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Examining the delivery of mental health services in primary care and public health collaborations using… Chau, Fangxiao Leena Wu 2016

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 EXAMINING THE DELIVERY OF MENTAL HEALTH SERVICES  IN PRIMARY CARE AND PUBLIC HEALTH COLLABORATIONS USING A POPULATION HEALTH FRAMEWORK by  Fangxiao Leena Wu Chau   B.A., The University of British Columbia, 2010   A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF   MASTER OF SCIENCE  in  The Faculty of Graduate and Postdoctoral Studies (Population and Public Health)  THE UNIVERSITY OF BRITISH COLUMBIA  (Vancouver)  December 2016 © Fangxiao Leena Wu Chau, 2016          ii  Abstract Background: More than 6.7 million people in Canada experience a mental illness during a one-year period. Mental illnesses are highly influenced by the determinants of health, which are the social, economic, and physical environments that contribute to an individual’s health status. Addressing mental illnesses requires a population health approach involving joint action across multiple sectors to focus on the determinants of health. This thesis examines the extent to which Primary Care (PC) and Public Health (PH) collaborations incorporated a population health approach to address mental illnesses. Methods: A secondary analysis of data collected through a multi-province (British Columbia, Ontario, Nova Scotia) study that examined factors related to strengthening primary health care through PC and PH collaboration was conducted. Focus group data from four cases of PC-PH collaborations that addressed mental health were used to examine whether mental health activities incorporated a population health approach, as well as to identify the enablers and barriers to carrying out the activities. A qualitative descriptive approach and thematic analysis were used. A coding framework and themes were developed deductively, based on the Public Health Agency of Canada’s population health framework, and through inductive analysis. Results: Twenty-nine themes and eighteen subthemes were identified that correspond to the Public Health Agency of Canada’s population health framework. Key enablers included working in a multidisciplinary team, addressing the determinants of health, and engaging the community. Key barriers were poor data systems, a lack of service integration, and a lack of action on demonstrating accountability for outcomes. Conclusions: Findings highlighted the relevance of a population health approach and demonstrate that certain         iii  aspects of the population health framework are more actionable than others in the area of mental health, thus identifying areas for the framework’s further development. The research also identifies enablers and barriers to conducting mental health activities, offering guidance on how to facilitate population health implementation. The results could help provide insight at the program and policy levels for PC and PH as well as other sectors related to collaborative strategies that could strengthen the delivery of mental health services by incorporating a population health approach.               iv  Preface This study draws on data collected through a four-year, multi-province: British Columbia (BC), Ontario (ON), and Nova Scotia (NS) study titled Strengthening Primary Health Care through Primary Care and Public Health Collaboration. The larger study, led by Dr. Ruta Valaitis, examined the nature of collaborative partnerships that currently exist in Nova Scotia, Ontario, and British Columbia and the structures and processes required to build successful collaborations between public health and primary care. The larger study was funded through the Research, Exchange, and Impact for System Support (REISS) research grant from the Canadian Health Services Research Foundation, now the Canadian Foundation for Healthcare Improvement (Grant #RC2-1604-06) in partnership with: the Michael Smith Foundation for Health Research, Health Services & Policy Research Support Network, McMaster University, Public Health Agency of Canada, Canadian Public Health Association, Capital Health Authority Nova Scotia, Hamilton Niagara Haldimand Brant Local Health Integration Network, Huron County Health Unit, Registered Nurses Association of Ontario (RNAO), Somerset West Community Health Centre, and Victorian Order of Nurses Canada. Ethics approval to conduct the secondary analysis was granted by the Behavioural Research Ethics Board at the University of British Columbia (certificate number H15-01058).              v  Table of Contents  Abstract ........................................................................................................................................ ii Preface ......................................................................................................................................... iv Table of Contents ...................................................................................................................... v List of Tables .......................................................................................................................... viii List of Figures ............................................................................................................................ ix Definition of Terms .................................................................................................................. x Acknowledgements ................................................................................................................ xx Dedication ................................................................................................................................xxi Chapter 1. Introduction .......................................................................................................... 1 1.1 Mental Health and Mental Illness .......................................................................................... 1 1.2    Rationale for the Research ....................................................................................................... 6 1.3    Research Questions .................................................................................................................... 7 Chapter 2: Literature Review ............................................................................................... 8 2.1    Delivery of Mental Health Services in Canada .................................................................... 8 2.2    Mental Health for All .............................................................................................................. 11 2.2.1    Dual Continuum Model of Mental Health and Mental Illness ......................................... 11 2.3    Importance of Mental Health Promotion: A Population Health Approach...................... 13 2.4    Mental Illness: Challenges for PC ....................................................................................... 15 2.5    Mental Health: The Role of PH ............................................................................................ 16 2.6    Population Health Approach ................................................................................................ 17 2.6.1    A Brief History ................................................................................................................................ 17 2.6.2    Influence of Population Health .................................................................................................. 21 2.6.3    Criticisms .......................................................................................................................................... 22 2.7    Theoretical Framework .......................................................................................................... 24 2.8    Collaboration ............................................................................................................................ 28 2.8.1    Collaboration Continuum ............................................................................................................. 28 2.8.2    Collaborations between PC, PH and other sectors ............................................................... 29 2.8.3    Need for Collaborations between PC and PH in the Area of Mental Health ............... 30 2.8.4    Barriers and Enablers to Collaboration .................................................................................... 32 Chapter 3: Methods ............................................................................................................... 35 3.1    Overview/Context .................................................................................................................... 35 3.2    Multiple Case Studies Examining Collaboration between PC, PH, and other Sectors ................................................................................................................................................................ 36 3.2.1    Participants ....................................................................................................................................... 36 3.2.2    Data Sources .................................................................................................................................... 37 3.2.3    Focus Groups ................................................................................................................................... 38 3.3    Secondary Analysis of Focus Group Data ......................................................................... 39 3.4    Population Health Framework ............................................................................................. 42 3.4    Analysis ...................................................................................................................................... 42 3.5    Ensuring Trustworthiness and Rigour ............................................................................... 47 3.6   Ethical Considerations ............................................................................................................. 49         vi  Chapter 4. Results .................................................................................................................. 50 4.1    Key Element 1: Focus on the Health of Populations ....................................................... 55 4.1.1    Focus on Populations vs. Individuals ....................................................................................... 56 4.1.2    Understanding the Larger Picture .............................................................................................. 57 4.1.3    Social Justice Focus ....................................................................................................................... 59 4.1.4    Measure and Analyze Population Health Status and Health Status Inequities ........... 59 4.2    Key Element 2: Address the Determinants of Health and their Interactions ........... 60 4.2.1    Income and Social Status ............................................................................................................. 61 4.2.2    Social Support Networks.............................................................................................................. 63 4.2.3    Education and Literacy ................................................................................................................. 65 4.2.4    Social Environments ...................................................................................................................... 67 4.2.5    Physical Environments ................................................................................................................. 68 4.2.6    Personal Health Practices and Coping Skills ......................................................................... 71 4.2.7    Healthy Child Development ........................................................................................................ 72 4.2.8    Health Services ................................................................................................................................ 74 4.2.9    Culture, Gender, Biology and Genetic Endowment, and Employment/Working Conditions ....................................................................................................................................................... 78 4.3    Key Element 3: Base Decisions on Evidence ..................................................................... 79 4.3.1    Identify and Assess Effective Interventions ........................................................................... 80 4.3.2    Poor Data Systems ......................................................................................................................... 81 4.3.3    Public Health Intervention Outcomes Take Time ................................................................ 82 4.4    Key Element 4: Increase Upstream Investments ............................................................. 83 4.5    Key Element 5: Apply Multiple Strategies ........................................................................ 84 4.5.1 Apply a Comprehensive Mix of Interventions and Strategies ............................................. 85 4.5.2    Provide Outreach Services ........................................................................................................... 86 4.5.3    Provide Referrals ............................................................................................................................ 87 4.5.4    Create Programs for Youth Health Services .......................................................................... 88 4.6.    Key Element 6: Collaborate Across Sectors and Levels ................................................ 89 4.6.1    Identifying and Supporting a Champion ................................................................................. 90 4.6.2    Investing in the Alliance Building Process ............................................................................ 91 4.6.3    Engage Partners Early on to Establish Shared Values and Alignment of Purpose .... 92 4.7    Key Element 7: Employ Mechanisms for Public / Community Involvement ............ 93 4.7.1    Apply Public Involvement Strategies that Link to Overarching Purpose ..................... 93 4.7.2    Build Relationships with Target Population .......................................................................... 94 4.7.3    Focus on the Community ............................................................................................................. 94 4.8    Key Element 8: Demonstrate Accountability for Health Outcomes ............................ 95 4.8.1    No Formal Evaluation Mechanisms and Accountability Structures............................... 95 4.8.2    Accountability Structures and Processes ................................................................................ 96 Chapter 5. Discussion ........................................................................................................... 97 5.1    Summary of Findings .............................................................................................................. 97 5.1.1    Mental Health Activities and Aspirations in Collaborations using a Population Health Approach ........................................................................................................................................... 97 5.1.2    Enablers and Barriers to Effective Mental Health Promotion using a Population Health Approach ........................................................................................................................................... 98 5.2    Contributions to the Literature ............................................................................................ 99 5.2.1    Widespread Influence of Population Health in Collaborations between PC, PH, and other Organizations in the Area of Mental Health: ............................................................................ 99 5.2.2    Population Health Approach as an Actionable Approach using PHAC’s Framework.......................................................................................................................................................................... 100         vii  5.2.3    Not all DoH are Equally Relevant to Mental Health ........................................................ 101 5.2.4    Poor Data Systems that do not Provide Accountability for Population Health ....... 102 5.2.5    Engaging the Public/Communities is Paramount in a Population Health Approach.......................................................................................................................................................................... 103 5.2.6    Collaboration is Necessary for Improving Population Health ...................................... 104 5.3    Strengths of the Research Approach ................................................................................. 105 5.4    Limitations of the Research ................................................................................................. 107 5.5    Recommendations .................................................................................................................. 109 5.6 Directions for Future Research .......................................................................................... 111 5.7 Conclusion ............................................................................................................................... 113 References .............................................................................................................................. 115 Appendices ............................................................................................................................. 141 Appendix A: Determinants of Health ......................................................................................... 141 Appendix B: Population Health Framework ............................................................................ 144 Appendix C: Original Research Questions ............................................................................... 147 Appendix D: Original Focus Group Questions ........................................................................ 148 Appendix E: List of Coded Focus Groups ................................................................................. 150 Appendix F: Final Coding Framework ...................................................................................... 151          viii  List of Tables  Table 1: Summary Table of Population Health Key Elements  ....................................... 25 Table 2: Description of the Four Cases  ........................................................................... 41 Table 3: Sample of Coding Framework ........................................................................... 45 Table 4: Final Coding Framework ................................................................................... 51 Table 5: List of Participant Role Descriptions ................................................................. 54 Table 6: Key Element 1 Themes and Subthemes ............................................................ 55 Table 7: Key Element 2 Themes and Subthemes ............................................................ 60 Table 8: Key Element 3 Themes and Subthemes ............................................................ 80 Table 9: Key Element 4 Themes and Subthemes ............................................................ 83 Table 10: Key Element 5 Themes and Subthemes .......................................................... 85 Table 11: Key Element 6 Themes and Subthemes .......................................................... 90 Table 12: Key Element 7 Themes and Subthemes .......................................................... 93 Table 13: Key Element 8 Themes and Subthemes .......................................................... 95           ix  List of Figures   Figure 1: Dual Continuum Model of Mental Health and Mental Illness  ........................ 12 Figure 2: Population Health Template  ............................................................................ 27 Figure 3: Coding Framework Legend .............................................................................. 46           x  Definition of Terms  Term   Definition Collaboration  A recognized relationship among different sectors or groups, which have been formed to take action on an issue in a way that is more effective or sustainable than might be achieved by the public health sector acting alone.(1) Collaboration Continuum The ways of working together in a collaboration ranges on a continuum. Based on work by Himmelman, collaboration is a dynamic process that requires all four strategies/relationships on the continuum: 1) networking, exchanging information for mutual benefit, and resources are generally kept separate; 2) coordination, exchanging information, and altering activities for mutual benefit and to achieve a common purpose and some resources may be shared; 3) cooperation, exchanging information, altering activities, and sharing resources for mutual benefit and to achieve a common purpose), and 4) collaboration, exchanging information, altering activities, sharing resources, and enhancing the capacity of another for mutual benefit and to achieve a common goal.(2) Community-based services Community-based services is care provided outside of the hospital setting. It includes services and supports provided across the continuum of care, including health promotion, illness prevention, treatment, and recovery. It includes not only treatment and crisis response, but also outreach, case management, and related services such as housing and         xi   Term   Definition employment supports and court diversion programs. This involves consultation and liaison services to general practitioners, primary health care, and private sector providers.(3) Community-based services identifies the importance of communities in supporting recovery.(4)  Determinants of Health Definable entities that cause, are associated with, or induce health outcomes. Public health is fundamentally concerned with action and advocacy to address the full range of potentially modifiable determinants of health – not only those which are related to the actions of individuals, such as health behaviours and lifestyles, but also factors such as income and social status, education, employment and working conditions, access to appropriate health services, and the physical environment. These determinants of health, in combination, create different living conditions which impact on health.(1) Policy A course or principle of action adopted or proposed by a government, political party, organization, or individual; the written or unwritten aims, objectives, targets, strategy, tactics, and plans that guide the actions of a government or an organization. Policies have three interconnected and ideally continually evolving stages: development, implementation, and evaluation. Policy development is the creative process of identifying and establishing a policy to meet a particular need or situation. Policy implementation consists of the actions taken to set         xii   Term   Definition up or modify a policy, and evaluation is the assessment of how, and how well, the policy works in practice. Health policy is often enacted through legislation or other forms of rule-making, which define regulations and incentives that enable the provision of and access to health and social services.(1) Health promotion The process of enabling people to increase control over, and to improve their health. It not only embraces actions directed at strengthening the skills and capabilities of individuals, but also action directed towards changing social, environmental, political and economic conditions so as to alleviate their impact on public and individual health. The Ottawa Charter for Health Promotion describes five key strategies for health promotion: build healthy public policy; create supportive environments; strengthen community action; develop personal skills; and re-orient health services. (A public health system core function).(1) Health protection A term to describe important activities of public health, in food hygiene, water purification, environmental sanitation, drug safety and other activities, that eliminate as far as possible the risk of adverse consequences to health attributable to environmental hazards. (A public health system core function).(1) Mental health A state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work         xiii   Term   Definition productively and fruitfully, and is able to make a contribution to her or his community.(5)  The capacity of each and all of us to feel, think, and act in ways that enhance our ability to enjoy life and deal with the challenges we face. It is a positive sense of emotional and spiritual well-being that respects the importance of culture, equity, social justice, interconnections, and personal dignity.(6)  Mental health continuum Mental health occurs on a continuum that consists of complete and incomplete mental health. Incomplete mental health may result from mental health problems or clinically diagnosed mental illnesses. People experience mental health problems, changes in thoughts and moods that impact the person’s coping and functioning, that fall along this continuum. They range from mild and reversible distress, such as the daily stresses we encounter, to moderate and more severe emotional distress, such as lingering feelings of sadness and hopelessness.(7)  Mental illness prevention A focus on avoiding mental illness, which is seen as a lack of mental health.(8) Mental health problems A mental health problem is a minor disruption in the interactions between the individual, the group and the environment, which causes some distress. Mental health problems involve signs and symptoms of insufficient intensity or duration to meet the criteria for any mental         xiv   Term   Definition illness. Almost everyone experiences a mental health problem at some time in their lives.(9)  Mental health promotion   Mental health promotion is the process of enhancing the capacity of individuals and communities to take control over their lives and improve their mental health.(10) Mental health promotion is concerned with achieving positive mental health and quality of life for the entire population.(11) By enhancing the strengths and competencies of individuals and communities, mental health promotion fosters individual resilience and promotes socially supportive environments.(10,11) Mental health promotion, therefore, focuses on improving the social, physical and economic environments that determine the mental health of populations. This requires the development of health and social policy to address the influence of broader determinants of mental health.(11) Mental health service delivery  The programs and actions designed to support mental health and the way they are delivered.(12) Mental health treatment  Providing appropriate treatment for those persons with defined mental illnesses is important.(8) For those living with mental illness, there is a variety of treatment options available, including psychotherapy, medication, case management, hospitalization, support groups, and supplementary and alternative medicine.(13) Although there is no         xv   Term   Definition universal treatment that works for everyone, psychotherapy, combined with medication, has been shown to be the most effective treatment.   Mental illness Mental illnesses are characterized by alterations in thinking, mood or behaviour associated with significant distress and impaired functioning.(14) Partnership  Collaboration between individuals, groups, organizations, governments, or sectors for the purpose of joint action to achieve a common goal. The concept of partnership implies that there is an informal understanding or a more formal agreement (possibly legally binding) among the parties regarding roles and responsibilities, as well as the nature of the goal and how it will be pursued.(1) Population health Population health refers to the health of a population as measured by health status indicators and as influenced by social, economic and physical environments, personal health practices, individual capacity and coping skills, human biology, early childhood development, and health services.(1)  As an approach, population health focuses on the interrelated conditions and factors that influence the health of populations over the life course, identifies systematic variations in their patterns of occurrence, and applies the resulting knowledge to develop and implement policies and actions to improve the health and well-being of those populations.(15)         xvi   Term   Definition Population health approach  Population Health Approach focuses on improving health status through action directed toward the health of an entire population, or sub-population, rather than individuals.(15) Population health approach: The Organizing Framework The PHAC population health framework that was used in this research,(16)  which was referred to as the “Population Health Framework,” for simplicity. Consists of eight key elements:  1. Focus on the health of populations 2. Address the determinants of health and their interactions 3. Base decisions on evidence  4. Increase upstream investments  5. Apply multiple strategies  6. Collaborate across sectors and levels 7. Employ mechanisms for public involvement 8. Demonstrate accountability for health outcomes Primary care The first point of entry to a health care system; the provider of person-focused (not disease-oriented) care over time; the deliverer of care for all but the most uncommon conditions; and the part of the system that integrates or co-ordinates care provided elsewhere or by others.(17)  Functions include(18):   Management of acute, episodic care and non-urgent routine care  Health promotion         xvii   Term   Definition  Disease and injury prevention   Chronic disease management  Primary health care Essential health care based on practical, scientifically sound and socially acceptable methods, and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. It forms an integral part both of the country’s health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process. Primary health care has been used to describe both a philosophical approach to care delivery and differentiate the types of health services delivered. It can encompass various social institutions, different sets of scientific and professional disciplines and technologies, and different forms of practice.”(18, p1) Public health An organized activity of society to promote, protect, improve, and when necessary, restore the health of individuals, specified groups, or the entire population. It is a combination of sciences, skills, and values that         xviii   Term   Definition function through collective societal activities and involve programs, services, and institutions aimed at protecting and improving the health of all people. The term “public health” can describe a concept, a social institution, a set of scientific and professional disciplines and technologies, and a form of practice. It is a way of thinking, a set of disciplines, an institution of society, and a manner of practice. It has an increasing number and variety of specialized domains, and demands of its practitioners an increasing array of skills and expertise.(1)  Functions include (among other things) (20):   Population health assessment  Health surveillance  Health promotion  Disease and injury prevention  Health protection Public Health Practitioner Synonym: public health professional, public health worker. A generic term for any person who works in a public health service or setting. They may be classified according to profession (nurse, physician, dietitian, etc.,); according to role and function (direct contact with members of the public or not); whether their role is hands-on active interventions or administrative; or in various other ways.(1) Surveillance Systematic, ongoing collection, collation, and analysis of health-related         xix   Term   Definition information that is communicated in a timely manner to all who need to know which health problems require action in their community. Surveillance is a central feature of epidemiological practice, where it is used to control disease. Information that is used for surveillance comes from many sources, including reported cases of communicable diseases, hospital admissions, laboratory reports, cancer registries, population surveys, reports of absence from school or work, and reported causes of death. (A public health system core function).(1)            xx  Acknowledgements I would like to express my deepest gratitude for my supervisors, Dr. Ruta Valaitis and Dr. Charlyn Black and committee member, Dr. Jane Buxton for your incredible support, patience, and invaluable wisdom, without which this would not have been possible. Thank you, Ruta; I appreciated every word of encouragement throughout the past seven years. Charlyn, your gentle pushing for me to arrive at conclusions on my own inspires me to teach. Thank you for always leaving your door open for me. Jane, thank you for your wonderful enthusiasm, dedication, and insight. I would like to also thank Beth Hensler for your tremendous guidance throughout this process. Thank you Emily Jenkins for all your help and insight. From our fateful encounter at that conference together, to many years later, I am grateful to call you my friend. Thank you Matthew Querée for your helpful feedback on my thesis. A special thank you to my dear friend, Lisa Truong, for your ongoing encouragement. Thank you Mom and Dad for your unwavering support and steadfast belief in me throughout my Master's program and throughout the years I was lost. Your incredible understanding and patience empower me to always try. You are my greatest source of strength. To my sister, Lindsay, and brother, Loren: you are the best siblings I could have ever asked for. Lindsay, thank you for your careful reading of my thesis and for bringing joy to our countless study sessions; your perceptiveness grounds me. Lastly, I would like to express the deep appreciation I have for my husband and to share this accomplishment with him. Your constant support in me, particularly during the tough times, has made this possible. Thank you for always listening, including to the things I do not say.          xxi  Dedication  To the memory of my grandfathers (爹爹 and 外公), who instilled a desire for learning in their children that was then passed on to me.                 1  Chapter 1. Introduction 1.1    Mental Health and Mental Illness  Mental health is described by the World Health Organization (WHO) as a state of wellbeing where an individual is capable of coping with the normal stresses of life, being productive, and contributing to the community.(21) The Public Health Agency of Canada (PHAC) defines it as the capacity to “feel, think, and act in ways that enhance our ability to enjoy life and deal with the challenges we face.”(6) Mental health is a fundamental component of overall health; there is “no health without mental health.”(21, p11)  Mental illness, a term that collectively refers to all diagnosable mental health problems,(9) is a serious global health issue, accounting for 13% of the global burden of disease.(23,24) Mental illnesses are a leading cause of human suffering.(25–27) Anyone at any stage in life can develop a mental illness,(23,28) although the onset most often occurs during adolescence and young adulthood.(29,30) The WHO reports that the number of individuals who experience a mental illness worldwide is expected to rise to 15% by the year 2020 primarily due to an increase in the number of individuals entering the age of risk for mental illness.(12,28,31) In Canada, more than 6.7 million people (1 in every 5 people) experience a mental illness during a one-year period (32,33); about 50% of the population will have experienced a mental illness by age 40.(34)  Mental illness encompasses a wide range of psychological problems with varied, persistent, and often debilitating symptoms that vary in severity and duration.(9,35) In order to be clinically diagnosed with a mental illness, the individual must be deemed to         2  experience disturbances in thinking, mood, behavior, and relationships with others, combined with impaired functioning and significant distress.(14) Impairments can be physical (e.g., impaired functioning, confused thinking), emotional (e.g., withdrawal from family and friends, distress), or societal (e.g., inability to maintain employment, high usage of healthcare resources).(25–27,29,30) The impact is not only felt by the individual, but also by family members, friends, and coworkers.   Examples of mental illnesses include schizophrenia, personality disorders (e.g., dissociative disorders), anxiety disorders (e.g., agoraphobia, panic disorder), and affective disorders (e.g., bipolar disorder). Clinical depression, the most common form of mental illness,(26,29) is ranked second for global disease burden (21,23) and is the leading cause of disability.(23) Morbidity and mortality rates are also higher in people with mental illness than those without.(24,36) This is associated with an increased risk of developing diabetes, cardiovascular disease, obesity, and other complications arising from the comorbid conditions.(36) In the most severe cases, mental illness may lead to suicide.(21,23,37) Up to 90% of the deaths by people committing suicide worldwide can be attributed to a mental illness.(38)   In addition to the substantial societal impact of mental illness, there are also significant economic costs.(21) Global economic costs, both direct and indirect, are estimated at $2.5 trillion, and is expected to rise to $6 trillion by 2030.(21) The costs to the Canadian economy are estimated to be over $50 billion per year: indirect health-related government expenditures account for $50 billion,(34,39) while direct costs account for $7.9         3  billion.(40) This value does not include many indirect costs such as costs to the criminal justice, education, and child welfare systems.(34) Over the next 30 years, the cost of providing treatment and support in Canada is expected to exceed $2.3 trillion.(34)   Mental health and mental illness exist on two separate continua. The mental health continuum ranges from complete to incomplete mental health, where those with complete mental health are flourishing with high levels of well-being, while those with incomplete mental health are languishing with low levels of well-being.(7) Mental illness exists on a separate continuum that ranges from mental illness to no mental illness. Individuals experience a range of mental health problems, changes in thoughts and moods that impact their coping and functioning, that fall along this continuum.(7) These range from mild and reversible distress, such as the daily stresses we encounter, to moderate and more severe emotional distress, such as lingering feelings of sadness and hopelessness, to a clinically diagnosed mental illness.(7) Thus, focusing on the treatment of mental illness does not guarantee mental health.   Mental illnesses are closely tied to the Determinants of Health (DoH), which are the 12 interrelated factors rooted in the social, economic, and physical environments that contribute to an individual’s health and social status.(41–44) They are termed “determinants” due to “an established or hypothesized causal role”.(33, p150) See Appendix A for a detailed description of the 12 DoH and examples. Since mental health is not simply the absence of mental illness, and preventing mental illness does not guarantee mental health,(7) it is important to focus on mental health promotion, the         4  process of enhancing the capacity of individuals and communities to take control over their lives and improve their mental health.(10) Mental health promotion is concerned with achieving positive mental health and quality of life for the entire population.(11) By enhancing the strengths and competencies of individuals and communities, mental health promotion fosters individual resilience and promotes socially supportive environments.(11,10) Mental health promotion, therefore, requires a population health approach to improving the DoH.(1)   There are eight Key Elements central to a population health approach (46,47): 1. Focus on the health of populations 2. Address the determinants of health and their interactions 3. Base decisions on evidence  4. Increase upstream investments  5. Apply multiple strategies  6. Collaborate across sectors and levels 7. Employ mechanisms for public involvement 8. Demonstrate accountability for health outcomes  While this research incorporates the full population health framework, it will focus on Key Element 2: Address the Determinants of Health and their interactions, as the DoH have been shown to be strongly related to mental health status. Certain DoH have a stronger impact on mental health than others. For example, income and social status affect the ability to meet basic needs and the degree of control individuals have over life         5  choices.(48,49) People with higher social status also have increased access to resources for engaging in mental health promotion and important treatment options that might otherwise be unavailable.(30,50) Another example is the importance of having a rich social support network, which helps act as a buffer from developing mental health problems by enabling people to form trusting relationships and receive support during stressful times.(41,49) Having trusting relationships with friends and family helps foster self-esteem, meaning in life, and social cohesion.(30) Lastly, providing affordable and safe housing is essential to maintaining people’s mental health and wellbeing and also supporting the recovery of individuals. (42) Those with mental health problems are particularly vulnerable to homelessness and unstable housing due to the lack of capacity to sustain employment and withdrawal from friends and family, resulting in reduced income and poor social support networks.(51,52) When basic needs, such as food and shelter, are not met, individuals dedicate an inordinate amount of energy towards survival and are thus unable to focus on positive mental health or recovery.(30,49) As most DoH are cross-cutting and fall outside the purview of the health services sector, addressing them requires coordinated intersectoral action, which is related to Key Element 6: Collaborate across sectors and levels.   Of the 12 DoH, 10 exert their influence largely at the community level.(53) Population health interventions are thereby focused there, where needs of the community are understood and links to institutional services can be strengthened. This is related to Key Element 7: Employ mechanisms for public involvement, which recognizes the importance of engaging key players (e.g., policy makers, communities) from the design         6  of health policy to the evaluation of health outcomes.(46) Community-based services, defined as services “provided outside the hospital setting,”(43, p4) can effectively support patients with mild to moderate symptoms and provide them the needed support with minimal disruption to their lives.(31,55) Research has shown that selected community-based collaborative mental health programs and initiatives focused on mental health promotion have been effective at increasing public understanding of mental health and illness,(12,31,56) increasing access to mental health services,(57) and improving mental illness outcomes.(57–59) 1.2    Rationale for the Research  Community-based services can effectively support people suffering from mild to moderate mental health illnesses,(9) but this is dependent on a timely diagnosis and prompt access to mental health services.(60,61) Detection of mental illness, particularly early on, is frequently missed.(62) Even with a diagnosis, many do not receive timely access to treatment or do not receive the appropriate treatment at all.(63,64) Furthermore, as mental health and illness exist on separate continua, the absence of mental illness does not equate to mental health; everyone is vulnerable to developing mental health problems and illnesses at some point in their lives.(65) Given the limitations of current mental health services, there is a need to focus efforts upstream on prevention and mental health promotion using a population health approach to address the DoH through collaborative intersectoral action.(6,66,67)   To date, the author could not find any work that has examined how PC, PH, and other sectors work together in collaborations that addressed mental health and the DoH by         7  incorporating a population health approach.  1.3    Research Questions The goal of this research is to develop knowledge that will inform the delivery of community-based mental health services by examining service delivery in existing collaborations using a population health framework.(16)  Specific research questions to be addressed are:  1. Do mental health activities, in collaborations between PC, PH and other organizations, incorporate a population health approach?   2. What are the enablers and barriers to conducting activities that incorporate a population health approach, in collaborations between PC, PH and other organizations, in the area of mental health services?  This study will examine how PC and PH-focused collaborations incorporated mental health promotion using a population health approach to address mental health problems. Lastly, this study will examine how mental health service delivery can be improved by identifying which aspects of the population health framework were poorly or not addressed at all.            8  Chapter 2: Literature Review 2.1    Delivery of Mental Health Services in Canada In order to appreciate the importance of using a population health approach to mental health service delivery, it is important to understand the structure of the Canadian mental health system. Canada is divided into 10 provinces and three territories. Canada has a decentralized healthcare system where responsibility for the delivery of mental health services lies with the provincial and territorial governments.(68) Canada created a Mental Health Commission in 2007 to provide a national focus for mental health problems.(69) Though the Mental Health Commission of Canada published the first pan-Canadian mental health strategy, “Changing Directions, Changing Lives”(55) in 2012, there is currently no national mental health policy in place.(70) This, in addition to a trend toward further regionalization of health care administration,(70) has resulted in a fragmented system of allied mental health services.(56,68) Although Canada has a universal publicly funded insurance program (Medicare), psychologists are generally not included in the coverage and are instead paid mostly through costly private billings to the patient (68,70) or through private insurance programs.(68)    Data for this study are from two provinces of Canada: British Columbia (BC) and Nova Scotia (NS). Mental health service delivery is described below for these two provinces.  British Columbia. In BC, the body responsible for the delivery of health services is the BC Ministry of Health (MoH).(71) The MoH provides a variety of services such as communicable disease prevention, harm reduction, and mental health promotion.(71)         9  British Columbia is further divided into one provincial health authority and five regional health authorities that plan and deliver health care services tailored to regional need.(71) The MoH works with all six health authorities to provide care.(71) In addition, the BC First Nations Health Authority was created in 2013 to plan and deliver culturally sensitive care to the First Nations people in BC.(72) The BC Mental Health and Substance Use Services (BCMHSUS), an agency of the provincial health authority, manages mental health service delivery.(73) The BCMHSUS also provides mental health leadership in health promotion and illness prevention, knowledge exchange, and research and academic teaching.(73)   “Healthy Minds, Healthy People” (2010) is the BC Government’s 10-year plan to address the mental health needs of British Columbians.(60) The plan, based on a population health approach, arose from multiple conversations with British Columbians and aims to: 1) improve mental health and wellbeing of the population, 2) improve the quality and accessibility of services for people with mental health and substance use problems, and 3) reduce the economic cost to the public and private sectors resulting from mental health and substance use issues. A key component to achieving the goals is “Collective Action”(51, p11) as it recognizes that promoting mental health is a shared responsibility that requires a population health approach with collaborations across multiple sectors (cross-ministry, health authority, academic, and community). Key achievements identified in their 2012 progress report include: increased screening for perinatal depression, enhanced programs that promote development and resilience in children, and increased support for families with parents that have mental health problems.(74)         10  Nova Scotia. In Nova Scotia, health services are delivered by a single health authority – the Nova Scotia Health Authority – and the Izaak Walton Killam (IWK) Health Centre.(75) The Department of Health and Wellness provides overall leadership for the delivery of health services, prevention of illness and injury, and health promotion and healthy living. Its mandate includes both PC and PH.(75) For example, the Department of Health and Wellness engages in population health assessment and surveillance (PHSA) that supports data and information for PH programming.(75) Its leadership in surveillance, utilizing a population health approach, focuses on understanding population health determinants and recognizing and assessing outbreaks. The Department of Health and Wellness provides a variety of programs and services that target specific concerns, such as addictions, continuing care, and mental health.(75) The Department of Health and Wellness works closely with partners across various sectors (e.g., government, communities) to provide mental health services.   In 2012, the Government of Nova Scotia developed its first ever mental health and addictions strategy, “Together We Can.”(76) In it, they outlined goals to: prioritize children and youth through screening children at 18 months of age, reduce wait-times for mental health services by providing more community-based supports for individuals living with mental illness and their families, break down healthcare system silos by bridging the gaps between programs and services, ensure sustainable outcomes by ensuring safe and affordable housing for those living with mental illness, and reduce stigma through delivering anti-stigma initiatives wherein people living with mental illness share their personal experiences.(76) In an update from 2016, significant progress         11  has been identified, including improved access to community-based treatment and support in the form of implementing province-wide telephone coaching for families, placing mental health clinicians in schools, and supporting collaborative care among PC and mental health providers.(77) 2.2    Mental Health for All  At the declaration of Alma Ata in 1978, health was described as a state encompassing physical, mental, and social wellbeing.(19) The declaration, convened by the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) recognized mental health as a fundamental component to achieving complete overall health due to its interdependence with physical and social functioning.(66)   A strong primary health care system is key to achieving the goal of an acceptable level of health for all.(19) Primary health care comprises both the PC and PH sectors. PC can be described as being “the first point of entry to a health care system; the provider of person-focused (not disease-oriented) care over time; the deliverer of care for all but the most uncommon conditions; and the part of the system that integrates or coordinates care provided elsewhere or by others.”(1,17) PH is described as an organized effort of society to promote health, prevent injury, and restore the health of populations.(1)  2.2.1    Dual Continuum Model of Mental Health and Mental Illness  Although mental health and mental illness are highly correlated, they exist on two separate continua (7); mental health is not simply the absence of mental illness. The mental health continuum ranges from complete to incomplete mental health. Those with complete mental health are considered to be flourishing with positive emotion and can         12  function well both psychologically and socially,(7) while those with incomplete mental health are languishing with low levels of well-being.(7) Mental illness exists on a separate continuum that ranges from mental illness to no mental illness. Individuals experience a range of mental health problems, from mild and reversible distress, such as the daily stresses we encounter, to a clinically diagnosed mental illness, that fall along this continuum.(7) Keyes shows that some individuals who do not qualify for a clinical diagnosis of a mental illness can experience mental health problems causing psychosocial impairment comparable to those who are clinically diagnosed with depression.(7) See Figure 1 for a visual of the dual continuum model. Since mental health is not synonymous with a lack of mental illness and preventing mental illness does not guarantee mental health,(7) it is important to focus on mental health promotion, the process of empowering individuals and communities to take control over their lives to strengthen their mental health.(10)  Figure 1: Dual Continuum Model of Mental Health and Mental Illness (79)           13  2.3    Importance of Mental Health Promotion: A Population Health Approach Community-based treatment for people suffering from mild to moderate mental illnesses can be effective.(80) For example, cognitive behavioural therapy has been shown to be effective for treating mood disorders (e.g., depression and dysthymia), antipsychotic medication has been shown to be effective for psychotic disorders (e.g., schizophrenia), and rehabilitation has been shown to be effective for treating substance-use disorders (e.g., drug and/or alcohol misuse).(80) An understanding that treating mental illnesses is possible can motivate people to seek care early on, thereby increasing the chances for improved clinical outcomes.(66) Effective treatment is dependent on a timely diagnosis and prompt access to mental health services,(61,81) yet mental illnesses are often not diagnosed in a timely manner or diagnosed at all, for various reasons noted below in Section 2.4, resulting in people living with mental illness that usually increase in severity over time.(81) Given the challenges in timely diagnoses of mental illness, it is important to concurrently target efforts upstream on mental health promotion to enhance individual resilience and foster supportive social environments.(1)   Mental health promotion strategies are grounded in a population health approach and are dependent on intra- and intersectoral collaboration. Successful strategies require the engagement of various sectors, including health (e.g., PC and PH sectors), government (e.g., federal and provincial/territorial governments), non-government (e.g., Work Safe), and local authorities (e.g., schools, communities) to provide joint action to address the DoH.(28,55,82) A population health approach also focuses mental health service delivery at the community level.(61,82) Community-based programs support links between         14  services and institutions and empower communities to develop tailored strategies that incorporate their unique values and needs,(82) such as building social capital and improving neighbourhood environments and community safety.(83) Community-based services also provide individuals living with mental illness the support they need that are close to their families and other support systems.(76) For example, the Community Assistance Program, located across 50 communities in BC, provides case management support for low-income individuals experiencing mental illness and other barriers.(60) The Program offers a low-barrier system by incorporating a one-door policy that connects individuals with various services including housing, skills training, legal aid, and mental health services. Another example is the Healthy Communities Movement, which was initiated across three provinces in Canada (Quebec, Ontario, and BC) in 1986, with BC receiving new funding in 2005.(53) The networks apply a holistic approach to health that links physical, social, and economic factors and provides a strong focus on community capacity building through collaborative action.(53)   Community Mental Health services in NS similarly support individuals with mental health problems by providing the required assessments and interventions in the community.(84) Community Mental Health connects individuals to an interdisciplinary team of occupational therapists, social workers, registered nurses, psychologists, and psychiatrists who work together to provide care within the individuals’ natural environments.(84) This provides opportunities for members of society, including volunteers and family members, to be more engaged and supportive, providing a greater support network. In recognition of the importance of community-based services, the         15  Community Action Initiative, whose mandate is to support local organizations providing community-based mental health services to individuals living with mental health problems and their families, was established in 2008 by the BC Alliance for Mental Health/Illness through a $10-million grant provided by the Province of BC.(85)   2.4    Mental Illness: Challenges for PC Primary care is usually the first point of contact an individual has with the healthcare system. Among those who seek treatment for mental health problems, the majority of people do so from their PC provider, who is often a family physician or sometimes a nurse practitioner (NP) and often their only point of contact with the healthcare system.(62,86–89) Many screening and diagnostic tools have been developed for depression, the most common type of mental illnesses,(90) such as the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (91), the PC Evaluation of Mental Disorders (PRIME-MD)(92), and the Patient Health Questionnaire (PHQ) (94). Yet, research shows that detection of depression and other mental illnesses are frequently misdiagnosed or not diagnosed at all (62,88,95–100); only 25% to 50% of patients with depressive disorders are accurately diagnosed by PC physicians.(88,101,102) There are many reasons for this, including the tendency for patients and physicians to attribute the symptoms to an overlapping medical illness, as people with mental illness often have additional illnesses (62,102) and the fact that primary care providers receive only minimal training in mental health screening and diagnosis.(63) To complicate the problem, people with mental health problems often do not seek help at all.(103)          16  Once a diagnosis has been made, family physicians and NPs also encounter barriers in helping their patients obtain needed specialist services. Psychiatrists are covered under the provincial medical plans but are often unable to accept referrals due to high volume.(104) Goldner et al.,(105) found that 70% of the psychiatrists they contacted were not accepting referrals, and of the remaining 30%, only 3% offered appointments that ranged from 4-55 days.(105) Psychologists are not covered under provincial medical plans so patients are often unable to afford their high-cost services.   Given that current mental health services provided in the PC setting do not aptly address mental health needs, there is a need for prevention and mental health promotion using a population health approach to provide care along the entire mental health continuum, prior to the manifestation of clinical mental illnesses.(8,106–108) A population health approach requires collaboration with other sectors, including PH, to provide joint action addressing the DoH.  2.5    Mental Health: The Role of PH Population health in Canada stems from a long history of PH.(109) Throughout the years, the role of PH has continuously evolved to adapt to the changing threats for health.(109) Beginning in the 1970s, Canadians oriented their thinking to the DoH, resulting in PH focusing more on promotion and improving health.(109) Current day PH is the science and art of preventing disease, prolonging the quality of life, and promoting health through the organized efforts of society.(95) The functions of PH include population health assessment, health surveillance, health promotion, disease and injury prevention, and health protection.         17  Currently mental health responsibilities is largely seen as being outside the purview of PH.(78) Although treatment for many mental health problems is addressed within a PC setting, the promotion of mental health and prevention and treatment of mental illness are key PH priorities. PH professionals have mental health promotion expertise to empower communities and populations to actively work on improving their mental health, including education encouraging positive behaviours and healthy lifestyles by focusing on the DoH that affect mental health.(95) Recently, numerous working papers and reports have called upon the renewal of primary health care as crucial to addressing the health challenges of the 21st century, including the increasing prevalence of mental illnesses and the resulting need for mental health promotion.(27,108,109)  2.6    Population Health Approach 2.6.1    A Brief History  Population health is a relatively new term that has been defined in different ways by various researchers, policy makers, and epidemiologists.(45) There has been no consensus on its precise definition or whether it refers to a field of study of the DoH or a concept of health.(45,110) Others have noted the confusion arising from its similarities with PH and community health, and the concept of health promotion.(111,112) This research will use the definition put forth by the Federal, Provincial and Territorial Advisory Committee on Population Health, as referenced by the Public Health Agency of Canada (PHAC) in their Population Health Template (38, p2):  Population health refers to the health of a population as measured by health status indicators and as influenced by social, economic and physical environments, personal health practices, individual capacity and coping skills, human biology, early childhood development, and health services.          18  As an approach, population health focuses on the interrelated conditions and factors that influence the health of populations over the life course, identifies systematic variations in their patterns of occurrence, and applies the resulting knowledge to develop and implement policies and actions to improve the health and well-being of those populations.  The overall goal of population health is to examine health outcomes and improve the health of the entire population by addressing the patterns of DoH and their distribution within populations.(1,110) Importantly, Kindig and Stoddart (110) refer to DoH as “patterns” of determinants, recognizing that they do not act independently on health outcomes. They identify the DoH as key to the field of population health.    Health promotion is a key tenet of population health. The concept of health promotion arose from the realization that medicine and the health care system are limited in their contributions to maintaining the health of populations and resultantly, there is a need to expand the responsibilities for health to beyond the health care system.(42,110,113) Health promotion shifted the focus from sickness to health and from individual risk factors to the context, or the wider determinants that affect health.(114) Limitations of the biomedical model, and the corresponding need for health promotion, were first acknowledged by Marc Lalonde in his 1974 report, “A New Perspective on the Health of Canadians: A Working Document,” which became known as the “Lalonde Report.”(113) Lalonde proposed the “health field” concept, distinct from medical care, as comprised of four interdependent “fields:” 1) human biology (e.g., genetic inheritance of the individual, maturation and aging), 2) environment (e.g., air, noise pollution), 3) lifestyle (e.g., personal decisions, habits), and 4) healthcare organization, which is where traditional         19  efforts of health care delivery are concentrated (e.g., medical practice, medical drugs).(113) Lalonde radically suggested that improving population health status required intersectoral and interorganizational collaboration between, for example, governments and the education system, to target populations rather than individuals. Additionally, the report proposed that interventions should focus on populations with the highest level of risk exposure.(115)   Similarly, Geoffrey Rose stated that to maintain population health, we need to understand and address the DoH that affect outcomes at the population level, rather than at the individual level because “the scale and pattern of disease reflect the way that people live and their social, economic, and environmental circumstances.”(86, p85) In his article “Sick Populations and Sick Individuals,” Rose emphasized that the responsibilities for population health lie not only with the health care sector, as most of the DoH fall outside its purview. In contrast to Lalonde’s health field concept however, Rose emphasized the importance of lowering the risk of the majority of individuals by also focusing on those that are at average risk, rather than only those at the tail end of the distribution. This was purported to be more effective due to the higher number of individuals that fall in the average risk-population (112) and would in turn would shift the whole distribution of outcomes in “a favourable direction.”(86, p431)   A prominent model of population health was introduced by the Canadian Institute for Advanced Research (CIFAR) in an influential paper, “Producing Health, Consuming Care,” by Evans and Stoddart.(117) The authors stated that dedicating more resources to         20  health care might actually be detrimental to the health of populations because in doing so, resources are diverted away from the numerous other DoH that influence health. Evans and Stoddart proposed a population health model for addressing the DoH that depicted how the health care sector is only one small part of the larger context that affects health and correspondingly, joint action across sectors is required to effectively address the DoH. The article brought increased awareness to population health and aided in its expansion.(118) The ideas proposed in this article were further discussed in the book “Why are some People Healthy and Others not? The Determinants of Health of Populations.”(42) Extrapolating from this, we can see how effective mental health promotion similarly requires joint action across sectors.   Link and Phanlan state that the main contribution of social science research to social change is through influencing policy.(50) Policy initiatives such as subsidized housing, head-start programs, and parental leave aim to address the fundamental DoH that affect mental health, most of which lie outside the health sector. Any type of change is structured by the decisions made at the policy level.(108) Rudolf Ludwig Carl Virchow, a prominent philosopher, scientist, and physician, said “Medicine is a social science, and politics nothing but medicine on a large scale.”(109, p181) Central to his aphorism is the idea that social inequality is the underlying cause of ill health; improvement of living conditions can benefit health more than medical care. Resource allocation influences the patterns of determinants; thus, policies and interventions are crucial to creating change in health outcomes. Rose similarly emphasized that policy changes aimed at reducing economic inequalities would in turn reduce health inequalities, thus leading to better         21  “national health overall.”(86, p127) Political action, although not the only required element, is necessary to first improve living conditions that would lead to a reduction in inequities. The health status of populations is a culmination of more than the health care system; it requires an understanding that it is the sum of all the DoH and policies and interventions that pervade their environment. Trying to improve mental health without understanding the context may be ineffective, as this does not address the underlying processes that lead the individual to be susceptible to developing mental illness.(50)  2.6.2    Influence of Population Health  In recognition of the overwhelming influence the DoH have on health, WHO stated in their 2008 report, “Health for All,” three components integral to addressing them: 1) multi-sectoral approach, 2) community involvement, and 3) appropriate technology.(120) This report provided a comprehensive strategy for improving health using a population health approach.(120) Relatedly, the Commission on Social Determinants of Health was established by WHO in March of 2005 to address the factors that lead to health inequities.(44) The Commission launched its final report on August 28, 2008 and in it, summarized its efforts to: 1) improve daily conditions, 2) tackle the inequitable distribution of power, money, and resources, and 3) measure and understand the problem and assess the impact of action by targeting the DoH and the ensuing results. A key recommendation was made that, in order to reduce health inequities and improve the health of populations, the DoH should be referred to as guiding principles.(44) As Marmot et al stated, “social injustice is killing people on a grand scale (3, p1661);” therefore, it is imperative to take action on the DoH by using a population health approach as the DoH exert their affects at the population level. Canada has taken a         22  leadership position in developing population health concepts and expanding its influence.(48) For example, Population and Public Health was included as one of PHAC’s branches,(121) the Canadian Population Health Initiative received $20 million funding for population health research,(122) and the Canadian Institutes for Health Research (CIHR), which funds research on population health through their Institute of Population and Public Health, included Population Health as one of their four pillars, alongside Biomedical, Clinical, and Health Services Research.(122) 2.6.3    Criticisms  Despite the influence and promise of population health for improving health status, population health as an approach is not without its criticisms. The first criticism is its perceived complexity (123) relating to its broadness in that it seemingly encompasses everything and is therefore not a strong candidate for guiding research or health reform policy.(110) Its vague nature has resulted in a lack of a common definition for population health in Canada (110) and confusion on how it differs from PH, community health, and health promotion concepts.(112) Relatedly, literature reports a lack of actionable strategies providing specific guidance for its mobilization.(123,124) It does not provide a “transparent means through which reality can readily be apprehended”(112, p393) and does not provide a useful model for enacting change.(7) Due to the lack of a repertoire of tangible actionable items in a population health approach, this has resulted correspondingly in a lack of agency from policy makers and healthcare professionals on reducing health inequities.(122)   The second criticism is related to the first, in that there is a lack of analysis on the context         23  surrounding the DoH, resulting in “context stripping,” as described by Raphael and Bryant.(118) A population health approach, while providing a clearer picture on the link between DoH and with health status, has been criticized for failing to address the wider influences – structural and circumstantial – that cause the differences in DoH in the first place and instead choose to focus on simply describing the differences.(124) Policy makers and healthcare providers avoid analyses of the causes of the social problems, the wider societal trends that influence living conditions and individual behaviours.(110) Integration of knowledge surrounding the DoH and action to reduce the differences to improve living conditions and health status rarely happens, as there is no single sector responsible for improving population health.(110) However, a key strength of a population health approach is its potential ability for analysis of outcomes across all the DoH.(110)  Thirdly, population health has been criticized for neglecting to seek input from individuals and communities on what they identify as their needs and their ideas on how they can take action to improve their own health.(124) There is a focus on policy, relying on top-down processes that depend on expert knowledge to create action residing at the policy level,(125) rather than grassroots and bottom-up processes that engage and empower communities by seeking input from those that are able to provide the most informed input.(118) Communities have been identified as the “crucible” (53) for a population health approach as most of the DoH exert their influence at the community level. Moreover, Vancouver Coastal Health Authority in BC has identified community participation as a cardinal tenet of a population health approach.(126) Encouraging         24  communities to assert their own power concurrently provides them with understanding of their situation and provides them with the required resources to address the “local reality.”(125) Only by seeking input from the communities in population health strategy design, implementation, and evaluation would we be able to truly address the health concerns.(115)   The last criticism relates to the fact that demonstrating benefits resulting from population health strategies is difficult as most outcomes require years to become apparent, and demonstrating a direct causal link between the strategies and the outcomes is even more difficult.(45) While many benefits of a population health will require time to materialize, there have been some positive outcomes, such as improved workplace satisfaction and increased sense of self through healthy workplace initiatives.(48) Data systems that can capture and validate the effectiveness of population health interventions will be required to convince policy makers to allocate more funds for upstream activities, including mental health promotion.(45) Thus, an important next step for a population health approach is to demonstrate its economic effectiveness on addressing the multiple DoH (45) and highlighting the DoH that require further resource allocation.(110) This will require a long-term commitment.(48)  2.7    Theoretical Framework Various theoretical frameworks, including Determinants of Health, Population Health, and Mental Health Promotion frameworks, were examined as a foundation for this thesis. The PHAC population health framework (16) was selected for a number of strengths,         25  including: 1) it is broad enough to capture the full complexity of the data selected for secondary analysis; 2) it is recent, from 2013; 3) the larger study from which this thesis draws upon used the PHAC definition of ‘collaboration,’ so there is alignment with the framework; 4) it is a Canadian framework that is relevant for the data used in this research, which come from two provinces of Canada; and 5) specific actions are provided under each Key Element to facilitate its mobilization.  Using the PHAC population health framework, there are eight Key Elements required for implementation of a population health approach and actions required by persons from all sectors for its mobilization, as listed in Table 1. Key Elements 1 and 2 are unique to a population health approach, while Key Elements three to eight “reflect implications of a population health approach and factors associated with good management practices.”(1, p5) All eight elements are crucial to implementing a population health approach. See Appendix B for a detailed explanation and rationale of the Key Elements and required actions for its mobilization (16):  Table 1: Summary Table of Population Health Key Elements (47) The goals of a population health approach are to maintain and improve the health status of the entire population and to reduce inequities in health status between population groups. Key Element  Actions  1. Focus on the Health of Populations: population health assesses health and health status inequities over the lifespan at the population level  Determine indicators for measuring health status   Measure and analyze population health status and health status inequities to identify health issues   Assess contextual conditions, characteristics, and trends  2. Address the Determinants of Health and Their Interactions: population health measures and  Determine indicators for measuring the determinants of health   Measure and analyze the determinants of health,         26  Key Element  Actions  analyzes the full spectrum of factors – and their interactions – known to influence and contribute to health and their interactions, to link health issues to their determinants  3. Base Decisions on Evidence: evidence on health status, the determinants of health and the effectiveness of interventions is used to assess health, identify priorities, and develop strategies to improve health    Use best evidence available at all stages of policy and program development   Explain criteria for including or excluding evidence   Draw on a variety of data   Generate data through mixed research methods   Identify and assess effective interventions   Disseminate research findings and facilitate policy uptake  4. Increase Upstream Investments: increasing efforts and investments “upstream” to maintain health and address the root causes of health and illness will help create a more balanced and sustainable health system  Apply criteria to select priorities for investment   Balance short and long term investments   Influence investments in other sectors  5. Apply Multiple Strategies: population health integrates activities across the wide ranges of interventions that make up the health continuum   Identify scope of action for interventions   Take action on the determinants of health and their interactions   Implement strategies to reduce inequities in health status between population groups   Apply a comprehensive mix of interventions and strategies   Apply interventions that address health issues in an integrated way   Apply methods to improve health over the life span   Act in multiple settings   Establish a coordinating mechanism to guide interventions  6. