis, Stevens, Bordley, Stuart, Harlan, Keyes-Elstein and Wisseh2001) and reduced child emotional and behavioral problems (Sanders et al., Reference Sanders, Ralph, Sofronoff, Gardiner, Thompson, Dwyer and Bidwell2008).
Health professionals
Outcomes for health professionals included enhanced educational experiences for students (Mayo et al., Reference Mayo, White, Oates and Franklin1996; Wilson et al., Reference Wilson, Wold, Spencer and Pittman2000; Oros et al., Reference Oros, Johantgen, Antol, Heller and Ravella2001) and development of new academic programs (Williams et al., Reference Williams, Riegelman and Grossman1999; Roff, Reference Roff2003). At the practice level, there were improvements in the understanding of PC and PH concepts, areas of responsibility and roles (Cornell, Reference Cornell1999; Headland et al., Reference Headland, Crown and Pringle2000; Leeds et al., 2000; Cook et al., Reference Cook, Gerrish and Clarke2001; Heller et al., Reference Heller, Edwards, Patterson and Elhassan2003; Morgan and Kelly, Reference Morgan and Kelly2004), team functioning (Gerrish, Reference Gerrish1999; Leeds et al., 2000; Andrews, Reference Andrews2002; Riley et al., Reference Riley, Harding, Meads, Underwood and Carter2003) and information sharing (Wood et al., Reference Wood, Farrow and Elliott1994; Banks-Smith et al., Reference Banks-Smith, Dowswell, Gillam and Shipman2001; Kaufman et al., Reference Kaufman, Derksen, Alfero, DeFelice, Sava, Tomedi, Baptiste, Jaeger and Powell2006).
Health service delivery
At the health service delivery level, the most frequent outcome was improved access to care (Ferguson et al., Reference Ferguson, Berkeley, Fourcher, Guyton and Reiner1992; Lasker and The Committee on Medicine and Public Health, Reference Lasker1997; Lundeen et al., Reference Lundeen, Friedbacher, Thomas and Jackson1997; Leeds et al., 2000; Banks-Smith et al., Reference Banks-Smith, Dowswell, Gillam and Shipman2001; Oros et al., Reference Oros, Johantgen, Antol, Heller and Ravella2001; Rothman et al., Reference Rothman, Lourie, Brian and Foley2005; Harrison et al., Reference Harrison, MacNab, Duffy and Benton2006; Kaufman et al., Reference Kaufman, Derksen, Alfero, DeFelice, Sava, Tomedi, Baptiste, Jaeger and Powell2006; PHRED, 2006; Shirin and Absher, Reference Shirin, Scotten and Absher2006; McElmurry et al., Reference McElmurry, McCreary, Park, Ramos, Martinez, Parikh, Kozik and Fogelfeld2009) and quality of care (Jenkins and Sullivan-Marx, Reference Jenkins and Sullivan-Marx1994; Wood et al., Reference Wood, Farrow and Elliott1994; Malcolm and Barnett, Reference Malcolm and Barnett1995; Lasker and The Committee on Medicine and Public Health, Reference Lasker1997; Headland et al., Reference Headland, Crown and Pringle2000; Banks-Smith et al., Reference Banks-Smith, Dowswell, Gillam and Shipman2001; Kaufman et al., Reference Kaufman, Derksen, Alfero, DeFelice, Sava, Tomedi, Baptiste, Jaeger and Powell2006; Wedel et al., Reference Wedel, Kalischuk and Patterson2007). Other outcomes were improved efficiencies through timelier case reporting and less duplication of care (Malcolm and Barnett, Reference Malcolm and Barnett1995; Hripcsak et al., Reference Hripcsak, Knirsch, Jain, Stazesky, Pablos-Mendez and Fulmer1999; Headland et al., Reference Headland, Crown and Pringle2000; Cook et al., Reference Cook, Gerrish and Clarke2001; Margolis et al., Reference Margolis, Stevens, Bordley, Stuart, Harlan, Keyes-Elstein and Wisseh2001; Dion, Reference Dion2004), enhanced individual patient and community satisfaction (Wood et al., Reference Wood, Farrow and Elliott1994; Leeds et al., 2000; Kearney et al., Reference Kearney, Bradbury, Ellahi, Hodgson and Thurston2005; Lea et al., Reference Lea, Johnson, Ellingwood, Allan, Patel and Smith2005; Wedel et al., Reference Wedel, Kalischuk and Patterson2007) and