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Organizational factors influencing successful primary care and public health collaboration Valaitis, Ruta; Meagher-Stewart, Donna; Martin-Misener, Ruth; Wong, Sabrina T; MacDonald, Marjorie; O’Mara, Linda Jun 7, 2018

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RESEARCH ARTICLE Open AccessOrganizational factors influencingsuccessful primary care and public healthcollaborationRuta Valaitis1* , Donna Meagher-Stewart2, Ruth Martin-Misener2, Sabrina T. Wong3, Marjorie MacDonald4,Linda O’Mara1 and The Strengthening Primary Health Care through Primary Care and Public Health CollaborationTeamAbstractBackground: Public health and primary care are distinct sectors within western health care systems. Within eachsector, work is carried out in the context of organizations, for example, public health units and primary care clinics.Building on a scoping literature review, our study aimed to identify the influencing factors within theseorganizations that affect the ability of these health care sectors to collaborate with one another in the Canadiancontext. Relationships between these factors were also explored.Methods: We conducted an interpretive descriptive qualitative study involving in-depth interviews with 74 keyinformants from three provinces, one each in western, central and eastern Canada, and others representing nationalorganizations, government, or associations. The sample included policy makers, managers, and direct serviceproviders in public health and primary care.Results: Seven major organizational influencing factors on collaboration were identified: 1) Clear Mandates, Vision,and Goals; 2) Strategic Coordination and Communication Mechanisms between Partners; 3) Formal OrganizationalLeaders as Collaborative Champions; 4) Collaborative Organizational Culture; 5) Optimal Use of Resources; 6)Optimal Use of Human Resources; and 7) Collaborative Approaches to Programs and Services Delivery.Conclusion: While each influencing factor was distinct, the many interactions among these influences areindicative of the complex nature of public health and primary care collaboration. These results can be useful forthose working to set up new or maintain existing collaborations with public health and primary care which may ormay not include other organizations.Keywords: Primary care, Public health, Organization, Collaboration, Partnership, Health care sectorBackgroundPrimary care [PC] and public health [PH] are viewed asdistinct sectors within the health systems of western so-cieties including Canada [1]. Canadian researcherspropose that better integration between PC and PH isnecessary for a more effective primary health care sys-tem to improve health and social outcomes [2]. Othernations have similar aims [3, 4]. In 2012, in the U.S., areport was released calling for better integration of pri-mary PC and PH services arguing that:the integration of primary care and public health couldenhance the capacity of both sectors to carry out theirrespective missions and link with other stakeholders tocatalyze a collaborative, intersectoral movement towardimproved population health. [5] p.1.Most discussion papers that promote greater integra-tion and collaboration between PC and PH maintainthat the goals of each sector can be supported by theother. PC can act as a source of critical data and clinical* Correspondence: valaitis@mcmaster.ca1School of Nursing, McMaster University, HSc Room 3N25, 1280 Maim StreetWest, Hamilton, ON L8S4K1, CanadaFull list of author information is available at the end of the article© The Author(s). 2018 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.Valaitis et al. BMC Health Services Research  (2018) 18:420 https://doi.org/10.1186/s12913-018-3194-7observation that can highlight health issues of potentialconsequence to PH and its mandate to promote healthand prevent disease as well as improve populationhealth. PH, through its assessment of community andpopulation health risks and needs can inform PC practi-tioners of things to look for in their patients, subse-quently assisting in differential diagnoses and improvedpatient care [2, 6, 7]. Others acknowledge synergies inhealth promotion that can occur when education withinPC settings aimed at behavioural changes to promotehealth is combined with PH strategies for creating sup-portive environments that enable healthy life styles andreduce environmental risks [8]. DeVoe and colleagues[9] discuss opportunities for PC and PH collaborationsto jointly address the social determinants of health.In 2013, a special issue of the journal HealthCare Pa-pers indicated a continuing interest by influential leadersin Canada for building stronger collaboration betweenPH and PC sectors [10, 11]. Various influences that im-pact collaboration between PC and PH sectors presentedwithin the international literature are discussed within ascoping review [12]. However, within this discussionthere is limited substantive evidence about the importantinfluences on successful PC and PH collaboration, howthese influences relate to each other, and the mecha-nisms occurring within these relationships.We report here on one of five studies conducted in aprogram of research [13] – Strengthening PrimaryHealth Care through Primary Care and Public HealthCollaboration. The program of research was guided byan ecological framework [14] describing three categoriesof determinants for inter-organizational collaborationsincluding systemic, organizational, and interactionallevels. This paper focuses specifically on factors that in-fluence PC and PH collaboration at the organizationallevel in the Canadian context. Our results can informcollaboration in countries with similar health care sys-tems. Here, organizational level influences refer to influ-ences at the local or regional level within the context ofan organization, large or small. Whereas, systemic levelinfluences are at a national or provincial level such asministry policies, strategic directions, and funding.Organizational influencing factors can be thought of asoperational attributes, processes or conditions within anorganization. Organizational factors affecting collaborationcan include, “structure and philosophy, team resources andadministrative support, as well as communication and co-ordination mechanisms” [14] p.138. Our scoping literaturereview identified five major organizational influences oncollaboration between PC and PH [12]. They included: lackof a common agenda; knowledge and resource limitations;leadership, management and accountability issues; geo-graphic proximity of partners; and shared protocols, toolsand information sharing. No research papers were found inour review that specifically explored influences on PC andPH collaboration. However, we extracted factors from re-sults and discussions of papers reporting on collaboration.The present study contributes new knowledge by validatingour previous review findings and delving deeply into factorsexplicitly influencing organizational influences on PC andPH collaborations supported by experiences of key infor-mants in PC and PH. It also explores mechanisms that helpto explain relationships between influencing factors.Within Canada, the organizational environment of PCand PH varies depending on the province or territory. Forexample, Ontario (ON) has public health units while NovaScotia (NS) and British Columbia (BC) have regional healthauthorities that provide public health programs and ser-vices. There are a variety of PC delivery models in eachprovince [15–17]. In ON, there are 11 models of primarycare delivery, such as solo physician practices, communityhealth centres, nurse practitioner-led clinics, and familyhealth networks. In BC, PC is mostly provided by physi-cians in solo and group family practices with some inte-grated health networks, and less commonly, healthauthorities also delivery PC through community health cen-tres, and specialized clinics (e.g., youth health, STI diagnosisand treatment) often by nurse practitioners. NS predomin-antly has solo and group physician practice models butthere are a growing number of interdisciplinary teams,particularly in rural areas. Furthermore, in some instances,PC and PH working spaces and regional reporting account-abilities are shared, while in others, each sector is visiblyand operationally its own entity [6, 15]. This diversity cre-ates a rich naturalistic opportunity for further defining theorganizational factors influencing PC and PH collaboration.This paper explores: what structures and processes do PCand PH stakeholders perceive influence successful collabor-ation between PC and PH? Table 1 provides our definitionsof PC, PH, and collaboration.MethodsWe conducted an interpretive descriptive qualitativestudy, which is a methodology developed specifically toconduct practice-oriented research in health care [16, 17].It involves descriptions and interpretations about aphenomenon from the perspectives of those who havelived it, in this case, those who have been involved in PHand PC collaborations. Interpretive description was anappropriate methodology for our purposes because itseeks to develop understandings of practice phenomena(e.g., PH and PC collaboration) that “illuminate their char-acteristics, patterns, and structure in some theoreticallyuseful manner” [17] (p. 6).We applied a purposive sampling approach [18] to en-sure representation across disciplines, roles, and sectors.Using snowball sampling, we recruited policy