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What systemic factors contribute to collaboration between primary care and public health sectors? An… Wong, Sabrina T; MacDonald, Marjorie; Martin-Misener, Ruth; Meagher-Stewart, Donna; O’Mara, Linda; Valaitis, Ruta K Dec 1, 2017

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RESEARCH ARTICLE Open AccessWhat systemic factors contribute tocollaboration between primary care andpublic health sectors? An interpretivedescriptive studySabrina T. Wong1,2* , Marjorie MacDonald3, Ruth Martin-Misener4, Donna Meagher-Stewart4, Linda O’Mara5and Ruta K. Valaitis5AbstractBackground: Purposefully building stronger collaborations between primary care (PC) and public health (PH) is oneapproach to strengthening primary health care. The purpose of this paper is to report: 1) what systemic factors influencecollaborations between PC and PH; and 2) how systemic factors interact and could influence collaboration.Methods: This interpretive descriptive study used purposive and snowball sampling to recruit and conduct interviewswith PC and PH key informants in British Columbia (n= 20), Ontario (n = 19), and Nova Scotia (n = 21), Canada. Otherparticipants (n = 14) were knowledgeable about collaborations and were located in various Canadian provincesor working at a national level. Data were organized into codes and thematic analysis was completed usingNVivo. The frequency of “sources” (individual transcripts), “references” (quotes), and matrix queries were usedto identify potential relationships between factors.Results: We conducted a total of 70 in-depth interviews with 74 participants working in either PC (n = 33) orPH (n = 32), both PC and PH (n = 7), or neither sector (n = 2). Participant roles included direct service providers(n = 17), senior program managers (n = 14), executive officers (n = 11), and middle managers (n = 10). Seven systemicfactors for collaboration were identified: 1) health service structures that promote collaboration; 2) funding models andfinancial incentives supporting collaboration; 3) governmental and regulatory policies and mandates for collaboration;4) power relations; 5) harmonized information and communication infrastructure; 6) targeted professional education;and 7) formal systems leaders as collaborative champions.Conclusions: Most themes were discussed with equal frequency between PC and PH. An assessment of the systemlevel context (i.e., provincial and regional organization and funding of PC and PH, history of government in successfulimplementation of health care reform, etc) along with these seven system level factors could assist other jurisdictionsin moving towards increased PC and PH collaboration. There was some variation in the importance of the themes acrossprovinces. British Columbia participants more frequently discussed system structures that could promote collaboration,power relations, harmonized information and communication structures, formal systems leaders as collaborationchampions and targeted professional education. Ontario participants most frequently discussed governmentaland regulatory policies and mandates for collaboration.Keywords: Primary health care, Canada, Health system, Health services delivery, Qualitative* Correspondence: Sabrina.wong@nursing.ubc.ca1School of Nursing, University of British Columbia, 2211 Wesbrook Mall, T161,Vancouver, Canada2Centre for Health Services and Policy Research, University of BritishColumbia, 201-2206 East Mall, Vancouver, CanadaFull list of author information is available at the end of the article© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Wong et al. BMC Health Services Research  (2017) 17:796 DOI 10.1186/s12913-017-2730-1BackgroundStrengthening primary health care is an important founda-tion towards building a more equitable and accessible sys-tem of care with better population health outcomes atreduced cost [1–4]. One approach to strengthening pri-mary health care is to purposefully build stronger collabo-rations between primary care (PC) and public health (PH)sectors [5]. Over two decades of mainly descriptive re-search at local levels suggests there are numerous factorsat multiple levels that can determine whether collabor-ation between PC and PH is successful [1, 6, 7]. Martin-Misener and colleagues’ [1] scoping literature review ofcollaboration between PC and PH found that successfulcollaboration between these two health sectors was relatedto systemic, organizational, and interpersonal factors. Col-laboration at the systemic level is defined as the provincialand national level environment beyond the organization[8] and is related to improved health-related outcomes, re-duced health disparities and increased access to healthservices [6]. At the organizational level, collaboration isdefined as health professionals’ positive feelings of beingpart of the team [7], co-location of the team [9], imple-mentation of new collaborative initiatives [10] and sustain-able programs [6]. Finally, at the interpersonal level,collaboration between health professionals is related toimproved patient health-related behaviors and the team’sincreased capacity and expertise [6].The few studies that have examined PC and PH col-laboration has taken place at the individual (inter- orintrapersonal) level [11]. More work is required at thesystemic and organizational levels to understand thecontribution of these factors to collaborations generally[9], or between PC and PH [1, 12]. Indeed, a scoping re-view on collaboration between PC and PH [1] suggestedthat systemic factors, such as policy supports and re-sources, are needed to facilitate the development andsustainability of collaboration if the impact of collabor-ation is to extend beyond individual treatment to popu-lation health improvement. Provincial or national levelpolices that support collaboration can create social, cul-tural, and educational environments that could reducethe silos between PC and PH. For example, policies sup-porting inter-professional team-based care can begin toaddress the nature of “siloed” care, providing the im-petus to address power differences that may exist be-tween health professionals [8]. Acknowledgement bythese system level policies for health professionals’ au-tonomy, working to their full scope of practice, and theirability to strengthen collaboration help set a stage for in-creased collaboration across sectors. Moreover, policiesthat shift how we educate health professionals for collab-orative practice can help students recognize the valuesand responsibilities of their respective professions whileinstructing them in professional plurality [9, 13]. Thepurpose of this paper is to report the perspectives fromkey stakeholder interviews on: 1) what systemic factors,provincial or national, influence collaborations betweenPC and PH; and 2) how systemic factors interact to in-fluence collaboration across these two health sectors.MethodsThis was an interpretive descriptive [14] study design.The data collected and reported here were part of a fouryear, multi-province (British Columbia-BC, Ontario-ON,and Nova Scotia-NS, Canada) program of researchexamining structures and processes required to buildsuccessful collaborations between PH and PC at the sys-temic, organizational, and inter-, intrapersonal levels. In-depth interviews with key informants were conductedacross the three provinces and at the national level.Within Canada, provinces are responsible for organiz-ing, delivering, and financing health care. There is alsosome federal transfer of funds to provinces for healthcare delivery. Each province has different divisions ordepartments of health; In BC, ON, and NS, PC and PHservice delivery fall under different departments. A keydifference between these provinces is the variety of PCdelivery models that exist in ON compared to BC andNS [11, 12, 15]. Primary care in BC is mostly providedby fee-for-service physicians in solo and group practiceswho are geographically linked to a division of familypractice. Less commonly, health authorities also deliverPC through community health centres and specializedclinics (i.e., youth health, STI/HIV diagnosis and treat-ment) often by nurse practitioners. In ON, there are 11models of primary care delivery, such as solo and groupfee-for-service physician practices and salaried commu-nity health centres, nurse practitioner-led clinics, andfamily health teams. Fee-for-service solo and group prac-tice physician models are common in NS but there are agrowing number of interdisciplinary teams, particularlyin rural areas. In public health, provincial funding flowsto regional jurisdictions to deliver services. BritishColumbia and NS have regional health authorities thatprovide public health programs and services whereasON has public health units.ParticipantsStratified purposive sampling [16] was used to recruitparticipants who represented policy-makers, managers,and inter-professional providers including nurse practi-tioners, public health nurses, registered nurses, primarycare physicians, nutritionists. Participants were alsoidentified and recruited using the snowball technique[16]. Eligibility criteria included: providing direct care orhaving responsibility for how services in PC or PH areorganized or delivered, or having knowledge of collabor-ation between these sectors. Participants at the nationalWong et al. BMC Health Services Research  (2017) 17:796 Page 2 of 10level were representatives of organizations with a na-tional presence or key informants representing agenciesthat were outside of the three study provinces.Recruitment and interviewsPotential participants were emailed inviting them to re-flect on their knowledge and experiences regardingbuilding and maintaining collaborations between PC andPH as a means to strengthen primary health care. Uponobtaining informed consent, participants answered ashort demographic questionnaire about how long theyhad been in their current positions, age, and gender.This was followed by interviews, which lasted between45 and 90 min, conducted by research team members,either face-to-face or over the telephone. All participantswere given the interview guide and a sheet containinginformation on how we defined PC, PH, and collabora-tions (see Table 1) ahead of the interviews. Prompts wereused where needed to explore the systemic factors; forexample: “At a systems level, what fosters/limits buildingand/or maintaining such collaborations (Prompts: social,economic, political, health environments, policies; fund-ing structures; legislation)?” All interviews were tapedand transcribed verbatim. All procedures were approvedby the researchers’ respective University Institutional Re-view boards and relevant health authorities who havetheir own ethics review boards for studies taking placewithin their jurisdiction.AnalysisWe conducted an interpretive content analysis of theinterview data using procedures for qualitatively deriveddata [17, 18]. Transcripts were repeatedly read by themembers of the investigative team to identify patterns inthe data. NVivo [19] was used to organize and supportcoding and analysis of the data. All authors contributedto coding which started with holistic coding; As moredata were collected and analyzed, coding categories wererefined. Next, provincial teams independently codedassigned transcripts before meeting with the full team.Following the practice of using conventional groundedtheory analytic techniques as pragmatic ‘tools’ in inter-pretive qualitative inquiry, the process of constant com-parison [20] guided the analyses of this study since theaim was to explore and uncover commonalities and pat-terns, and to understand social phenomena [16, 18, 20].After this first-level coding was conducted, the team cat-egorized these codes into second-level codes or patterncodes and generated a draft code book [21]. All tran-scripts were coded by at least two members of the re-search team.We examined the frequency of “sources” (individualtranscripts) as