improved continuity and coordination of care (Shandro, Reference Shandro2003; PHRED, 2006; Shirin and Absher, Reference Shirin, Scotten and Absher2006). Care delivery processes were strengthened by an increased focus on health promotion and illness prevention (Lasker and The Committee on Medicine and Public Health, Reference Lasker1997; Banks-Smith et al., Reference Banks-Smith, Dowswell, Gillam and Shipman2001; Lemelin et al., Reference Lemelin, Hogg and Baskerville2001; Iliffe and Lenihan, Reference Iliffe and Lenihan2003; Riley et al., Reference Riley, Harding, Meads, Underwood and Carter2003; Morgan and Kelly, Reference Morgan and Kelly2004; Kearney et al., Reference Kearney, Bradbury, Ellahi, Hodgson and Thurston2005) and population health needs (Renfrew et al., Reference Renfrew, Kempe, Lowery, Chandramouli, Steiner and Berman2001; Dion, Reference Dion2004; Morgan and Kelly, Reference Morgan and Kelly2004), use of needs assessments in PC (Danila et al., Reference Danila, Lexau, Lynfield, Moore and Osterholm1997; Lasker and The Committee on Medicine and Public Health, Reference Lasker1997; Jordan et al., Reference Jordan, Wright, Wilkinson and Williams1998; Cornell, Reference Cornell1999; Banks-Smith et al., Reference Banks-Smith, Dowswell, Gillam and Shipman2001; Cook et al., Reference Cook, Gerrish and Clarke2001; Hurst et al., Reference Hurst, Ford and Gleeson2002) and support for quality improvement (Danila et al., Reference Danila, Lexau, Lynfield, Moore and Osterholm1997; Lasker and The Committee on Medicine and Public Health, Reference Lasker1997; Harrison and Keen, Reference Harrison and Keen2002; Hurst et al., Reference Hurst, Ford and Gleeson2002; Desai et al., Reference Desai, Solberg, Clark, Reger, Pearson, Bishop, Roberts, Sniegowski and O'Connor2003). Cost outcomes included increased funding support and enhanced sustainability as a result of collaboration among formerly competing organizations (Oros et al., Reference Oros, Johantgen, Antol, Heller and Ravella2001; Kaufman et al., Reference Kaufman, Derksen, Alfero, DeFelice, Sava, Tomedi, Baptiste, Jaeger and Powell2006; de Guzman, Reference DeGuzman2007) and efficiencies through resource sharing (Ferguson et al., Reference Ferguson, Berkeley, Fourcher, Guyton and Reiner1992; Banks-Smith et al., Reference Banks-Smith, Dowswell, Gillam and Shipman2001; Cook et al., Reference Cook, Gerrish and Clarke2001).
Negative outcomes of collaboration
There were also some negative outcomes and risks associated with collaboration between PC and PH including reservations about the gains to be made given the modest evidence base (Hurst et al., Reference Hurst, Ford and Gleeson2002; Stevenson Rowan et al., Reference Stevenson Rowan, Hogg and Huston2007) and cost (Andrews, Reference Andrews2002). Benefits to individuals and populations were not always realized (Wood et al., Reference Wood, Farrow and Elliott1994; Gillam and Schamroth, Reference Gillam and Schamroth2002) and the extent to which team members felt part of the team varied (Wiles and Robison, Reference Wiles and Robison1994; McDonald et al., Reference McDonald, Langford and Boldero1997; Baptiste and Drennan, Reference Baptiste and Drennan1999; Cook et al., Reference Cook, Gerrish and Clarke2001). Questions remain about how to provide PH leadership in PC (Brown et al., Reference Brown, Burns, Chapel, Cronin, Evans, Gray, Howard, Kendall, Lewendon, Mackenzie, Miles, Morgan, Orme, Tolley and Weil2007) and concerns that PH skills might be spread too thinly (Marks and Hunter, Reference Marks and Hunter2005). Financial incentives to achieve health promotion targets can conflict with professional philosophies and be demoralizing when they shape practice in a way that shifts care away from local priorities and ignores inequities (Marks and Hunter, Reference Marks and Hunter2005).
For PC, the values underpinning collaboration with PH and a community-oriented approach can be at odds especially with traditional medical training (Gillam and Schamroth, Reference Gillam and Schamroth2002; Stevenson Rowan et al., Reference Stevenson Rowan, Hogg and Huston2007). There is risk too that the time PC providers have for patient care will be diminished as a result of the time needed to collaborate with other professionals (McDonald et al., Reference McDonald, Langford and Boldero1997). For PH, dispersal of PH staff into PC settings can lead to a lack of critical mass, risking erosion of PH expertise (CIHR, 2003). Added to this, there is uncertainty whether collaboration with PC has the potential to address a broad PH agenda and questions about the current capacity of PH organizations to apply PH skills in PC (Heller et al., Reference Heller, Edwards, Patterson and Elhassan2003).
Discussion
The purpose of this scoping literature review was to determine the structures and processes required to build successful collaborations between PH and PC and the outcomes and markers of these collaborations to inform a program of research focused on strengthening PHC through collaboration between these sectors. The review revealed that successful collaboration was thought to have occurred when there were positive systems, organizational or interactional changes. At the system level, collaboration was successful with improvement in health-related outcomes, reduction in health disparities and improvement in access to health services (Porter et al., Reference Porter, Ross, Chapman, Kohatsu and Fox2007). At the organizational level, collaboration was successful with a feeling of being part of the team (Wiles and Robison, Reference Wiles and Robison1994), full co-location of the team (Wedel et al., Reference Wedel, Kalischuk and Patterson2007), implementation of new collaborative initiatives (Desai et al., Reference Desai, Solberg, Clark, Reger, Pearson, Bishop, Roberts, Sniegowski and O'Connor2003) and sustained programs (Riley et al., Reference Riley, Harding, Meads, Underwood and Carter2003; Wedel et al., Reference Wedel, Kalischuk and Patterson2007). At the interactional level, collaboration was successful with improvement in health-related knowledge, attitudes and or behaviors (Porter et al., Reference Porter, Ross, Chapman, Kohatsu and Fox2007) and increased capacity and expertise (Desai et al., Reference Desai, Solberg, Clark, Reger, Pearson, Bishop, Roberts, Sniegowski and O'Connor2003). As such, there is evidence to support collaboration between PC and PH as a strategy to address principles of equity and access in health care and enhance the potential for achieving the goal of ‘health for all’ (WHO, 2008). Attention to the structural and process factors that impede and facilitate collaboration between these sectors is likely to be worthwhile and requires the efforts of policymakers, managers and healthcare providers.
At a systems level, strong leadership from policymakers is needed to create policies that support collaboration, reduce the silos between PC and PH and enable enhanced communication and cooperation within and between levels of government. The use of alternative funding mechanisms to remunerate PC physicians and provide incentive to collaborate with PH was advocated by some authors of articles in our review. However, a recent article reviewing the use of financial incentives to promote PH activities in PC in the United Kingdom found that incentivizing activities may lead to negative health outcomes and further health inequities (Peckham and Hann, Reference Peckham and Hann2008). This calls into question whether alternative funding mechanisms necessarily are an enabler of collaboration that will result in improved health for populations. Another major systems level barrier to collaboration between PC and PH is the lack of sustainable funding available to support service providers to participate in collaboration as well as the lack of funding for information systems and evaluation. This is consistent with findings from a narrative review of Comprehensive Primary Health Care in Australia which concluded that for the model to be realized ‘resources will need to be directed beyond individual treatment to population health issues, cross-sector collaboration and consumer participation’ (Hurley et al., Reference Hurley, Baum, Johns and Labonte2010: 147).
At an organizational level, managers and senior administrators have a significant role to play in fostering PC and PH collaboration by striving to achieve a unified vision and goals and a shared understanding and valuing of the unique cultures and contributions of both sectors. Leadership is also required at this level particularly with respect to facilitating joint planning between PC and PH and the community. Community participation in health is a principle of PHC that has been difficult to achieve. A recent review of community-oriented PC, an approach developed more than 50 years ago for PC physicians to address community health found that full implementation of the model with community engagement and participation in PC practices was rare (Gavagan, Reference Gavagan2008). At the interactional level, our review suggests that service providers within an organization have a key role to play to enable collaboration between PC and PH. Working together to achieve open consistent communication and strong interprofessional relationships with a clear understanding of the roles of PC and PH team members is particularly important. Writing about the Australian experience, McDonald et al. (Reference McDonald, Powell Davies and Fort Harris2009) identify that coordinated and integrated primary and community care is enhanced by interorganizational and interprofessional partnerships.
This scoping review aimed to capture context-free, context-sensitive and colloquial evidence (Culyer and Lomas, Reference Culyer and Lomas2006) about the structures, processes and outcomes of this collaboration. By casting such a wide net, the results of our initial search strategy yielded many more articles than we had anticipated, a phenomenon we believe occurred because of the overlap in our focus of interest with closely related areas such as community intervention research, health promotion and community participation. Moreover, it was difficult to discern between collaboration and other similar processes such as cooperation, coordination and integration. This made the review process challenging and resource intensive (Valaitis et al., in press). Many articles described collaborations initiated by universities responding to unmet health needs in a locality through service learning opportunities for students. Our review did not include educational literature and further research should be carried out to understand the training required to enable PC and PH collaboration.
The review provides a broad overview of the characteristics of collaboration between PC and PH. It provides the foundations of a framework from which our ongoing research can develop a more complex understanding of when, where and under what contextual conditions collaboration is effective and when it warrants time and financial resources. Clearly, there are considerable structural and process-based factors impacting collaboration at systemic, organizational and interactional levels. What is less clear is how these factors interrelate and influence one another. Moreover, questions remain as to which factors are necessary but not sufficient for collaboration and which compilation of factors is sufficient to create a successful collaboration. Our review indicates that PC and PH collaborations involve various health professionals practicing in diverse models of care and geographic and social contexts. All of these factors influence PC and PH collaboration. For example, some PC models are likely more enabling of collaboration than others (Lamarche et al., Reference Lamarche, Beaulieu, Pinealut, Contandriopoulos, Denis and Haggery2003) and in rural settings collaboration may be necessitated by a smaller resource base. Future research should explore these relationships and interactions.
Across countries, most collaboration between PC and PH was initiated and implemented at a local level, reflecting the grass roots nature of innovation and change. Unmet health needs and gaps in health services would undoubtedly be more visible at a local level generating a response by concerned stakeholders. The leadership and risk-taking inherent in local efforts provides a starting point and potential lever for broader change. However, this review shows that it is important for countries and organizations to have policy supports and resources in place to facilitate the development, evaluation and sustainability of collaboration if the impact of collaboration is intended to extend beyond a local level and a reliance on the good will of those involved.
This scoping review includes a large proportion of articles that are descriptive accounts of collaboration. Furthermore, of the 34 articles reporting results from research studies, 75% used qualitative, cross-sectional survey or mixed methods designs. Although these designs limit what can be concluded about the outcomes of collaboration, the benefits of collaboration between PC and PH, particularly in chronic disease management, communicable disease control and maternal child health, cannot be discounted. Just as importantly, potential risks and costs of collaboration for both PC and PH require careful consideration. The conditions and contexts in which potential gains from successful collaborative synergies outweigh associated risks and costs need further exploration.
More primary research and development of theoretical constructs and frameworks are needed to develop the science and inform the practice of successful collaboration between PC and PH. Our ongoing program of research will build on the results of this scoping review by investigating collaboration between PC and PH in the Canadian context, developing a framework and drafting indicators of successful collaboration. It is the first study in a four-year program of research (http://strengthenPHC.mcmaster.ca) that aims to understand how PHC can be strengthened through collaboration between PC and PH, what types of collaboration are best suited for particular contexts, the indicators of collaboration and when collaboration makes the most sense.
Acknowledgments
We sincerely thank the following sponsors for their financial and in-kind support for this program of research: the Canadian Health Services Research Foundation; Health Services and Policy Research Support Network (HSPRSN) Partnership Program; the Michael Smith Foundation for Health Research; McMaster University, School of Nursing and the Faculty of Health Sciences; the Public Health Agency of Canada; Huron County Health Unit; Victorian Order of Nurses Canada; Registered Nurses’ Association of Ontario; Capital District Health Authority, Nova Scotia; Canadian Alliance of Community Health Centres Association; Somerset West Community Health Centre (SWCHC); Canadian Public Health Association; and Hamilton Niagara Haldimand Brant Local Health Integration Network.