makers,managers, and direct service providers in PC and PH,Valaitis et al. BMC Health Services Research  (2018) 18:420 Page 2 of 17and from a variety of disciplines. Recruitment was doneby email with a letter of consent attached; agreement toparticipate was deemed as consent. Key informants werefrom three provinces (BC, ON, and NS) and representa-tives of national organizations. No one refused to par-ticipate, however, a few did not respond to invitations.We continued to invite participants and send remindersuntil we reached comparable levels of participation fromeach sector and province. Although we did not closelytrack the number of those approached for participation,we obtained our sample easily. Some participants wereonly approached once and then not pursued since wehad reached our target.Seventy-four key informants participated including: BC(n = 20; 27.0%); ON (n = 19; 25.7%); NS (n = 21; 27.0%);and national organizations, government, or associations(n = 14; 18.9%). Of these 74 participants: 78.4% werefemale; 43.2% worked in or were responsible for PC,44.6% worked in or were responsible for PH, 9.5% repre-sented both sectors, and 2.7% worked in neither and wereresearchers or leaders in professional associations orinvolved with national policy. Table 2 reports the partici-pant breakdown by sector and region and Table 3 showstheir role and discipline. Participants had 5 to 40 years ofexperience in healthcare; 68 % had over 20 years.Forty-five to 90 min interviews took place by phoneguided by a semi-structured interview guide (seeAdditional file 1). A core question was “Why do you thinksome collaborations between PC and PH have workedwhile others have not?” Prompts were used to explore sys-temic, organizational and interpersonal factors. Interviewswere audio-taped, transcribed, cleaned and anonymized.Researcher co-leads in each province included one PCand one PH expert [LO, DMS, MM, RMM, RV and SW].Each provincial team collected their province’s data andthe ON team conducted interviews at the national level.There were a few instances in which interviewers had pastrelationships with interviewees due to the relatively smallprovincial PH communities. Where this occurred, theirdata were analysed by another team member. All authorshave extensive experience in conducting qualitative andpublishing qualitative research and research staff hadqualitative coding experience.Coding was supported with NVivo 10 software [19].Following a careful reading of interview transcripts, twowere coded independently by two researchers. First levelcodes were then categorized into second level codes[20], to create a first draft of a code book. Provincialteams then independently coded another subset of tran-scripts before meeting with the full team.We used an interpretive thematic analysis approach[16, 17, 21] drawing on the constant comparativemethod of grounded theory [22] for inductive codingand analysis because it allows both description and inter-pretation as analysis proceeds through first level codingto developing categorizations and interpretations ofthese categories at higher levels of abstraction. A finalcode book was created through multiple full team meet-ings where consensus was reached. The code book in-cluded three levels of coding including: first level nodes(e.g., information systems for sharing data) which werecollapsed into elements (e.g., effective communicationstrategies) followed by influencing factors (e.g., strategiccoordination and communication mechanisms).Saturation was reached at the level of the elements.Credibility of our analysis was supported by memoing,constant comparison, and continual evaluation with thefull team. These techniques helped to expose influencingfactors and relationships among them. Matrix queries inNVivo 10 were used to examine potential cross-sectoraland cross-provincial differences. Queries pulled textpassages coded for one influence that were located ‘near’another influence. A manual review of these text pas-sages was conducted to identify potential evidence ofrelationships and mechanisms among the influencingfactors to support our interpretive descriptive approach.Table 1 Definition of TermsPrimary Care:“…the crucial foundation of a health care system, and defines the keyfeatures of primary care as being the first point of entry to a healthcare system, the provider of person-focused care (not disease oriented]over time for all but the most uncommon conditions and the part ofthe system that integrates or co-ordinates care provided elsewhere orby others.” (Starfield, 1998)Public Health:“…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, andvalues that function through collective societal activities and involveprograms, services, and institutions aimed at protecting and improvingthe health of all people. The term “public health” can describe aconcept, a social institution, a set of scientific and professionaldisciplines and technologies, and a form of practice. It is a way ofthinking, a set of disciplines, an institution of society, and a manner ofpractice. It has increasing number and variety of specializes domainsand demands of its practitioners [and] increasing array of skills andexpertise” (Public Health Agency of Canada, 2008) p.13.Collaboration: is defined as: “a recognized relationship among differentsectors or groups, which have been formed to take action on an issuein a way that is more effective or sustainable than might be achievedby [any one group or sector] acting alone.” (Public Health Agency ofCanada, 2008). p.9Table 2 Provincial Representation of Participants by SectorSector BCn (%)ONn (%)NSn (%)Nationaln (%)Totaln (%)PC 10 (50.0) 9 (47.4) 10 (47.6) 3 (21.4) 32 (43.2)PH 10 (50.0) 10 (52.6) 10 (47.6) 3 (21.4) 33 (44.6)PC and PH 0 (0) 0 (0) 1 (4.8) 6 (42.9) 7 (9.5)Neither 0 (0) 0 (0) 0 (0) 2 (14.3) 2 (2.7)TOTAL 20 (100) 19 (100) 21 (100) 14 (100) 74 (100)Valaitis et al. BMC Health Services Research  (2018) 18:420 Page 3 of 17ResultsInfluencing factors on collaboration at the organizationallevelSeven organizational influencing factors affected or deter-mined the nature of PC and PH collaboration: 1) ClearMandates, Vision, & Goals; 2) Strategic Coordination andCommunication Mechanisms between Partners; 3) FormalOrganizational Leaders as Collaborative Champions; 4)Collaborative Organizational Culture; 5) Optimal Use ofResources; 6) Optimal Use of Human Resources; and 7)Collaborative Approaches to Programs and Services Deliv-ery. Each influencing factor is described by its elements(shown in italics); both are summarized in Table 4. Note-worthy relationships among elements are identified aseach organizational influencing factor is presented. Wealso indicate differences by province and sector whereevident. Quotes are used to showcase influencing factorsindicating the participant’s sector [PC or PH] and province[ON, NS or BC]. ‘Primary healthcare’ is used in quotationswhen it was used by participants to refer to PC. Nationallevel participants or those from provinces outside of BC,ON or NS are identified as ‘national’ along with theirsector where applicable [PC, PH, Both, or Neither].Relationships among influencing factors are addressed inthe final section of results.Influencing factor 1: clear mandates, vision, and goalsClear Mandates, Vision, and Goals was a keyorganizational level influencing factor affecting PC andPH collaboration. Its five elements include: a) clearmandate for supporting collaboration; b) congruent focus;c) formal agreements, d) organizational structures thatenable collaboration, and e) role delineation.Having a clear mandate for supporting collaboration atthe organizational level was an important element notedby many participants.Together you have responsibility to make this placework. [National/Both].One PC administrator noted that there are mandates inhospitals to collaborate more so than in the communityand highlighted the need to strengthen this imbalance:So organizationally, collaboration became a mandateand became a way of doing things. That hasn’thappened yet in most Health Authorities. And itcertainly hasn’t happened at the community level tothe extent that there is potential. I think that there’sopportunity for the organization and governance ofthings to facilitate that at some point. [NS/PC].Being clear about the mandate of each sector and en-suring that they are well understood by both parties wasalso important. Misinterpretations about each other’smandates seemed to be detrimental to collaboration:If you think population health is [about] acting only ata policy level then you are not going to collaboratewith PC, are you? [NS/PH].This quote reflects a participant’s view that some col-leagues have a narrow view of population health thatignores other actions beyond policy interventions, suchas early childhood development that can improve thehealth and well-being of populations.Similarly, all provinces noted that having a congruentfocus between sectors was an important element forTable 3 Roles and Disciplines of ParticipantsRole Number PercentDirect service providers 17 22.9Senior program managers 14 18.9Executive officers 11 14.9Middle Managers 10 13.5Policy Makers 8 10.9Other (e.g., health educator, coordinator, consultant, researcher) 14 18.9Total 74 100Discipline Number PercentPhysicians 14 18.9Registered nurses (not including public health nurses) 14 18.9Public health nurses 11 14.9Business administrators 8 10.8Nurse practitioners 7 9.5Other professional disciplines (health promoter, dietitian, social worker, epidemiologist, psychologist, public health dentist, etc.) 20 27.0Total 74 100Valaitis et al. BMC Health Services Research  (2018) 18:420 Page 4 of 17supporting collaboration. Health promotion, disease pre-vention and chronic disease management and preventionpractices were described as having “a lot of overlap”[National/Both] between sectors. Each sector, however,takes a different approach when addressing the same issue:The work processes in PC tend to be individual, episodicand, in the case of PH they tend to be quite different interms of the way that the business process works.There’s a lot more group work, there’s a lot more in thefield work and a lot more regulatory [work]. [BC/PH].Because each sector takes a different approach tohealth promotion and disease prevention, recognition ofthis congruent but specialized focus by practitionersfrom each sector can lead to an understanding of thevalue of collaborating to cover the full spectrum ofpractice.Formal agreements were often lacking, but were alsoseen as a way to support collaborations. For example,one collaboration described a MOU:So we have what is called an MOU – a memorandumof understanding – of how we work together. So theMOU says that each partner agrees to put 4 h of servicein on a weekly basis. And from that memorandum, wehave a planning day every year. And so it could be thatPH is going to do some immunizations for us.Table 4 Organizational Influencing Factors and Elements in PC and PH Collaboration: Comparison between Study Results andScoping Review Results [12]Organizational Level Influencing Factors Elements of Each Factor from this Study Comparable Scoping Review Results(Factors and related descriptors)1. Clear Mandates Visionand Goals• Clear mandate for collaboration• Congruent focus• Formal agreements• Organizational structures that enablecollaboration• Role delineationLack of a common agenda• Lack of a common agenda or vision• Different focus• Lack of joint planningLeadership, management and accountability issues• Contractual agreements• Designated staff supportingcollaboration• Supportive job descriptions2. Strategic Coordination andCommunication Mechanismsbetween Partners• Formalized communication processes• Strategic plan development by partners• Coordinated clinical and administrative services• Exchange of client/health informationShared protocols, tools and information sharing• Shared standardized information systems• Shared protocols re: practice, quality assurance,data collection and dissemination3. Formal OrganizationalLeaders as CollaborativeChampions• Ability to move towards a common goal• Leadership buy-in to collaboration• Transformative leadership qualities and skillsLeadership, management and accountability issues• Change management• Optimal functioning of healthcare providers• Stable, diverse teams• Management training for supporting collaborativeteams4. Collaborative OrganizationalCulture• Valuing the work of the other sector• Organizational readiness for collaboration• Avoiding turf protectionLack of a common agenda• Lack of organizational support• Differences in organizational culture• Devaluing PH activities5. Optimal Use of Resources • Investment of resources to initiate andmaintain collaboration• Funding mechanisms• Geographic proximity of partners• Time for working on collaborationKnowledge and resource limitations• Financial Resources• Space limitations• Lack of time for collaborationGeographic proximity of partners• Co-location to facilitate communication,information exchange, trust6. Optimal Use of Human resources • Matched professional skills to needs• Professionals work to optimal scope ofpractice• Organizational mandates enable workingto optimal scope of practice• Flexible, accommodating application ofskill setsKnowledge and resource limitations• Human Resources• Needs assessment skills in PHLeadership, management and accountability• Optimal functioning of healthcare providers• Stable, diverse teams• Administrative support7. Collaborative Approaches to Programsand Services Delivery• Engaged community• Client-centred approach• Inter-professional teams,• Integrated or coordinated programs andservices between public health and primary careLeadership, management and accountability issues• Community based committees with diversemembership• Community engagement• Involvement of multiple professionalsValaitis et al. BMC Health Services Research  (2018) 18:420 Page 5 of 17Participants spoke about the need to develop moreformal working relationships for particular issues, suchas pandemic planning or influenza outbreaks. The au-tonomy and independence of PC physicians was per-ceived to hamper building relationships and subsequentdevelopment of formal agreements to work in collabor-ation with PH. This was related to PC having had a verylong history of being in independent practice.A few participants believed that there wereorganizational structures that enabled collaboration orpresented barriers. Most often PC participants spokeof PH’s large bureaucratic unionized organizationalstructures being a barrier. A PC practitioner noted:The bureaucracy drives me crazy and the inactivity andinability that happens when you get caught up in meetingsand bureaucracy. And you’re unable to act because youare too busy talking about how to reach the sex tradeworker and, what are the attributes of a sex trade workerand, rather than getting out there and actually talking,touching, and making connections. [NS/PC].On the other hand, non-unionized PC environ-ments, such as community health centres, wereperceived to be more flexible in how they managetheir human resources which enable collaborations.A PH participant in NS articulated how role delinea-tion and communicating any differences in roles be-tween PC and PH was essential for collaboration:…if we think about any of the roles where PH and PCintersect. Whether it’s community health assessment,immunization, chronic disease, communicable disease,even emergency preparedness, there are certain pieceswithin each of those that require a PH philosophy anda PC philosophy. And it may be just a matter ofsitting down with each program and having adiscussion with somebody from PC and PH to say,‘okay, what do you do under this heading? What canyou offer?’ This is where you [PC] would come in.This is where I [PH] would come in. [NS/PH].Once roles were defined they were documented in for-mal agreements as noted in an earlier quote. This quotealso illustrates the relationship between the elementsrole delineation – being clear about what each sectorcan contribute - and having a congruent focus - applyingdifferent approaches to disease prevention and healthpromotion but each being congruent with the other.Influencing factor 2: strategic coordination andcommunication mechanisms between partnersStrategic Coordination and Communication Mecha-nisms between Partners has four elements: a) formalizedcommunication processes; b) strategic plan developmentby partners; c) coordinated clinical and administrativeservices; and, d) exchange of client/health information.Formalized communication processes were criticallyimportant for facilitating collaboration in all provincesand sectors. Effective and ineffective communicationprocesses were reported. Having formalized meetings,case conferences, or other communication processes toensure regular opportunities to stay connected was a keyenabler. Agreeing on a common language was alsohighly valued in starting collaborations:Language has played an important role in thedivision of culture between these two groups andso finding common terminology and words thatpeople can live with and the lens that people arebringing to the application of those words has beenvery important in doing translation and in findingjoint projects. [BC/PH].The element, strategic plan development by partnerswas closely linked with formalized communication pro-cesses. Although this element was not raised often in in-terviews, participants saw it as being necessary to ensurecoordination of programs. The relationship betweenthese two elements is illustrated as follows:Everybody communicates, collaborates. Do your gapanalysis. Say ‘this is what we bring to the table’. Share,and then whoever is best positioned to move an initiativeforward does so. And then it is done in cooperation withall the other groups. Then you can pull back and developyour program, and then you come back forward againand say ‘okay, how are we doing’. Rather than thetraditional, which is, develop your own program inisolation of everybody else. [NS/PC].There were a few cases in which PH staff sat on FamilyHealth Teams boards (an ON interprofessional PCteam-based model). A PC provider explained:[PH] are right here when we’re making our most basicdecisions of our governance and vision and whatwe’re looking for, for the following year [ON/PC].Coordinated clinical and administrative services wasidentified as an important collaboration element distinctfrom organizational strategic planning, the former beingmanaged at the program delivery level. The following ex-ample describes how coordination was needed for servicedelivery for vaccine programs involving both sectors:If you’re going to leave it to family docs, you don’tjust say, ‘good luck guys go and do immunization.’Valaitis et al. BMC Health Services Research  (2018) 18:420 Page 6 of 17You have to actually organize getting them thevaccine. You have to organize them reporting whothey vaccinated... [PH/BC].The above quote supports the element – exchangeof client/health information. It was reported in allprovinces, most often by BC participants. This wasoften related to sharing patient information (e.g., in-fant follow up, immunization records) with PH aswell as other partners (e.g., home care). A BC PHphysician explained that:There would be more regularized referrals betweenPC and PH. […] particularly [if you had] more recordsand electronic medical record sharing between thetwo sectors [BC/PH].Not sharing client records was reported more oftenthan sharing. As another physician explained:We had an automatic relationship with [PC], butoften we don’t get reports back from physicians as towhat families they’ve immunized and it makes itdifficult for our records, etc. [BC/PH].A barrier for sharing information was the use of differ-ent forms of documentation:There is data collection by PH that we could notpiggy back onto. We couldn’t add our notes orassessments [PC/ON].If PC and PH sectors cannot share data, it is difficultto collaborate effectively.Influencing factor 3: formal organizational leaders ascollaborative championsAn important influencing factor supporting collabora-tions is having Formal Organizational Leaders as Collab-orative Champions. This includes the elements: a)ability to move towards a common goal; b) leadershipbuy-in to collaboration; and, c) transformative leadershipqualities and skills. This factor was less commonlyraised by participants compared to other factors; none-theless it was identified by some participants in eachprovince and sector.The element - ability to move towards a common goaldescribes attributes needed by organizational leaders tohave the power to move collaborations forward. Onesuch attribute is the importance of having a vision:So, if the leader doesn’t have a vision of what it’sgoing to look like then they’re not going to lead theway. [PH/ON].Middle and senior level managers were identified asleaders with a role in enabling collaborations:And it’s up to the managers, I believe. That is a key roleof directors, but especially the managers, to create theenvironments to allow that to happen. [NS/PC].Leadership buy-in to the collaboration was viewed asanother significant element in successful collaborations.Having leaders at a senior level who “really believe in it”was essential for collaborations to work, whereas, a lackof leadership buy-in was a barrier. A BC PC participantdescribed wanting to share immunizations records forhis older adult patients with PH nurses, however, the re-gional health authority was unsupportive:[the health authority did not] see [deliveringimmunizations to older adults] as their role. Theydon’t see that there’s any importance to that. And soit really… hampers community-based provision of ap-propriate care to people at risk. [BC/PC].This quote illustrates a relationship between factors.The example illustrates how PC leadership buy-inaround collaboration for immunization data exchangewas obstructed by PH’s organizational mandate that ex-cluded tracking older adult immunizations. Some partic-ipants also noted that it can be challenging whenleadership changes, which can negatively influence thecommitment towards collaboration.Although not explicitly named as such, some partici-pants spoke about transformative leadership qualitiesand skills that were needed to support collaborations:…a more democratic, open, sort of leading from theheart, not just the head type of approach. So theability to put yourself in each other’s worlds andunderstanding where people are coming from. […]And recognizing that everybody has a part to play,and that one role isn’t more important than the other.But all together, we can make such a difference, apositive impact on the outcomes for clients, forcommunities, for populations. [NS/PH].Transformative leaders consider the value brought byeach player within the collaboration to ensure optimumuse of human resources to support collaborations, whichis another factor to be discussed later.Influencing factor 4: collaborative organizational cultureHaving a Collaborative Organizational Culture is an es-sential influencing factor for supporting collaboration atthe practice level. It consists of three elements: a) valuingValaitis et al. BMC Health Services Research  (2018) 18:420 Page 7 of 17the work of the other sector; b) organizational readiness forcollaboration; and c) avoiding turf protection.Valuing the work of the other sector was a strong influ-ence on collaboration, identified as being essential byboth sectors and all provinces. A condition for valuingthe other sector was having an understanding of it. Asone participant explained:There is a lack of respect sometimes for primaryhealthcare providers. If people understood what [PC has]to deal with day-in and day-out and the volume ofwork, there would be more understanding. [NS/PC].PH also felt misunderstood and wanted to increasetheir credibility with their PC partners. One area thatwas misunderstood was related to:…the importance of PH and prevention within thecontext of chronic disease and its management. [ON/PH].PH was also concerned about being perceived ashaving a more passive and undervalued consultantrole rather than a more active role:I think the whole world wants to see PH actuallydo something. PH [has] to show themselves to becredible. And they’re not credible by handing outpamphlets. I think that all PC people are lookingto have a partnership where PH doesn’t seethemselves as a consultant but sees themselvesas a worker […] prepared to get their hands dirty.[ON/PH].Organizational readiness for collaboration was oftenidentified, in all provinces and both sectors, as a positiveinfluence on collaboration. Participants reported severalexamples of existing collaborative working groups.Readiness to collaborate was associated with havingcommon goals and values:… the goals and the principles and values as well areimportant to have, so that people … are thinking ofthings in a similar way. [ON/PC].A lack of readiness was attributed to rigidity ofpractices in PC and PH. This generally related to PCphysicians who were too busy for collaboration, andPH being too structured and unprepared to meetPC’s needs.We would like a PH nurse to come out 4 h a week todo a breast feeding clinic. And it actually got turneddown because they thought if they did it for us, theymight have to do it for other clinics too. [NS/PC].Avoiding turf protection was raised by several partici-pants across sectors and provinces. But most often wasexpressed as PH protecting their turf.When some of our ‘primary healthcare’ people get intoprevention… PH is saying, ‘That is ours.’ [NS/PC].PH’s turf protection was considered by some to be aresponse to their fear of losing resources as captured bythis sentiment:…We [PC] want to work with you. And they say: ‘Justa minute now. I’m a little worried when you say thatbecause typically what that means to me in the past isto come along and take away. Take away our business,take away our resources.’ [Nat/PC].Influencing factor 5: optimal use of resourcesCollaboration is very difficult without adequate fiscal,material and space resources. Given the difficulty experi-enced by both sectors in obtaining resources for collab-oration, any resources that are available must be usedoptimally. Optimal Use of Resources consists of four ele-ments: a) funding mechanisms; b) investment of resourcesto initiate and maintain collaboration; c) geographicproximity of partners; and, d) time for working oncollaboration.Funding mechanisms that support collaboration was acommonly identified concern for PC as well as PH.Unfortunately, in an effort to perhaps reconcile andprotect [PH’s] scarce resources, we are finding apretty strong line about not only what they will do ornot do but what they will even be involved inplanning. [NS/PC].PC practitioners face their own funding constraintswhich dictate what activities they take on creating chal-lenges for PH:So [PH is] not quite sure about how to connect upwith the [PC] system where people don’t work thatway. I mean, of course, [PC does not] pay somebody,they don’t get paid (to collaborate) and so [PH] feelsawkward to try to get to [PC] to loosen up timewhen they’ve got bills to pay and staff to pay and soon. [BC/PC].Funding for collaboration is not ensured in either sector.A related element, investment of resources to initiateand maintain collaboration is required by both sectors.This is a particular challenge for non-salaried PC pay-ment structures, which is explained as follows:Valaitis et al. BMC Health Services Research  (2018) 18:420 Page 8 of 17…if I wanted to bring a PH nurse out to have a homein our clinic 4 h a week, logistically there [are]overhead costs associated. We have computerizedpatient records. So they would need a computer. Theywould need supplies and equipment. The receptionistwould be checking in patients so there is additionalworkload. They would need a phone. And that isbecause they (PC) are private businesses right now.It’s fee-for-service. So they have to pay for everythingthat happens in that clinic. [NS/PC].For PH, resources investments were most often tied totime. As expressed by a health promoter:I think an acknowledgment from management tosenior management to funders of the amount of timeand dedication that it takes to develop, sustain andmaintain collaborations. That’s critical…. to developand sustain. (ON/PH).Geographic proximity of partners was generally de-scribed as an enabler for collaborations:There’s many other small examples of collaboration. Oneof them is the fact that ‘primary healthcare’ and PHadministratively are side by side in the same corridorwhich allows for greater collaboration. [NS/PC].Physical proximity was viewed as a support to buildingrelationships through increased face time that also madefor easier referrals. Although reported less often, geo-graphic distance was viewed as a barrier. Some partici-pants suggested that people need to be in a commonnetwork if not in the same space. Not sharing space ledto inefficiencies:Unfortunately, the nurses that were there were kind ofbopping back and forth between the two placescarrying their records with them. And it just becamevery difficult for them. Ultimately, we would like tohave a one site vision where we would all be in onesite under the same roof. [Nat/PC].Time for working on collaboration was presented as abarrier. Despite being a less commonly identified element,it was noted in each province and sector. Time was neededto get to know and understand the other sector as well ascommunicate with collaboration partners. Time became abigger challenge when working with PC teams in collabora-tions. As noted by a PC business administrator:There’s a cost and energy to that communication. […]thinking that you were, for example, in a communityhealth center and you had a team of eight people. Thenumber of times you have to communicate to be clearis totally different than if you only have two people[BC/PC].Giving time to collaborations has monetary tradeoffsthat need to be acknowledged. For physicians,their income depends on moving clients through theirfee-for-service system. We’ve had more success break-ing down that barrier, if we can provide them withauxiliary staff to support the project. [BC/PH].This relates to the need for dedicated human resourcesto support collaborations - the next factor.Influencing factor 6: optimal use of human resourcesTo enable collaboration in systems with scarce re-sources, it is essential that human resources be used ef-fectively to optimal scope to support the goals and workof the collaboration. Optimal use of Human Resourceshas four elements: a) matching professional skills toneeds; b) professionals working to optimal scope of prac-tice; c) organizational mandates that enable working tooptimal scope of practice; and d) flexible, accommodatingapplication of skill sets.Participants expressed the need to ensure that there arematched professional skills to needs, thereby, ensuring thestaff have the skills required to address the needs that arethe focus of the collaboration. One participant presented anexample of how PC and PH collaborations use a range ofprofessional skill sets to address population health needs:They’re trying to get some synergies out of theprogram. If the PH dieticians end up with somepeople participating in their programs that actuallyneed a little bit more counselling, they can refer themonto the dieticians in Family Health Teams. PHdieticians are a little bit more adept at understandingthe Canadian community health data statistics thatcome out. And so they can interpret those and worktogether to try to address the needs in thecommunity. [NAT/Neither].The element, professionals working to optimal scope ofpractice, requires an understanding of each other’s scopeto maximize the use of human resources:We really want to see PC services delivered accordingto many different models; some based on generalneeds, others on population health needs. So, thatrequires inter-professional collaboration. And theroles of registered nurses in PC and PH really beingwell understood and nurses being able to work totheir full scope of practice. [NAT/BC].Valaitis et al. BMC Health Services Research  (2018) 18:420 Page 9 of 17To ensure optimum scope of practice, participantsacknowledged the need to match professional skills toneeds so that the right people were in the right place atthe right time.Another element, organizational mandates enableworking to optimal scope of practice, means allowingprofessionals to work using the skills for which they arespecifically trained:… one of the things that I think is so positive about‘primary healthcare’ models is that it’s taking thatpressure off one or two providers to do everything foreverybody. But the benefit of that larger team to sharethe responsibility and the patients. I think that is atremendous help to seeing it from again a healthier,more balanced perspective and then you can startthinking about the collaboration. [BC/PH].Flexible, accommodating application of skill sets im-plies a willingness to do what’s necessary to make thecollaboration work:So, sometimes you just got to pitch in and do thedirty work together. And they did it. Those nurseswere incredible that did that. See, that’s not your [job].No one would sign up for that. It was time limitedand they thought [it was] a way of building thepartnership. [ON/PH].Organizational mandates enable working to optimalscope of practice, and, flexible, accommodating applica-tion of skill sets, were identified as related elements thatinfluenced each other. Both elements were further linkedto professionals working to optimal scope of practice asdescribed above. The relationship among these elementswas summarized as follows:So organizational mandates do get in the way ofcollaborative work. We need to know what oursubsequent roles are, absolutely, and what ourboundaries and scope of practice is. But within that,there needs to be flexibility to work with thecommunity. So that dietician wasn’t going to be doingsomething outside of her scope of practice [forexample] to go to this wellness day. And the flexibilityto be able to enable that. It was determined that itwas a good idea to do an 18 month wellness[assessment]… for the PH nurse to be able to go workwith that family practice and not say, ‘No, that is thefamily practice’s thing. They’ve got a nursepractitioner. She can do it.’ [NS/PH].Organizational mandates are identified as a barrier tocollaboration in the quotation above. On the other hand,establishing organizational mandates that encourage col-laboration could ensure that partners work together withpositive outcomes. In summary, organizational policiesneed to allow for flexibility in practice balanced withproviders working to optimal scope of practice, therebyallowing collaborative work to flourish.Influencing factor 7: collaborative approaches to programsand services deliveryThe final influence on PC and PH collaboration is ensur-ing that the approaches to programs and service deliveryfacilitate collaboration. Collaborative Approaches toPrograms and Service Delivery consists of four elements:a) engaged community; b) client-centred approach; c)inter-professional teams; and, d) integrated or coordi-nated programs and services between PH and PC.The element engaged community refers to workingwith communities directly in program planning, devel-opment and delivery. This concept was raised more byPH than PC and by participants in BC compared toother provinces. This element was identified most oftenin relation to working with marginalized populationsand often referred to using community developmentapproaches in collaborative work. Community develop-ment activities that require engagement by communitymembers was identified as a potential strategy for PCand PH collaborations. A NS PHN explained:A lot of PH staff have been trained in communitydevelopment. They could be that [dedicated resource]person who makes the links between all the pieces ofthe system [NS/PHN].A PC physician spoke about leveraging partnershipswith other community organizations, including PH, toapply for funds for collaboration. In addition, engagingcommunity made the most sense where PC and PH bothserved a specific geographic community. As noted byone national level participant:...you have to be able to bring it up to a communityarea level […] So, you need to bring all your clientstogether and then look at what the community needs.[Nat/Both].A client-centred approach is an element identified andapplied by community health centres, which provideinterprofessional care to marginalized populations. Pro-viders in these settings tend to focus on the specificneeds and assets of individuals:It is the whole client focus that is so central to thewhole community health centre way of thinking.[PC/ON].Valaitis et al. BMC Health Services Research  (2018) 18:420 Page 10 of 17This approach was key to PC and PH collaborationbecause the motivation to collaborate then focuses onclient-centred health goals that are understood and com-mon in both sectors.Inter-professional teams is another element for effect-ive collaboration acknowledged in all provinces and bothsectors, although it was not commonly reported. PC andPH participants described inter-professional teams intheir organizational contexts that could support collabo-rations. In BC, participants commented on the historicallack of resources and supports for team formation andnew mandates for them to work inter-professionally. Afew commented that PH staff such as health promoters,PH nurses, and epidemiologists could contribute to PCthrough potential secondments. Some felt that it wouldbe easier to collaborate with teams rather than inde-pendent practitioners:I would assume that in Family Health Teams,particularly where there are more disciplines that arerepresented, that the coordination and collaborationwith PH is probably easier than in those family healthteams that only have physicians or nurses [PH/ON].The final element for this category of influence on collab-oration is the appeal of integrated or coordinated programsand services between PH and PC. Although this was de-sired, most participants reported that in reality the twosectors work in silos rather than in an integrated fashion:If you were meeting with [PH] and saying: ‘We havethis set of population, these people. Who could dowhat to serve those people best?’ But I think we arestill very much in our own little silos [NS/PC].Some participants spoke about the need for incentivesto increase the development of integrated or coordinatedprograms and services:…you have to incentivize getting group practicestogether. And I think one of the ways you canincentivize a group practice is by providing to a grouppractice PH services. But that will require anexpansion of PH services to be able to meet a growingdemand. [BC/PH].In summary, engaging clients, ensuring a client-centredapproach, using inter-professional teams and building in-tegrated programs can help ensure that a collaborativeculture exists to support successful collaborations.Relationships among influencing factorsAll seven organizational influencing factors were foundto interact with each other although some were notedless often in our data. For the sake of brevity, we onlyhighlight interrelationships among influencing factorswhere they were most apparent in our results (Fig. 1)and pose possible mechanisms that explain theserelationships. Clear Mandates, Vision, and Goals (influ-encing factor 1) interrelated most readily with all otherfactors. The relationship between this factor and Stra-tegic Coordination and Communication Mechanisms(influencing factor 2) is described as follows:...if you start with the leadership and the vision thenyou need to have your processes in place. Having ateam that’s knowledgeable enough to know whatneeds to be integrated. What would promotecollaboration, like the agreement that we talked about,Fig. 1 Commonly reported relationships among influencing factors for primary care and public health collaborationValaitis et al. BMC Health Services Research  (2018) 18:420 Page 11 of 17or having the same phones, the same computersystem for their whole information technology thatpromotes collaboration. [Nat/Both].The above quote illustrates that having a ClearMandate, Vision and Goals for a collaboration is re-quired to support the development of Strategic Coordin-ation and Communication Mechanisms to support thecollaboration to move forward thus identifying the tem-poral nature of the relationship between these factors.The following example further illustrates the nature ofthese interrelationships and how the first influencingfactor drives the second.[Having] a common vision, identified common goals.If there were a collective of primary caregivers aroundthe local [PH] unit, [and] there was an agreement thatlow birth weight rate in the city that you live in wouldgo from six to five or seven to five or whatever, withcommon planning, that would work. [ON/PH].This quote illustrates how having a congruent focus,an element of the influencing factor, Clear Mandate,Vision and Goal, drives joint decision-making to setmeasureable goals. In turn, this informs joint strategicplanning and coordination processes, an element of in-fluencing factor 2, Strategic Coordination and Commu-nication Mechanisms between Partners). The reverserelationship also exists. For example, lacking StrategicCoordination and Communication Mechanisms cannegatively influence the development of clear goals for acollaboration. A participant explained how strong com-munication mechanisms are needed to develop commongoals to begin a collaboration:People who work in those two different settings arejust oriented to those different approaches. So, tobring them together to solve a mutual concern…and Ithink that’s one of the other issues is that PH and PC,from my experience, have rarely been brought to thesame table to address a common issue. [ON/Both].Clear Mandates, Vision, and Goals (influencing factor 1)was also tied to Optimum Use of Resources (influencingfactor 5) and Optimal Use of Human Resources(influencing factor 6). A business administrator explained:PH has all-embracing vision statements. So I think asboth groups started to think a little more about whatreally is our role and where can we make the greatestimpact, [there was] some kind of refinement of thosevisions and concepts. I think as both realized that towork together that you can no longer be doing the samething. So I think part of it has been driven by resources,not just money, but human resources. And having tolook at just to practice differently, away from the familydoctor, everything - to family practice nurses and prac-titioners. And people were more open to what couldhappen to work better together. [NS/PH].The goals and vision that a collaborative initiallyidentifies often will require revision based on availablehuman resources and flexible, accommodating appli-cation of skills (element of influencing factor 6- Opti-mal Use of Human resources). This relationship alsoworked in reverse:They’ve never had these resources available to themand they’ve not had to think about changing the waythey do business to incorporate other team members.[BC/PC].The new influx of resources forced them to rethinktheir goals and how to work together.Collaborative Approaches to Programs and ServiceDelivery (influencing factor 7) is related to Optimal Use ofHuman Resources (influencing factor 6). This relationshipwas aptly described by a national leader in PC and PH:We really want to see PC services delivered accordingto many different models; some based on generalneeds, others on population health needs. So, thatrequires inter-professional collaboration and the rolesof registered nurses in PC and PH really being wellunderstood and nurses being able to work to their fullscope of practice (Nat/Both).This quote highlights the benefit of working in interpro-fessional teams (element of influencing factor 7) that isleveraged by the use of collaborative approaches, such asorganizational mandates that enable providers to work tooptimum scope of practice, (element of influencing factor6). By promoting an understanding each other’s roles, thiselement also links to valuing the work of the other sector,(element of influencing factor 4- CollaborativeOrganizational Culture). Increasing the understanding ofeach other’s roles and functions can correct negative mis-conceptions and fill knowledge gaps thereby increasingappreciation of the value added by each sector.A BC public health administrator provided an exampleof how the relationship between Optimum Use ofResources (influencing factor 5), Optimal use of HumanResources (influencing factor 6), and CollaborativeApproaches to Programs and Service Delivery (influen-cing factor 4) affect each together.Younger physicians and practitioners in generalcoming out are getting more used to work in groupValaitis et al. BMC Health Services Research  (2018) 18:420 Page 12 of 17practices. […] You have to incentivize getting grouppractices together. And I think one of the ways youcan incentivize a group practice is by providing to agroup practice PH services. But that will require anexpansion of PH services to be able to meet a growingdemand then, and it would require some level offunding. (BC/PH).PC could see how linking PH human capital supportedthrough additional funding could contribute to interpro-fessional and inter-sectoral practice models.A relationship between understanding and valuing thework of the other sector (element of influencing factor 4 -Collaborative Organizational Culture) and geographicproximity (element of influencing factor 5 - Optimal Useof Resources) is illustrated as follows:There’s a complete difference in socialization thatleads to a major barrier in understanding betweenphysicians and other staff. And that is probably themost huge barrier. And then, of course, just the factthat they’re not in the same location [BC/PH].This quote illustrates how the unique socialization ofphysicians, which is exacerbated by physical separationfrom other sectors, isolates disciplines contributing to apoor understanding of one another.Finally, collaborative organizational culture (influen-cing factor 4) was found to be influenced either posi-tively or negatively by the presence or absence ofstrategic coordination and communication mechanismsbetween partners (influencing factor 2). For example, aphysician shared a scenario in which lack of communi-cation and a siloed culture reinforced strong divisionsbetween sectors and programs:You find new stuff and you develop a program aroundit. Unknown to you, you do that [in PH]. But thesame program is also being built or has been built in[PC]. If you are not discussing and communicating,you don’t know that each other has this going on.Once you’ve gotten into it and you start developing it,you develop a certain ownership of it in terms ofprotection, and the empire is built. [NS/PC].The quote also points to turf protection that can result inthe absence of a collaborative organizational culture andstrategic coordination and communication mechanisms.DiscussionParticipants in this study identified seven keyorganizational influencing factors that contribute to thesuccess of PC and PH collaboration. While each influ-ence was distinct, many interactions among factors areindicative of the complex and interconnected nature ofPH and PC collaboration. This study contributes a richunderstanding of these interactions and the potentialmechanisms that are at play. The study also providesspecific examples of how these influencing factors workin PC and PH collaborations, which can be transferredto others planning or working to sustain such collabora-tions. Finally this study validates results from our earlierscoping literature review on PH and PC collaboration[12]. Seven influencing factors identified in this currentstudy aligned with five factors found in our scoping lit-erature review.As seen in Table 4, the results from both studies em-phasized different factors with respect to the hierarchyof influences on interorganizational collaboration, (over-arching factors vs. subordinate elements or themes). Theinfluence of organizational culture, for example, al-though receiving mention in our scoping review, roseabove other constructs to become a separate identifiableinfluencing factor from the perspective of our study par-ticipants. Indeed, an element of the influence, avoidingturf protection, speaks to the dilemma faced by both PCand PH organizations in wanting to collaborate but be-ing challenged to do so when both are reliant on scareresources designated for community health compared tofunding available to institutional health care [10, 15].Turf protection can also arise from the perceived powerthat one organization has over the ‘other’ for resourcesthat are tied to their mandated roles pointing to it.Walker and colleagues [23] explored risk, trust and con-trol in PC partnerships in Australia. These partnershipsaimed to support integration between PC and othercommunity-based organizations. They argue that whenorganizations work collaboratively they give up somecontrol over their actions and expose themselves to theconsequences of other organizations’ activities. This canresult in potential harms or risks that must be managed.Partners are driven to protect what they have, and maysee ‘overlaps’ in their work as counter to their defensefor continued funding [24], rather than as opportunitiesfor collaboration.Other research published since the scoping literaturereview validates and expands on our findings.Organizational influences on collaboration identified inour research and supported by the work of others in-clude: the importance of sharing of health data and com-patible information systems [25–28], and developingmechanisms and structures for coordination andinter-organizational communication [29, 30]. Data shar-ing along with effective communication and coordin-ation structures (influencing factor 2) enabledopportunities for leveraging the distinct strengths ofeach sector. For example, in an immunization campaigncarried out in Colorado [29], PH took responsibility forValaitis et al. BMC Health Services Research  (2018) 18:420 Page 13 of 17a patient recall/notification program, a population healthmeasure, while PC received patients for administeringvaccines, offering individual health care. Despite positivereports in our study as well as other research related tosuccessful exchange of client information, much morework is needed to close the data sharing loop.Sharing of resources to deliver programs (influencingfactor 7) may be an incentive for collaboration [29, 31]although designated or realignment of resources (i.e.,funding) for collaboration (influencing factor 5) are alsoneeded [12, 15, 27–29], as well as human resources tosupport collaborations (influencing factor 6) [5]. Withrespect to optimal use of resources (influencing factor5), geographic proximity or use of shared space wasoften highlighted in the literature as important resultingin synergies for achieving both PC and PH service objec-tives [11, 12, 15]. Clinical services continue to be offeredthrough some PH organizations in Canada includingclinical services for sexually transmitted infections andother communicable diseases, immunization clinics, aswell as maternal child health and travel health services[15, 32]. Quite often these services are provided to highrisk populations or in areas where PC service gaps areevident [6]. Although these are not necessarily collabora-tions with designated PC organizations, they do demon-strate the benefit of clinical services operatingconcurrently with population-based PH programs aspart of a population health strategy. Shared space be-tween PH and PC has enabled opportunities for sharingadministrative and other costs while more appropriatelyassigning and matching human resources to need, henceaugmenting each other’s talents while enabling practi-tioners (e.g., PHNs, nurse practitioners, physicians) tooperate to their full scope of practice [33]. This illus-trates the significant interrelationship between the influ-ences – Optimal Use of Human Resources (influencingfactor 6) and Optimum Use of Resources (influencingfactor 5) and their effects on successful collaboration.The current study supports the view that having aClear Mandate, Vision and Goals for collaboration (in-fluencing factor 1) is a key factor in enabling collabora-tions between PC and PH. How we interpreted thisrequires discussion, however, knowing thatorganizational mandates are influenced to a degree byprovincial standards and Ministry directives that do notnecessarily outline a mechanism for collaboration [34].Another paper from our group (Wong et al., submitted)explores the interactions among systems andorganizational level influences. In a complementarystudy under the same program of research, there weredifferences of opinion among practitioners and govern-ment representatives on the importance of mandates[28]. How organizational mandates are operationalizedlocally was not considered, and may explain some of thedisagreement. What did reach consensus in support ofcollaboration was having a shared vision, as well as ameans of interpreting mandates that allowed for ‘blur-ring of the lines’ between the sectors.As another paper suggests, changes to legislated man-dates at the provincial level can take considerable time(i.e., 10 to 20 years) [24], and are not likely responsive tomore immediate needs and/or opportunities for collab-oration on issues of common interest to both PC andPH. Instead, collaborations reported to be successfulwere often empowered through the ingenuity and con-structive planning witnessed at the local level, targetingspecific health-related activities, and bringing togethercommunity stakeholders beyond PC and PH.In the cases presented in the literature, PC and PHroles are articulated and their specific skill sets and re-sources utilized toward a common objective. Examplesinclude: immunization [29, 31], obesity campaigns [8],infectious disease and syndromic surveillance [25, 27],sexually transmitted infection management [10, 35] anddiabetes prevention [36]. In these examples, a culture ofcollaboration (influencing factor 4) is encouragedthrough an awareness of each other and what each canoffer [5, 12, 35]. This also ties to formal organizationalleaders as collaborative champions (influencing factor 3)at the local level that encourages participation inco-planning initiatives. For example, in New York City,the PH authority worked with the Institute of FamilyHealth representing 26 non-profit health centres, to de-velop a list of health priorities for targeted communities;priorities were then addressed through campaigns(i.e., ‘Take Care New York’) and patient interventionsin a collaboration between the PH authority and PCproviders [25].Two elements under Collaborative Approaches toPrograms and Services Delivery (influencing factor 7),continue to be recognized as contributors to collabor-ation between PC and PH – community engagement,and inter-professional teams or inter-professional collab-oration [5, 6, 37]. Our program of research began withthe WHO’s definition of primary health care, with recog-nition that a true model of primary health care encom-passes more than just designated health care providers,but other sectors that can and do influence the health ofcommunities [38]. Opportunities for this are more likelyto exist within the local context where multiple stake-holders are apt to witness similar concerns, geographicdistances are less of a barrier, and community membersdemand better services through coordinated effort.Broader, more inclusive participatory approaches can beenablers for collaboration between PC and PH in re-sponse to a collective community agenda [5]. That said,aligning PH staff to legislated programs rather than geo-graphically designated neighbourhoods may deter PHValaitis et al. BMC Health Services Research  (2018) 18:420 Page 14 of 17from participating in local community initiatives [28], aconcern also raised in this study.Collaborations in most reported instances in the litera-ture were very purposeful and project-based; agreementsconcerning resource needs and strategies on how toproceed were set out by the partners involved in imple-menting the plan within their own communities. How-ever, for a sustained commitment toward collaboration,formalized relationships could have advantages forencouraging supportive funding, structures andprocesses. As Walker and colleagues [23] point out, for-mal governance structures, contracts, and policies thatenable tracking and rewarding performance in collabora-tions is a way that power among organizations can beexercised to regulate the partnership. Further, as statedin the IOM report [5]:At a minimum, each partner should be committed to ashared goal of improved population health and be willingand able to contribute to achieving that goal. Thecontribution may range from ideas and planningassistance, to financial or human resources, to goods or aphysical space, but ideally will include a shared vision foran ongoing and sustainable relationship and a continualdialogue that goes beyond a single project. (p. 29).As noted in our results, optimal use of resources (influ-encing factor 5) and optimal use of human resources (in-fluencing factor 6) were tied to collaborative approachesto programs and service delivery (influencing factor 7).This may be most true for clinical services or programsoffered by both PC and PH, for example, immunizationclinics [29, 31]; this can also apply to chronic diseaseprevention programs [36]. Based on results from ourstudy and others, opportunities for collaborations areenhanced when resources and staffing are assigned tosupport the collaboration. Palinkas et al. [39] exploredbarriers and enablers in the provision and sustainabilityof a collaborative care model in PC with mental healthorganizations for underserved populations. Their resultsindicated that added workload for clinical staff, delays ininformation sharing, and lack of resources to sustain theprogram created collaboration barriers. As in our study,PC physicians whose practices follow a fee-for-serviceservice delivery model [15] are often hampered fromparticipating in collaborations whereas PC settings con-sisting of interdisciplinary teams are more apt tooptimize the scope of practice of the different disciplinesthrough selective assignment of staff to collaborativeservice initiatives [6].Notably in the three different provinces participatingin the study, different models of community-based PChave evolved, such as Community Health Centres, withdifferent funding schemes that can enable greatercommunity engagement and consequential collabora-tions with PH and other community partners [6]. How-ever, it is important to note that despite thesedifferences, the influencing factors were seen in all prov-inces with one exception. Engaged community wasraised more often in BC than other provinces whichmay be related to the particular BC key informants whowe included. For example, one participant held commu-nity development in his portfolio. Another possibility isthat community development and coalition building arenoted in BC evidence reviews which are used to guidePH practice.Strengths and limitationsWe conducted a descriptive interpretative qualitativestudy with multiple sites; the biases of individual codersmay have influenced results, although all codingschemes were ratified through discussions amongresearch team members. We used a snowball samplingtechnique which can lead to sampling of participantswith similar views and those who agreed to participatemay have had a natural bias towards the topic. However,although the collaboration influences identified in thisstudy were supported by many respondents, theirexperiences with these influencing factors were mixed –some positive and some negative - indicating that oursample was represented by people with varied experi-ences and views. We did not obtain feedback from ourparticipants. There are conflicting opinions in the lit-erature about whether this is advisable or appropriate[40, 41]. However, the results validated those reportedin our scoping review [12] and have been validated bythe findings of other studies. The differentorganizational structures and programing offered by PCand PH in the different provinces, although rich in con-text, added complexity to the interpretation.ConclusionsGiven that all influencing factors on collaboration identi-fied through our research were related to other factorsaffecting collaboration between PC and PH, practitionersand managers in organizations need to take all influ-ences at different levels into consideration when plan-ning for or implementing a collaboration. No categoryof influence should be ignored, although some influen-cing factors may have more importance at various pointsin the evolution of a collaboration from the developmentphase to the implementation and evaluation of thecollaboration. For example, the development of clearmandates, vision and goals for the collaboration, antici-pated in response to shared interests, would likely bemore apparent at the development phase, but needs tobe continually communicated and refined over the life-time of a collaboration. In addition, understandingValaitis et al. BMC Health Services Research  (2018) 18:420 Page 15 of 17relationships among influences on collaboration, whichare often two-way relationships, is vital for managersand providers working in collaborations. For example,having formal leadership for collaboration will be influ-enced by and will have an influence on the presence of acollaborative organizational culture.The seven influencing factors on PC and PH collabor-ation as identified in this study align with the results ofour scoping literature review [12] as well as that of othercurrent research that validate these factors. They alsoprovide more depth in understanding of these variousinfluences, with examples that are specific within thecontext of the Canadian experience. With sensitivitiestoward these influences, successful collaborations aremore likely, along with the potential for a sustained rela-tionship between PC and PH organizations.In two companion papers, we consider the influences ofsystems level [42] as well as interpersonal level factors oncollaboration [43]. In two forthcoming companion papers,we explore the very nature of successful collaborationincluding the structures and processes and characteristicsof collaboration, and a final ecological model for successfulcollaboration (see toolkit2collaborate.ca) highlighting theinterrelationships across all levels (systemic, organizational,inter and intra-personal levels) situated within the contextof the nature of the collaboration. As suggested in ourdiscussion, systemic change is acknowledged to take timerelative to the dynamic of local level processes, opportun-ities and evolutions within communities requiring a moreresponsive network of service organizations. Supportiveorganizational influencing factors on collaborations operat-ing between and within local PC and PH providers can andhave, in fact, jump-started collaborations locally acrossCanada and elsewhere. Key influences have been acknowl-edged in this more current research with greater emphasisplaced on supportive organizational cultures that engagecommunity stakeholders and enable collaborative planningof services and programs directed by a common vision, andwith PC and PH practitioners empowered to work withintheir full scope of practice.Additional fileAdditional file 1: Semi-structured Interview Guide. (DOCX 18 kb)AbbreviationsBC: British Columbia; NS: Nova scotia; ON: Ontario; PC: Primary care;PH: Public HealthAcknowledgementsWe would like to acknowledge the members of The Strengthening PrimaryHealth Care through Primary Care and Public Health Collaboration Team.Team Members include: Andrea Baumann, Paula Brauer, Michael Green,Janusz Kaczorowski, Rachel Savage, Patricia Austin, Kristin MacLellan, KarenMcNeil, Nancy Murray, Sandy Isaacs, and Leena Chau.FundingThe research team gratefully acknowledges the following for their supportfor this program of research. Our funding agencies the Canadian HealthServices Research Foundation (Grant RC2–1604), the Michael SmithFoundation for Health Research HSPRN Partnership Program, McMasterUniversity (School of Nursing, Faculty of Health Sciences), the Public HealthAgency of Canada, Huron County Health Unit, VON Canada, RegisteredNurses’ Association of Ontario, Capital District Health Authority (Nova Scotia),Somerset West Community Health Centre, Canadian Association ofCommunity Health Centres, Canadian Public Health Association, HamiltonNiagara Haldimand Brant LHIN.Availability of data and materialsThe datasets generated and/or analysed during the current study are notpublicly available since we did not request permission of participants toshare this data with others nor include this in our consents.Authors’ contributionsRKV led the overall study. RKV, DMS, RMM STW, MM, LO conceptualized thestudy, led their respective provincial teams, collected and analysed the dataand contributed to the writing and review of the paper. All authors haveread and approved of the final version of the manuscript.Ethics approval and consent to participateEleven research ethics board approvals were obtained from each province’suniversity represented on the team as well as relevant provincial regionalHealth Authorities. A list can be provided on request. Participants’ agreementto participate in interviews was deemed as consent.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, McMaster University, HSc Room 3N25, 1280 Maim StreetWest, Hamilton, ON L8S4K1, Canada. 2Dalhousie University, Room G26,Forrest Bldg., PO Box 15000, 5869 University Avenue, Halifax, NS B3H 4R2,Canada. 3UBC School of Nursing and Centre for Health Services and PolicyResearch, T201 2211 Wesbrook Mall, Vancouver, BC V6T 2B5, Canada.4University of Victoria, HSD B220, 3800 Finnerty Road, Victoria, BC V8P 5C2,Canada.Received: 8 July 2017 Accepted: 9 May 2018References1. White F. Primary health care and public health: foundations of universalhealth systems. Med Princ Pract. 2015;24(2):103–16.2. Stevenson Rowan M, Hogg W, Huston P. Integrating public health andprimary care. 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