well as references (coded text excerpts)within sources to assist in deriving the factors. Matrixqueries were conducted in NVivo to determine anypotential differences by sector and province and iden-tify potential relationships between codes at the sys-tems level. “NEAR content” matrix queries were usedto identify text passages in which text was coded asone factor and located ‘near’ text coded for anotherfactor. Data from these searches were then examinedto explore potential relationships among the codes. Amanual search of these text passages was done to findpotential quotes that showed the presence of relation-ships between factors.ResultsWe conducted a total of 70 in-depth interviews with 74participants who were working in either PC (n = 33), PH(n = 32), both sectors (n = 7), or neither sector (n = 2).Those who reported not working in either sector werehealth services researchers or educators. Participantroles were diverse, and included direct service providers(n = 17), senior program managers (n = 14), executive of-ficers (n = 11), and middle managers (n = 10). The major-ity of participants were women (n = 58) with similarnumbers of interviews being completed across BC (n =20), ON (n = 19), and NS (n = 21). The remaining partic-ipants (n = 14) were working in or knowledgeable aboutcollaborations in PH and PC but were located in otherCanadian provinces, or working at a national level.Our analysis suggests there were a total of seven sys-temic factors that influence collaboration: 1) health servicestructures; 2) funding models and financial incentives; 3)governmental and regulatory policies and mandates; 4)power relations; 5) harmonized information and commu-nication infrastructure; 6) targeted professional education;Table 1 DefinitionsPrimary care: “…the crucial foundation of a health care system; Keyfeatures of primary care include the first point of entry to a health caresystem, the provider of person-focused care (not disease oriented) overtime for all but the most uncommon conditions and the part of thesystem that integrates or co-ordinates care provided elsewhere or byothers.” [2]Public health: “…an organized activity of society to promote, protectand improve, and when necessary, restore the health of individuals,specified groups, or the entire population. It is a combination ofsciences, skills, and values that function through collective societalactivities and involve programs, services, and institutions aimed atprotecting and improving the health of all people. The term “publichealth” can describe a concept, a social institution, a set of scientific andprofessional disciplines and technologies, and a form of practice. It is away of thinking, a set of disciplines, an institution of society, and amanner of practice. It has increasing number and variety of specializesdomains and demands of its practitioners [and] increasing array of skillsand expertise.” [32]Collaboration: “a recognized relationship among different sectors orgroups, which have been formed to take action on an issue in a waythat is more effective or sustainable than might be achieved by [anyone group or sector] acting alone.” [32, 33]Wong et al. BMC Health Services Research  (2017) 17:796 Page 3 of 10and 7) formal systems leaders as collaborative champions.Table 2 lists the influencing factors, from most to leastcommonly occurring, and the differences found amongprovinces, and between PC and PH sectors, arehighlighted and discussed further below.Health services delivery structures that promote PC andPH collaborationBoth PC and PH participants discussed the import-ance of health services structures in promoting col-laboration. However, queries by province suggest thatBC participants perceived this factor as more import-ant than either ON or NS participants. Three ele-ments in this factor include: infrastructure to supportcollaboration, structures and mechanisms for publichealth and primary care to transcend silos, andshared PC PH portfolios. All elements were expressedas barriers to collaboration. Ministries of Health pur-posely created structures that provided opportunitiesfor collaboration. For example, mandatory reportingof sexually transmitted infections that requires partnernotification, and the provision of immunizations, areareas where structures already exist in the three prov-inces. What promotes collaboration between thesetwo sectors are mechanisms for who (e.g., PH nurseor PC office) will complete the partner notification orexplore benefits of collaboration in the case ofimmunizations.Participants noted that having a clear governancestructure and mechanisms that align with provincial di-rections on collaboration can facilitate stronger linksbetween the PC and PH sectors. This participant de-scribed important structural configurations, two depart-ments in the provincial government, that reinforce silosand may prevent collaboration,“I am quite closely associated with PC, with theirpolicy advisor, and also traditionally probably wasn’tas closely aligned with PH in just the way theorganization works within government… we have the 2departments which has been a little bit of a challenge.The Department of Health which looks after PC,preventive care. A lot of things that we would callwithin PH. You know, illness prevention and PC,primary healthcare prevention, that sort of thing.Public safety and infection prevention, diseaseprevention, that focuses a little bit more on the variousdeterminants of health. Some of that sits over atHealth Promotion and Protection. As we are fond ofsaying, 2 departments, 1 system.” [NS 16]Moreover, participants suggested that provincially man-dated governance structures at regional or local levels ex-plicating a team-based approach, or policies to providedirection on implementing models of care that support in-terprofessional collaboration, would be helpful. Whilethese kinds of local structures exist in ON (e.g. FamilyHealth Teams), they remain relatively scant in BC and NS.Funding models and financial incentives supportingcollaborationMany participants discussed the important role of fund-ing and financing in facilitating collaboration betweenTable 2 Systemic factors influencing public health and primary care collaborationFactor [add row] Health service deliverystructuresElement [add row] Infrastructure to support collaboration (e.g. Information Technology, physicalspace);Opportunities for PC and PH to transcend silos (e.g. inter-branch/divisions/department committees);Shared PC PH portfoliosFunding models and financial incentives Increased/sufficient allocation of financial resources for collaboration;Alignment of funding models and incentives for public health and primary care collaboration;Potential strategies of funding collaboration (e.g., secondments, incentives, fee codes)Governmental and regulatory policies andmandates for collaborationExpectations that partners are essential;Clear governmental policies, mandates for collaboration;Consistency of standards around collaboration for public health and primary care;Expectations/accountability for reporting on collaborations using common quality indicatorsPower Relations Leveling the playing field;Turf protectionHarmonized Information and CommunicationInfrastructureClear and effective information and communication infrastructures;Interoperable public health and primary care communication systems and electronic record systems(Electronic Medical Record; Electronic Health Records)Formal Systems Leaders as CollaborativeChampionsIdentification and formalization of systems leaders;Leadership for collaboration;Long-term strategy for collaboration;Leadership understanding of benefits of collaboration.Targeted Professional Education: Educating new professionals for collaboration between public health and primary care;Continuous professional development for collaboration between public health and primary careWong et al. BMC Health Services Research  (2017) 17:796 Page 4 of 10PC and PH. Both BC and ON participants discussed thisfactor more than NS interviewees and PC participantsdiscussed funding and incentives more than their PHcounterparts. We categorized three elements for this fac-tor: increased/sufficient allocation of financial resourcesfor collaboration; alignment of funding models andincentives for PC and PH collaboration; and potentialstrategies of funding collaboration.Participants recognized that additional financial re-sources could strengthen collaboration between PC andPH. Provincial funding used for paying health profes-sionals to work together in the health care system wasone suggestion to support collaboration. Participantsalso discussed how funding new staff positions, wherepart of the role would be to increase collaboration pur-posefully, could create systemic changes in the deliveryof health services. As one participant stated,“it [collaboration] happens because someone is willingto pay for it and willing to support the infrastructureto make it happen…you are not going to getpharmacists in physician offices unless they are paid”[NS 13]Another example is the willingness of provinces to payfor and position nurses within PC practices to increasecollaboration with PH, as well as deliver PH services.Participants discussed the importance of funding beingaligned with provincial, and less often federal, policies.Provincial policies, such as the implementation of nursepractitioners to deliver PC using a population health ap-proach, create the impetus to flow funding to regionaljurisdictions. This participant speaks of funding becom-ing available to specific health units,“….the nurse practitioners were brought inspecifically…..because that funding became availableto the [public] health unit.… for the pre and postnatalproject that had the nine sites......there was a prettystrong link to the Healthy Babies, Healthy Childrenprogram…..the [provincial] Ministry obviouslysupported with funding.” [ON 15]This quote also suggests a potential strategy for fund-ing collaboration at the systemic level was for provincialministries of health to work with regional jurisdictionsor negotiate with the Federal government (e.g. a federalPrimary Health Care Transition Fund) to allocate fund-ing to support policy related to increasing collaborationbetween PC and PH.Participants recognized that current funding struc-tures, such as fee-for-service (FFS) and salaries for physi-cians, were well established across Canada. However,they suggested funding strategies such as theintroduction of incentive billing codes designated forinter-professional collaboration could enable strongerand more frequent collaboration. Another suggestionfrom PC participants was to provide some combinationof salary and FFS billing to facilitate collaboration. Asthis participant points out, providers need some incen-tive to work together,“the way people are reimbursed is going to be aproblem as far as doctors go in some places…PCphysicians…they aren't going to want to take time outof their day from seeing patients to put an effort intoPC prevention and collaboration if it is going to takeaway from their billing.” [NS 19]The above quote suggests incremental changes (e.g.,incentive billing codes) implemented at the provinciallevel may be able to persuade increased collaborative be-havior of physicians at the intrapersonal level. Moreover,in attempts to strengthen collaboration, it was incum-bent upon the insurer (e.g., the province) to make thebusiness case that FFS health care providers would notbe financially disadvantaged if they were to collaboratewith non-FFS counterparts. Put another way, FFS en-courages individual billing and “efficient” (e.g. visitsshorter than 15 min for each patient) throughputs versuscollaboration to address a patient’s health and healthcareneeds.Governmental & regulatory policies & mandates forcollaborationOntario participants identified the importance of pol-icies and mandates at the provincial level more oftenthan those in BC or NS. Public health participantsdiscussed this factor more frequently than their PCcounterparts. There were four interconnected ele-ments of this influencing factor: expectations thatpartners are essential; clear governmental policies,mandates for collaboration; consistency of standardsaround collaboration for PC and PH; andexpectations/accountability for reporting on collaborationsusing common quality indicators.Participants identified an increased need for govern-ment policies mandating collaboration between PC andPH. Leadership at the provincial level is necessary to de-liver a vision of collaboration and partnerships forjurisdictional (e.g., health authorities) policies andmandates to be influenced. As one participant notes,provincial governments can support collaboration byproviding direction on how they would see organizationsworking together,“…provincial policy…different branches with thatministry have to really believe in this and support it.Wong et al. BMC Health Services Research  (2017) 17:796 Page 5 of 10Write policy that says these organizations are going towork together….really important that the provincialpolicy be supportive...allowing it to happen rather thanputting up road blocks.” [ON 02]In addition, participants identified that the divisionswithin the provincial ministries responsible for PC andPH service delivery need to develop consistent stan-dards to strengthen collaboration. Participants providedexamples of PH nurses and nurse practitioners caringfor patients who had a regular PC provider but wereunable to access needed health services or were beingseen by PH for another issue (e.g., immunization).Whereas the PH standard was to communicate withPC, no such standard to exchange information existedwithin PC.Participants also suggested the government couldunderstand whether collaboration was occurring at thesystem level by measuring and reporting the degree towhich PC and PH were improving health system and pa-tient reported outcomes together,“…it is possible the linked database allows us…a fairamount of opportunity to measure and…..[monitorcollaboration], we don't use that enough…there aregreater opportunities for evaluating the effectiveness ofthe current system……of bringing people together in anew way.” [BC 03].In making system changes for collaboration, partici-pants expected there be evaluation of whether thesechanges were beneficial.Power relationsStructures at the systemic level, meant to improve thehealth of the population, decrease or increase powerstruggles between the two sectors. Participants in BCdiscussed systemic power relations more often than ei-ther ON or NS interviewees, and discussed this fac-tor similarly between PC and PH. Power relationsbetween PC and PH act as a strong force to keep thestatus quo, thus presenting barriers to collaboration.Two elements were evident: leveling the playing fieldand turf protection.The disparity in resources between PC and PH perpet-uates service delivery and workforce silos. Provincialministries of health have tried to address unequal distri-bution of power (resources and funding) by creating po-sitions in which the portfolio includes responsibilitiesand oversight of service delivery or program implemen-tation in both PC and PH. The following quoteillustrates the day-to-day differences between thesehealth sectors with respect to health human resourcesand funding,“PH and PC don't really have a level playing field interms of funding, public image and…attention…for anykind of collaboration it's nice for there to be equalpower…the PC system has a lot more money and a lotmore people than the PH system does” [ON 13].Both the PC and PH sectors enact power to protectwhat they see as their turf. In the case of delivering fluvaccine or immunizations, both sectors feel responsiblefor delivering these services,“It’s [using PH to deliver immunizations] usuallycheaper, it’s a better way to go but, you know, a lotof family docs don’t want to give up on what theysee as a fundamental part of PC….so you’ve got acombination of turf wars and funding wars and sortof reporting record keeping, administrative wars.”[BC 06].This quote illustrates the need for PC to protect itsability to deliver this kind of service since it is tied to an‘easy’ source of funding (versus billing for working withpatients who have multiple chronic conditions) andmeets their goal for delivering health prevention. In thiscase of a dual provider system, that both PH and PC de-liver immunizations, power is enacted through turf pro-tection, separate information systems and funding splitbetween PH and billings in PC. Systemic challenges tocollaboration are exacerbated by factors such as lack ofshared space and irregular communication.Harmonized information & communication infrastructureThe systemic influence of having an information infra-structure and mandates for using different modes ofcommunication was important. Having a harmonized in-formation infrastructure was most frequently discussedby BC and PC participants. There were two elements inthis theme: clear and effective information andcommunication infrastructures and interoperable PC andPH electronic record systems.Each sector’s ability to use existing communicationand information infrastructures influenced collaboration.Participants used technology (e.g., email, fax) and struc-tured communication forms such as SBAR technique(Situation, Background, Assessment Recommendation),to try and increase the exchange of clear and effectiveinformation. Systemic investment in information tech-nology systems was required to ensure that the modes ofcommunication for sharing patient information were se-cure and the privacy of the patient was maintained.Participants recognized that the lack of informationsharing between the two sectors could negatively influ-ence collaboration. As one participant pointed out:Wong et al. BMC Health Services Research  (2017) 17:796 Page 6 of 10“[if] physicians would have access in some way toPanorama [public health electronic informationsystem] they could then put their information into it…they have a record of the immunization that theycould access easily at any time.” [NS 02].Interoperability of information systems and use of pro-vincial or pan-Canadian systems was viewed as an op-portunity that could strengthen collaboration. However,many participants thought that since health is governedprovincially, information interoperability was a particu-larly difficult challenge that would need to be addressedat the systemic level within and across jurisdictions.Formal systems leaders as collaborative championsHaving leadership at the provincial (system) level was im-portant in promoting collaboration. This theme was dis-cussed similarly amongst ON and NS participants butmore frequently by participants in BC. PH participantsdiscussed the need for formal system leaders more fre-quently than PC participants. Four elements captured thedialogue of participants including: identification andformalization of systems leaders; leadership forcollaboration; long-term strategy for collaboration; andleadership understanding of benefits of collaboration. For-malizing system leaders through an appropriate govern-ance structure at the provincial level to supportcollaboration between PC and PH was important. Thisquote captures participants’ perceptions on an environ-ment unable to nurture collaboration,“it requires a great deal of wisdom at the level of theminister to make sure that people are assured. And I… I just don’t think that our political system enablesthat to happen at the moment.” [ON 10 PC]Participants noted the lack of a long-term strategy, ei-ther at the provincial or federal level, for strengtheningcollaboration across the two health sectors. Participantsfelt that some leaders were unaware of the tangible ben-efits of systemic collaboration,“You need to have policy change in order to havesystem change. My concern is that the people whoare writing the policy aren’t understanding whatthe real issues are, and they are not making policythat is actually going to change things for people’slives” [NS 05].Moreover, participants were concerned that systemlevel policies or mandates needed direct input fromleaders within both PC and PH in order to be effectivepolicy directors.Targeted professional educationParticipants believed that the system could strengthencollaboration by providing guidance and program leversto influence inter-professional education. This themewas, again, more frequently discussed in BC than theother provinces, although both PC and PH discussed theneed for professional education with similar frequency.There were two elements for this influencing factor:educating new professionals for collaboration between PCand PH; and continuous professional development forcollaboration.Many participants believed both initial and ongoingtraining of health care providers could begin by breakingdown how PC and PH have traditionally operated,“Have a good look at our core education and theeducation system in terms of building that capacityand valuing and understanding…You shouldn't comeinto healthcare if you are not prepared to be in ateam…critical piece - I think the ongoing education…peer review is really important in terms of team work.”[NS 18]Participants believed that providers needed training onhow to work together, in addition to their disciplinaryand sector-specific knowledge, and named several areasthat could be a common base of knowledge, such ashow to collaborate, making good use of technologies(e.g., teleconferencing), respectful communication, popu-lation health concepts, social determinants of health,and team-based care. Participants also suggested moreintegrated academic and real world practice training thatincluded both PC and PH would help facilitate collabor-ation; many suggested that learning about health profes-sional’s scopes of practice issues also needed to beincorporated into provider’s training,“While we are transitioning to a whole new systembecause of shortages with physicians and nurses andall the other health system workers we need to look ata different way of working…what role can thephysicians play in supporting and promoting thatdifferent way of practice” [NS 15].Relationships between systemic influencing factorsWe found relationships between influencing factors atthe systemic level which speaks to the complexity ofthis field of study. Our analysis identified relationshipsbetween several systemic level factors, including:governmental and regulatory policies and mandatesand health care delivery structures that promote col-laboration and formal system leaders as collaborativechampions; health care delivery structures and fundingWong et al. BMC Health Services Research  (2017) 17:796 Page 7 of 10models and harmonized information systems; and in-formation systems and targeted professional education.We present here two quotes of relationships that weremost apparent. This first quote illustrates the relationshipbetween a province-wide mandate and models of servicedelivery structures with accountability for PC and PH col-laboration. This participant suggests a province-widemandate could be more than an invitation to participatebut an expectation of transforming the PC and PH deliv-ery systems to be more integrated,“… I think until we have a complete mandate ……forhealth services to be delivered through family healthteams [in Ontario]…..[only] a hundred and fifty[family health teams exist] is nothing when youcompare to like… Brazil with nearly thirty thousand ofthem…[primary health care] is expected to bedelivered, not simply we invite you to participate byapplying for a grant or whatever…it’s actually makingit an expectation… that if you are going to bedelivering primary health, then you do it through afamily health team, which is collaborative internally first,not led by, you know, a particular quarterback. It’s reallya team. And also it’s required there be… accountability toensure that there’s linkages with PH.” (ON PH)As this participant suggests, different models of servicedelivery that encourage PC and PH collaboration are pos-sible but require governmental policies and mandates.Formal leaders championing these service delivery struc-tures, such as family health teams, can serve as a founda-tion for expectations about what services are delivered,who delivers the services, and how team members withcomplimentary expertise work together.Not surprisingly, health service delivery structures thatpromote collaboration between PC and PH need funding.Without these systemic influences, collaboration occurssporadically at the interpersonal level until there is a pro-vincial or pan-Canadian need to communicate,“… a good example of this was SARS…there was fairlypublic criticism about this, when you’re in the middleof an emergency suddenly you realize that thereactually aren’t harmonized communication vehicles.So, for instance, PH needing to get out messages withregard to the implications for individualpractitioners… And really there isn’t a harmonizedcommunication system to allow for that.” (Nat PH)This quote also points to the need for PC and PH sectorsto receive ongoing education on where to find informationand how to collaborate in areas with common goals (i.e.communicable disease surveillance, prevention, andtreatment).DiscussionOur analysis provides insight into seven common, yetdistinct, systemic level influences across three Canadianprovinces that are clearly interrelated. While all systemlevel factors are important influences, some factors suchas governmental mandates and health service deliverystructures and funding, may be key to building strongercollaboration between PC and PH. The interrelation-ships between the systemic influences provides clues towhat ingredients are needed at a systems level for suc-cessful PC and PH collaboration.Similar to what is reported by Tomoaia-Cotisel et al.[22], the external environment or rather, the systemiccontext of each province, can account for the variationin emphasis of the importance of specific structures.Our results suggest there was some variation in the im-portance of the themes across provinces, where BC par-ticipants more frequently discussed system structuresthat could promote collaboration between PC and PH,power relations, harmonized information and communi-cation structures, formal systems leaders as collaborationchampions and targeted professional education. Ontarioparticipants most frequently discussed governmental andregulatory policies and mandates for collaboration. NovaScotia participants were most frequently in-between BCand ON.Most themes were discussed with similar frequencybetween PC and PH, except where PH more fre-quently discussed the importance of formal systemsleaders and the need for governmental mandates tofacilitate collaboration between the two sectors. Inpart, it could be that PH participants were collectivelyvoicing their concerns that health ministries placemore emphasis on acute care system objectives thanon population health objectives [23]. However, formalsystem leaders could provide opportunities to collab-orate through joint work on policies or reforming thecurrent delivery structures to take advantage of eachsector’s expertise. Primary care and PH sectors, andthose who educate these health professionals, couldbe held accountable through system levers such asfunding and incentives that support educating aboutand delivery of services using collaboration.Indeed, carrying on with “business as usual,” or rather,working in silos seemingly presents no immediate harmsto patients or the population. Yet, the potential forreaching system goals of increased effectiveness, equity,and efficiency are possible by strengthening collabor-ation between PC and PH. At least 50 years of evidencesuggests strengthening primary health care can result inimproved health of the population and decreases inhealth system expenditures due to use of less expensivecommunity-based care compared to acute care [3]. Col-laboration between the sectors could be encouragedWong et al. BMC Health Services Research  (2017) 17:796 Page 8 of 10through governmental vision and policies calling forthem to work together.Undertaking reform to increase collaboration is com-plex. While we present power relations as a specifictheme, it becomes operationalized across many differentfactors, as well as at the systemic, organizational, and in-dividual level. At the systemic level, power relations be-tween the sectors and the lack of disruption in systemicfactors (e.g. teaching health professionals within their re-spective disciplines) acts as a strong lever to keep thestatus quo.Team based models, supported by policy and teachingof health professionals, could be considered a disruptionprocess to power relations. A recent review by Levesqueand colleagues [12] suggests there are potential modelsof care such as Family Health Teams (Ontario, Canada)[24], Accountable Care Organizations (United States ofAmerica) [25], and Multidisciplinary Health Clinics(France) [12] that hold promise for strengthening collab-oration between PC and PH. Notably, the implementa-tion of models of care whose mission is to provideshared PC and PH activities were enabled by systemicfactors such as funding, provincial and national man-dates, and the establishment of formal system leaders.One example of a provincial mandate was found in On-tario where new legislation has been passed [26] to ‘putpatients first.’ It argues for stronger systems integrationand a focus on population health by building strongerlinks between PH and other health services.Limitations of this study emerge from the recruitmentprocess for participants. Since we focused on partici-pants from three Canadian provinces, with the additionof a few informants from other provinces and at a na-tional level, there may have been key informants fromother provinces or territories with suggestions for othersystemic factors needed for successful collaboration be-tween PC and PH. Furthermore, the snowball samplingtechnique may have led to sampling of participants withsimilar views. However, the systemic influences identi-fied in this study were supported by many respondents,and their experiences with these factors were not dis-cussed with similar frequency, indicating that our samplewas representative of people with varied experiences andviews. The reliability of these results was enhanced byinput from of our co-investigators and collaboratorswho were situated in each of the provinces and held po-sitions within primary care or public health. Finally,these factors, except for health service delivery struc-tures and formal systems leaders, were also reported inour scoping review [1].ConclusionOur results suggest there are systemic factors associatedwith successful PC and PH collaboration. More could bedone at the systemic level to strengthen collaborationbetween PC and PH: focusing on having formal systemleaders who champion PC and PH collaboration, shiftingfunding to increase and strengthen collaboration be-tween these two sectors and further implementation ofinterprofessional teams. An assessment of the systemlevel context (i.e., provincial and regional organizationand funding of PC and PH, history of government insuccessful implementation of health care reform, etc.)along with these seven system level influences could as-sist other jurisdictions in moving towards increased PCand PH collaboration.When operating together, PC and PH sectors couldpotentially lead to transformative system learning andchange. The “collaborative advantage” of PC and PHworking together, where benefits accumulate from agroup working together on a common goal [27], cannotmaterialize without systemic support in training futuregenerations of clinicians. Notably, collaboration is con-sidered to be an overarching, requisite process in effect-ive clinical practice [28], in addition to successfullycarrying out inter-professional education [29, 30]. Tar-geted education that includes attention to power dynam-ics, co-creation of actionable knowledge [31] and usingeach other’s existing knowledge [9] needs to be sup-ported by additional infrastructure such as universitycurricular changes and health systems investing in col-laborative learning communities of practice.AbbreviationsPC: Primary care; PH: Public healthAcknowledgementsWe would like to acknowledge the respondents, the many researchassistants who helped with the data collection, coding and managementprocess, and Dr. Nancy Murray and Ms. Patricia Austin who coordinated theoverall project.FundingThis study was funded by the Canadian Health Services Research Foundation(# RC2–1604-06) in partnership with: the Michael Smith Foundation forHealth Research; Health Services & Policy Research Support Network;McMaster University; Public Health Agency of Canada; Canadian PublicHealth Association; Central zone (formerly Capital Health Authority), NovaScotia; Hamilton Niagara, Haldimand Brant Local Health Integration Network;Huron County Health Unit; Somerset West Community Health Centre;Registered Nurses Association of Ontario (RNAO), and Victorian Order ofNurses Canada. M. MacDonald was supported by a CIHR/PHAC AppliedPublic Health Chair Research award (Grant No. 92365) during the time thisstudy was conducted.Availability of data and materialsThe datasets used and analysed during the current study are available fromthe nominated principal investigator, Dr. Ruta Valaitis on reasonable request.Authors’ contributionsAll authors were involved in data collection, analysis, writing, critical revisionand conceptualization of the manuscript. SW, MM, RV completed theanalysis; RMM, DM-S, LO’M were involved in the interpretation of the results.All authors read and approved the final manuscript.Wong et al. BMC Health Services Research  (2017) 17:796 Page 9 of 10Ethics approval and consent to participateThis study was approved by the following ethics boards:Ontario: McMaster University = (previously named: McMaster UniversityHamilton Health Sciences/Faculty of Health Sciences Research Ethics Board);Renamed: Hamilton Integrated Research Ethics Board (HiREB) and Queen’sUniversity = Health Sciences and Affiliated Teaching Hospitals Research ethicsBoard (HSREB).British Columbia: University of Victoria/Vancouver Island Health Authority(Human Research Ethics, University of Victoria) = University of Victoria/Vancouver Island Health Authority Joint research Ethics Sub-Committee;Vancouver Costal Health Research Institute (Vancouver Community) = Van-couver Costal Health Research Board; University of British Columbia = TheUniversity of British Columbia: Behavioural Research Ethics Board (BREB).Nova Scotia: Dalhousie University = Health Sciences Human Research EthicsBoard; Capital Health Research Ethics Board, Halifax, NS = Capital HealthResearch Ethics Board; Guysborough Antigonish Strait Health Authority =Guysborough Antigonish Strait Health Authority Research Ethics ReviewCommittee; South Shore Regional Hospital = South Shore Regional HospitalEthics Committee; Pictou County Health Authority = Pictou County HealthAuthority Research Ethics Board.Consent for publicationAll participants provided their consent to participate in this study.Competing interestsThe authors declare that they have no competing interests.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Author details1School of Nursing, University of British Columbia, 2211 Wesbrook Mall, T161,Vancouver, Canada. 2Centre for Health Services and Policy Research,University of British Columbia, 201-2206 East Mall, Vancouver, Canada.3School of Nursing, University of Victoria, HSD B220, 3800 Finnerty Road,Victoria, BC V8P 5C2, Canada. 4Dalhousie University, Room G26, Forrest Bldg.,5869 University Avenue, PO Box 15000, Halifax, NS B3H 4R2, Canada. 5Schoolof Nursing Health Sciences Center Room 3N25E, McMaster University, 1280Main Street West, Hamilton, ON L8S 4K1, Canada.Received: 6 February 2017 Accepted: 14 November 2017References1. 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