Health Education Research Advance Access originally published online on December 21, 2004
Health Education Research 2005 20(5):499-513; doi:10.1093/her/cyh006
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Health Education Research Vol.20 no.5, © Oxford University Press 2004; All rights reserved
Using linking systems to build capacity and enhance dissemination in heart health promotion: a Canadian multiple-case study
1 School of Geography and Geology, McMaster University, Hamilton, Ontario L8S 4K1, 2 Department of Geography, University of Ottawa, Ottawa, Ontario K1N 6N5, 3 Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec H3A 1A2, 4 Centre for Behavioural Research and Program Evaluation, University of Waterloo, Waterloo, Ontario N2L 3G1, 5 Department of Health Studies and Gerontology, University of Waterloo, National Cancer Institute of Canada, Centre for Behavioral Research and Program Evaluation, Waterloo, Ontario N2L 3G1 and 6 Faculty of Education, University of Manitoba, Winnipeg, Manitoba R3T 2N2, Canada
7 Correspondence to: K. Robinson; E-mail: krobins{at}mcmaster.ca
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Abstract |
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The purpose of this paper is to examine the utility of linking systems between public health resource and user organizations for health promotion dissemination and capacity building, and to identify factors related to the success of linking systems. The design is a parallel-case study using key informant interviews and content analysis of project reports (synthesized qualitative and quantitative data) of three provincial dissemination projects of the Canadian Heart Health Initiative—Dissemination Phase. Each provincial project used linking activities with public health user groups including meetings, skill building, resources, collaboration, networking and research feedback to facilitate capacity building for and implementation of heart health promotion activities. This paper presents empirical examples of linking system designs, activities, and qualitative and quantitative changes in the public health user groups' health promotion capacity, program delivery and sustainability. The findings indicate enhanced health promotion skills, partnerships, resources, infrastructure, and increased programming and sustainability in the targeted public health organizations of all three provincial projects. Identified barriers to the success of linking systems included lack of appropriately skilled personnel, funds, buy-in and leadership. We conclude that linking systems can be flexibly used to build capacity and disseminate health promotion innovations, and suggest conditions for success.
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Introduction |
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TopAbstractIntroductionThe linking systems approachMethodsResultsDiscussionAppendixReferences |
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A linking systems approach to support effective public health practice and workforce competency is a viable bridge between public health resource groups and user groups for health promotion capacity building, and dissemination of best practices and research findings (McCormick et al., 1995
; Orlandi, 1996). Defined, linking systems are the interactions between public health resource groups and user groups in the development, transfer and use of knowledge, practices and programs (Orlandi et al., 1990). The goal of a linking system process is to enhance capacity for, and the transfer and uptake of, a given set of practices or programs by public health user groups. Given the well-documented gap between health promotion research and practice, and limited understanding of knowledge transfer processes (Anderson et al., 1999; Glasgow, 2003), a study of linking systems as a tool for knowledge transfer and capacity building in public health can contribute to evidence-based practice. Although the term ‘linking systems’ may seem new to health promotion, the type of activities undertaken within a linking system build on the early days of capacity building for cardiovascular disease prevention (Schwartz et al., 1993; Jackson et al., 1994). While the concept of involving a user group in identifying needs and planning is familiar in health promotion, this has not typically been the case in dissemination strategies. The unique aspect of linking systems compared to other dissemination approaches is the explicit focus on relational and exchange processes between resource and user groups. The failure of traditional dissemination approaches to result in uptake of public health innovations (e.g. primary care guidelines) highlights the need for more interactive dissemination approaches such as linking systems.
There is a strong rationale for improving the fit between research and practice in health promotion (Buchanan, 1996; Nutbeam, 1996). However, there are few practical examples of linking systems to support public health capacity building and dissemination (King et al., 1998). Published examples tend to be descriptive with little evaluation (process or outcome-related) (Lomas, 2000a) or focus on the adoption of a particular program (Indyk and Belville, 1995), rather than examining a set of practices to support complex initiatives. Thus, we know little about how to use linking systems to disseminate health promotion practices and programs from resource groups to users (Johnson et al., 1996; Hawe et al., 1997; Anderson et al., 1999; Cameron et al., 2001).
The purpose of this paper is to examine the utility of a linking systems approach to support capacity building and dissemination of (heart) health promotion by: (1) describing three examples of linking systems, (2) examining how they worked and what they achieved, and (3) identifying facilitators and barriers to their use for health promotion dissemination. The linking systems examined stem from three provincial heart health projects in Canada that conducted similar capacity-building and dissemination initiatives within different contexts. These projects are compared on the basis of key linking players, system design, activities, and health promotion capacity and implementation changes in order to identify conditions of linking system success.
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The linking systems approach |
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The linking systems approach to dissemination has its origins in Rogers' work on diffusion of innovations (Rogers, 1962
). This early work described the role of communication channels and key individuals in facilitating exchange between those who develop innovations (resource groups) and those who adopt them in practice (user groups). Once seen as a passive sender-to-receiver process, diffusion has been supplanted by dissemination, a one-way active transfer process from resource to user groups (Williams and Gibson, 1990). Criticism of one-way dissemination stems from its lack of success in transferring knowledge and failure to adapt to context and user needs (Basch, 1986). This led Havelock (Havelock, 1973), Kolbe and Iverson (Kolbe and Iverson, 1981), and later Orlandi (Orlandi, 1987) and Rogers (Rogers, 1995) to propose an active two-way linking relationship. The premise here is that better exchange between the ‘two communities’ of research/resource groups and decision-making/user groups at more than simply the product or end stage of innovation development is required for new knowledge to be applied in practice (Lomas, 2000b). Linking systems therefore allow for joint involvement of resource groups and users in the development of needs-based, tailored health promotion practices/programs and transfer strategies. The current research is guided by this view of linking systems as an interactive, two-way approach to dissemination (Figure 1).
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The design of linking systems includes basic core elements in terms of players, structure, functions and activities. The scope of a linking system can facilitate interaction between resource and user groups at community, regional, provincial/state or national levels. Key players in a linking system include members of a resource group (researchers, trainers), public health user groups (local or regional decision makers, public health practitioners) and facilitators who play a key role in assisting exchange and joint activities (McCormick et al., 1995
). Facilitation roles in a linking system are perhaps most ably played by what have been described as ‘knowledge brokers’ or ‘knowledge purveyors’ (Lomas, 1997). Such individuals or organizations have specialized training and experience in communication, public relations and translation of research into policy applications (Crosswaite and Curtis, 1994; Canadian Health Services Research Foundation, 1998). The structure of a linking system is ideally based on a combination of joint linking groups, involving resource and user group members, and individual linking agents, either from resource or user groups, that facilitate exchange through communication and activity initiation (Havelock, 1973).
The functions of a linking system are characterized by mandate and knowledge building; contexts and capabilities communication; appraisal and translation of evidence; and interaction to develop and adapt practices/programs and support implementation (Canadian Health Services Research Foundation, 1998; Lomas, 2000a). The types of activities undertaken within a linking system are geared to these functions and the linking system's overall purpose, and may include training, networking, exchange of materials and joint research (Orlandi, 1987). Linking activities are aimed at supporting the transfer and uptake of public health innovations through (1) capacity building and (2) communication strategies to support evidence-based practice and program implementation. In practice, dissemination in the health sector is often challenged by differences in perspectives, communication styles, mandates and culture, and lack of time and interaction (Schwartz et al., 1993; Canadian Health Services Research Foundation, 1999), which a linking system can help overcome. Linking systems also allow for multi-level connections between funding/governing agencies, dissemination/resource groups and local implementers (Schwartz et al., 1993). As well, linking systems by their very nature focus on group interaction, particularly among different target organizations in the user group to allow for peer sharing in the processes of uptake and implementation. This does not occur in traditional dissemination processes between a resource body and individual users in what is often a one-way and one-on-one transfer process.
Based on the limited literature, there is no single recipe for linking system success. In the absence of a gold standard, a linking system can be assessed based on the nature of its linking processes and achievement of its main purpose. In our Canadian study, we examined the linking processes in the extent to which there is two-way information exchange between resource and user groups (i.e. active involvement of both groups in evaluating needs and evidence, developing practices/programs, and knowledge transfer). We identified the enhancement of capacity and implementation of comprehensive heart health promotion as outcome measures of success of the linking system in achieving its main purpose. Health promotion capacity is the capability of an organization to promote health effectively, made up of multiple dimensions including will, knowledge, skills, partnerships, resources, infrastructure and leadership (Jackson et al., 1994; Hawe et al., 1998; Goodman et al., 1998; Singapore Declaration, 1998). Four key dimensions of capacity are presented here as outcome indicators of the linking system: knowledge/skills, partnerships, resources and infrastructure (see Table III for operational definitions). Knowledge and skills were collapsed into one category given the thematic overlap in the interview findings between health promotion knowledge and skills development. Will and leadership were not included as outcome indicators as there was insufficient data from the interviews to include them in the analysis. Enhanced comprehensive heart health promotion was measured based on changes in the scope (strategies, risk factors, audiences addressed) and level of program implementation. These indicators of capacity and implementation are used to determine the success of these linking systems.
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Methods |
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This research represents one part of a larger research program, the Canadian Heart Health Dissemination Project (CHHDP), designed to investigate the learnings of the provincial projects involved in the Canadian Heart Health Initiative (CHHI)—Dissemination Phase (Elliott et al., 2003
). As a national initiative, the CHHI itself embodies the principles of a linking system in its partnership of policy makers, research groups and regional public health organizations focused on the translation of science into community programs, consensual and multi-level policy development, federal–provincial co-funding arrangements, and a management model linking national, provincial and local levels (Stachenko, 1996). National champions encouraged the CHHI network and its provincial counterparts to take on a similar linkage–partnership approach in their respective dissemination projects, although not all projects did. The CHHI—Dissemination Phase focuses on capacity building in the public health system as one element of a comprehensive dissemination process for health promotion (Riley, 2003). This paper presents findings from a parallel-case study of three of the eight provincial heart health projects under study in the CHHI using key informant interviews and project reports (including qualitative and quantitative data). Prince Edward Island (PEI), Ontario and Manitoba are the first of eight CHHI provincial dissemination projects completed, and are the only three projects that explicitly embraced a linking systems approach within the CHHI (the study of Saskatchewan and Newfoundland will be completed 2004, and British Columbia, Alberta and Quebec are ongoing to 2005). As such they provide a partial, but illustrative, picture of the use of health promotion linking systems in Canada. While all three projects actively used common goals and a linking system framework to build capacity and disseminate health promotion programs from resource groups (provincial project teams) to user groups (public health organizations/community groups), the projects targeted diverse organizations and used different research designs. The projects occurred in different geographic, social and health system contexts, providing a unique opportunity to study linking systems (see Table II). These differences provide a diverse set of provincial cases from which to draw learnings.
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PEI is a small Atlantic province (138 000 people) with four reformed regional health authorities mandated to address acute and continuing care, as well as public health promotion. The PEI project aimed to transfer previously developed practices/programs from one region to another through community mobilization and Participatory Action Research (PAR) in an era of health reform with limited resources. Ontario is Canada's largest and wealthiest province, with its 12 million people primarily located in urban centers. Ontario's public health system is provincially mandated with cost-shared, regional delivery of health promotion programs. Given the province's investments in capacity building and resource system development in the 1990s, the Ontario project focused on research/monitoring. Manitoba, a geographically large, rural province with two urban centers representing 70% of its just over 1 million people, underwent significant health reforms in the mid-1990s creating 11 health regions with acute, long-term care and limited health promotion duties. The Manitoba project focused on resource-poor rural communities with limited provincial support.
Key informant interview respondents (14 in PEI, and 13 in each of Ontario and Manitoba) were purposefully sampled to achieve maximum variation in opinions from diverse perspectives (researchers, government, community agencies) (Weiss, 1998). A purposive sample captures information-rich views of each provincial case in order to study the topic of inquiry in-depth based on multiple perspectives (e.g. provincial versus regional level, research versus stakeholder views). An advantage is that common themes arising from such a diverse sample most likely reflect consistency and prominence of issues.
Over half of the interview respondents were project stakeholders, while 45% were project research members all with a minimum of 3 years of involvement in their respective provincial projects (Table I). The interview guide was developed to address the research objectives of the CHHDP and was pilot tested with three individuals representing researcher and stakeholder perspectives (see Appendix for a sample of the questions). Following pilot testing, the interview guide was modified to clarify questions and simplify language. All 40 interviews were taped, transcribed verbatim and imported into NUD*IST for thematic analysis.
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In addition, 30 provincial project reports (e.g. funder reports, journal publications, final reports; nine from PEI, 14 from Ontario and seven from Manitoba) were analyzed in NUD*IST. The documents were selected to reflect content related to capacity and dissemination, a range of time periods in each project, and different audiences (academic, funders). The reports document research and intervention activities, provincial context, challenges and supports to capacity building and dissemination, and evaluation findings, both qualitative (interviews and focus groups) and quantitative (surveys and tracking data).
Both the interview transcripts and the project report text were analyzed thematically to identify core consistencies and meaning using a coding scheme to index, search, summarize and analyze the data (Patton, 2002). The coding schemes emerged from the interview guide and report analysis questions, and were expanded through a preliminary reading of the interviews and reports as well as discussion and feedback among the research team. Analysis included searches of text both within and across the provincial cases based on thematic frequency and patterns of similarities and differences. A subset of interviews (n = 10) and project reports (n = 3) were coded by two researchers showing approximately 70% agreement on very detailed coding, close to 90% agreement for main categories and 80% code–recode dependability (from time 1 to time 2), indicating good coding dependability (Miles and Huberman, 1994). The provincial analysis summaries were validated through a member-checking process (Creswell, 2003) where interview respondents and project representatives reviewed reports to determine the accuracy of interpretations. Decision rules about what evidence was required to justify reporting a result were: evidence available from both data sources to triangulate results via multiple sources, evidence available from more than one province, and interview findings on observed changes were based on several respondents to ensure multiple perspectives. Findings from the interview and document analysis were integrated along key categories (e.g. context, areas of capacity and implementation change, facilitators and barriers) and are presented as a descriptive and comparative analysis with key themes in each category presented in order of greatest frequency.
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Results |
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Linking system design and nature of interactions
System scope and key players
The three provincial cases differed in the scope of the linking systems, likely reflecting differing provincial health system contexts, mandate and stage of development of health promotion. Given very limited health promotion resources and recently restructured health regions, PEI and Manitoba could not afford to support province-wide linking systems, and instead chose to focus on a few areas with higher need. The scope had implications for key players involved, particularly in defining the user groups (Table II). In the case of PEI, the key target audience was the regional heart health coalition and its community. Ontario's primary user groups were all 37 local public health units. Manitoba's user groups were five rural, community committees made up of volunteer citizens to address underserved, rural community needs.
System structure and linking roles
The structure of the linking systems in all three cases involved a combination of groups and individuals. All three projects' linking systems and in fact the efforts of all provinces involved in the CHHI can be viewed through the lens of participatory action research (PAR) due to the CHHI's basis on a policy–research–intervention partnership (this issue is the focus of another manuscript in preparation and will not be discussed here). In reality, PAR extends beyond the process of a linking system, as it focuses more on the full research process itself. PEI is the only province that explicitly set out to engage in PAR both throughout its research process and linking system activities. Its community volunteers and agencies were integrated with the project team, meeting frequently as a steering committee and a community-research work group. These groups jointly developed tools and collected data; community members disseminated research to fellow citizens, advocated for sustainability and modified the project's phases.
A partnership was built where there could be ongoing communication. What the health system wanted was feedback and information, input from the community. And what the community wanted was more commitment and health promotion action from the region. And what was built was a structure in which community volunteers would link with health professionals around those working groups. [PEI]In Ontario, a selection of local health units, provincial government, resource centers and researchers were linked through a project advisory group and a number of other groups. These groups interacted in meetings focused on research or resource system issues. The advisory group undertook a few joint activities to determine policy options and create a provincial health promotion resource system to support the detailed provincial mandate. As well, the health units and resource centers partnered on numerous capacity building activities. Like PEI, Manitoba's rural community committees linked the provincial project team with local communities to identify priorities for programming and resource use and present health survey results to schools or local agencies. The Manitoba project also linked with NGOs to form a provincial Alliance for Chronic Disease Prevention for advocacy and system development in the absence of strong provincial commitment to a health promotion mandate and resources.
All three systems involved members of the user groups in linking roles to facilitate communication, yet the nature of linking roles varied. Health region staff in PEI played linking roles by actively pairing themselves as mentors with community co-chairs and interacting regularly with the project team through a research group. Ontario's use of linking agents was more limited with local Medical Officers of Health or managers providing a first point of contact with public health staff. In Manitoba, committee facilitators played key linking roles spending at least 1 day a week on networking, training committee members and providing an ongoing information and resource channel. Both PEI and Manitoba's linking systems also involved dedicated staff in knowledge brokering roles, although not explicitly labeled as such. In PEI, one provincial research member played a key role in communicating, training and facilitating community involvement in research and dissemination processes, while in Manitoba, a field coordinator provided communication, technical assistance and research utilization support between the rural community committees and the provincial research team.
Linking activities
Common themes were present in the linking activities to support heart health capacity building and dissemination (Table II). Regular communication, training and collaboration were central to all linking systems. Facilitation, networking and mentoring were key to the two community-oriented systems. All three projects disseminated research findings to support reflection on performance. This activity was most central to the Ontario team.
What we chose to do was to focus the intervention on feedback reports...the other piece was with the Project Advisory Group. The real aim there was that this linking mechanism brought together policy makers, public health staff, and researchers to provide that interface between those three different groups. Instead of coordinating all those pieces [training, consultations], we established our niche in terms of a research policy practice interface. [Ontario]Though the three linking systems included common elements, they played out differently in terms of the nature of interactions between resource and user groups. In PEI and Manitoba, the interactions were characterized by a two-way exchange between resource and user groups, facilitated in PEI by the coalition and community-research group, and in Manitoba by local coordinators. For Ontario, users were not actively involved in evidence appraisal and practice/program development and transfer due to the large number of user groups (health units and resource centers). Instead the research team supported partners in the growth of a coordinated, provincial resource system including strategic and ad hoc user-resource capacity-building interactions.
Achieving changes in health promotion capacity and program implementation
Interview respondents from all three provinces observed a number of areas of health promotion capacity and programming demonstrating growth during their projects. However, the linking systems did not exist in a vacuum; other provincial health system changes, professional development opportunities and health promotion activities occurred concurrently. Hence, observed changes must be seen in this broader context. Both qualitative (interview-based) and quantitative (survey, tracking data) changes in capacity (skills, partnerships, resources, structure) and program implementation (level, scope, sustainability) were observed in the committees, coalition and public health unit user groups. Although the type of documentation of capacity and implementation changes varies by province, as well as differing scope of the linking systems, there are patterns in the nature of capacity and implementation developments (Table III).
Capacity changes
Knowledge/skill development
Expansion of health promotion knowledge and skills was found in all provinces, but more frequently mentioned in the community-oriented projects (PEI and Manitoba) where volunteers experienced substantial enhancement. Research involvement by volunteers in PEI was seen to have a direct impact on community research skills including taking an evidence-based approach. Across all three projects skill building centered on needs assessment, planning and evaluation:
They developed an action plan, and it clearly showed that they had an awareness and understanding; that they were able to identify groups of concern and key issues; that they were able to start doing some program planning. Later they were able to reflect on what worked well and what didn't in evaluation. [Manitoba]
Partnerships
Progress in the development of partnerships was also evident in all provinces. PEI respondents observed that the project created more community–agency contact resulting in new cooperative programs, e.g. with the Heart and Stroke Foundation. In Ontario, the level of participation in and number of coalitions was a more prominent theme (Table III). Manitoba's committees began with a few individuals and progressed to ‘uniquely making use of short term informal coalitions, or "piggy backing" on others’ initiatives' (Gelskey et al., 2001).
Resource acquisition
The ability to obtain expanded resources to support programming efforts was also frequently mentioned. In PEI, volunteer and NGO time on joint activities increased along with cash and in-kind resources through co-sponsorship (Table III) (Sweet et al., 2001). Similarly, in Ontario, shifts related to mandate and resource allocation led to heart health attaining a higher priority with increased staffing (Cameron et al., 1998). Manitoba's rural committees' new grant-writing skills resulted in obtaining new in-kind contributions (Gelskey et al., 2001).
Infrastructure
Positive, although varied, structural changes were also observed, including integration of roles, centralization or decentralization of groups and tasks. The PEI project underwent growth from a few volunteers and agencies, to program working groups, to the formation of a regional health coalition with community co-chairs (Sweet et al., 2001). New teams emerged in Ontario:
I think that we observed in a number of cases that there were structural rearrangements in terms of the emergence of interdisciplinary teams. You've got people working together with a common cause...that previously hadn't happened in the same way. It led to some re-alignments in staff that gave focus and resources at the staff level to promoting heart health as a higher priority. [Ontario]For Manitoba the committees went from one cumbersome planning and delivery body to smaller, more efficient workgroups geared towards specific tasks.
Implementation changes
Level of program delivery
With program implementation, two cases documented an increased level of program delivery. Ontario experienced a surge in programming from an already high baseline compared to the other provinces; this increase took place over a period of several years (Table III).
We had a veritable explosion of local heart health projects across Ontario and I think that it became regarded as an attractive thing for most health units to do, not as a burden that was being pushed on them by the Ministry. [Ontario]Manitoba observed that all sites carried out 50% more initiatives in their third year in comparison to their first, indicating that programming increases take a few years (Gelskey et al., 2001
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Programming type/scope
In both the type and scope of programming (Table III) there was greater comprehensiveness in risk factors addressed, strategies used or groups targeted. PEI tracked an increase in the variety of health promotion strategies used for programming (e.g. skill building, policy development) (Sweet et al., 2001). Ontario's survey showed that public health staff increased their time spent on integrated multi-risk factor activity (Taylor et al., 1998) as opposed to single risk factor activities.
Program sustainability
Sustainability of programming was highlighted primarily in the community-oriented projects as a sign that linking activities had transferred health promotion practices to user groups. In all three projects, increased connections with community groups and partners were key to sustainability. Together research and training were seen as boosting lasting change:
The first part was research, but it went beyond that, it didn't just become a report on somebody's shelf. There was the animation part...the ‘pebble in the pond’ thing where the heart health resource group came in, linked and worked with a community and I guess they explored ways of educating, equipping, preparing people within communities to further develop and continue that process. [Manitoba]
Factors affecting linking systems
All three provincial cases identified similar facilitators or barriers for capacity building and dissemination via linking systems. Interview respondents spoke most often of people (staff and volunteers), funds, priority and leadership (Table IV). Differences in the ranking of the factors for the provinces reflect the specific nature of the projects. For example, in PEI an important condition for success was having appropriately skilled/committed resource staff to anticipate technical assistance needs and connect user groups with other supports. Similarly, in Manitoba's community-driven project having appropriately skilled/committed people to play linking roles was critical for networking and on-site committee support.
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PEI and Manitoba identified lack of resources and staff turnover related to provincial funding reductions and health reforms as key challenges. For Manitoba there were no provincial resources available for linking activities. Low-cost alternatives such as volunteer facilitators, telephone consultations and train the trainer approaches were essential.
Provincially, I think that the Province was supportive but in a state of transition due to health reform. There's a lot of turnover within the senior bureaucratic circles... So it was hard to get a commitment because of the huge turnover and also the transition from a centralized to decentralized model to a regionalized structure. No one really knew quite what that meant. [Manitoba]In Ontario, few resources were dedicated to the linking process by the provincial research team. Thus, there were few mechanisms to engage the user groups in acting on the research findings.
Leadership was identified as contributing significantly to resource dedication for heart health and the priority of health promotion on an organization's agenda. It was most important in Ontario to get initial buy-in of provincial and regional leaders to commit to health promotion funding and central resource system support. However, that initial leadership did not translate into strong linking roles by user group members. This was compounded by relatively low priority for knowledge translation among the provincial research team. Lack of communication was felt to contribute to limited practice-oriented recommendations:
Excellent information had been collected but it wasn't presented in a form that would be helpful to us. We wanted to tailor our training and our consultation framework around that information. It should have been automatically built-in to the research, but it wasn't. [Ontario]Emerging partnerships compensated for PEI and Manitoba's lack of provincial resources and mandate to support health promotion capacity, and the Ontario research team's lack of emphasis on capacity building and regular linking activities. Partnerships were seen as providing access to existing support services of provincial agencies and public health peers in different communities. In PEI, the project's community mobilization process and participatory action research approach contributed to a sustaining structure (the coalition) that allowed active involvement of users and provincial team members in research and programming.
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Discussion |
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In sum, the three provincial linking systems are characterized by differences in scope, composition (i.e. resource and user group players), and linking processes. These, in turn, appear to be related to contextual factors such as the stage of development of health promotion, and the structure and mandate of a public health system. For example, with a longer history of a relatively strong provincial mandate for health promotion and resource support, capacity building and implementation in Ontario were not as hindered by resources, as was the case in PEI and Manitoba. The PEI and Manitoba systems therefore had to rely more heavily on community-based efforts and volunteers for their activities. On the other hand, due to Ontario's large size and greater number of target organizations and resource bodies, a more decentralized approach was taken, while in PEI and Manitoba the project teams played a more active role in linking with target groups one on one and facilitating ongoing two-way exchange. Despite their differences, all three systems used a similar system structure with a combination of centralized and decentralized interaction. Centralization through joint resource–user groups provided some continuity across user groups and decentralization through individual linking roles in user groups supported power sharing and two-way exchange. Each system contained particular strengths illustrating three dimensions of successful linking systems: Manitoba's linking roles of committee facilitators, PEI's close-knit community-research linking group, and Ontario's strong linking relationships among the research team and other provincial partners in a central provincial resource system.
Furthermore, the common linking functions and activities found in the three provinces fit Anderson et al.'s (Anderson et al., 1999) characterization of linking activities as centering on awareness, communication and interaction. The findings add a new facet to linking activities; capacity building supports adoption of practices/programs by creating skill/resource bases, enabling structures and relationships. Reported changes in health promotion capacity and implementation were also consistent across the cases, even with nuances in the changes and varied data sources.
The findings do suggest that whether a linking system operates at a community, regional or provincial/state level, similar conditions for success emerge. Two-way exchange and active involvement of resource and user groups depend on commitment and communication channels. Linking systems center on interaction between diverse groups, hence senior leader buy-in and the presence of appropriately skilled people in facilitation roles are essential. Research on an HIV/AIDS prevention community exchange system (Indyk and Belville, 1995) and school adoption of dental programs (Monahan and Scheirer, 1988) supports this conclusion. Moreover, our findings support those of other Ontario studies, where partnerships, resource support and internal coordination were related to heart health capacity, and organizational priority was related to program implementation (Riley et al., 2001).
Linking systems are more likely to fail if there is insufficient commitment for joint processes, implying that success depends on structural adjustments and incentives in both resource and public health organizations (Schwartz et al., 1993). Thus, key barriers to resource–user interactions include the cost and time involved, lack of communication and consistent players, divergent organizational cultures and priorities, environmental factors (e.g. health reform), and structural issues (Schwartz et al., 1993; Crosswaite and Curtice, 1994; Jackson et al., 1994; Scheirer et al., 1995; Taylor et al., 1998; Weenig, 1999).
While there is no gold standard method for linking systems, they must be actively initiated and include the following: active commitment of resource and user groups; strong communication channels through joint resource-user groups or extended networks; and people dedicated to assume linking roles. This study is limited to a comparison of three case examples of linking systems. However, the diversity of provincial contexts and approaches to joint linking groups, players and activities provides a wide range of experiences that concretize our understanding to contribute knowledge of the implementation and impacts of linking systems on public health system development for chronic disease prevention.
A drawback of this analysis is the inability to directly compare quantitative outcomes of linking systems due to differences in provincial project intervention and research designs.
Further evaluation is needed to assess the implementation process and impact of specific linking activities. In addition, further study of the interplay between different factors affecting linking systems is also warranted. CHHDP's ongoing study of linking system processes and impacts using standardized data collection tools will provide useful information on levels of health promotion capacity and implementation across Canada, and the extent to which different linking activities and contextual factors contribute to capacity and dissemination impacts. Quantitative testing of linking systems across different contexts, health issues and innovations will contribute to expanded knowledge in this area of what constitutes best practice.
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Appendix |
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Table AI. Sample of interview guide questions
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Notes |
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* Strategic Advisory Group: Deborah Bradley, Catherine Donovan, Myrna Gough, Scott McLean, Kelly McQuillen, P. J. Naylor, Gilles Paradis, Kim Raine; Research Advisory Group: Lori Ebbesen, Ken Fowler, Ernest Khalema, Viviane Leaune, Murray McKay, Olive Moase, Barb Riley
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Acknowledgments |
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The authors would like to acknowledge that this work would not be possible without the research, intervention efforts and interpretations of the provincial dissemination project teams: Prince Edward Island Heart Health Program (Rosemary White, Lamont Sweet, Terry Mitchell, Elizabeth Gyorfi-Dyke, Olive Moase), Manitoba Heart Health Project (Dale Gelskey, Dexter Harvey, Ethel Hook, Murray McKay, Diane Cepanec) and CHHI Ontario Project (Martin Taylor, Roy Cameron, Susan Elliott, Richard Schabas, Rosemary Walker, Barb Riley). The authors would like to thank Murray McKay for his work on the Heart Health Indicators Project, which informed the CHHDP. This research is funded by the Canadian Institutes of Health Research.
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References |
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Received on March 9, 2004; accepted on November 16, 2004
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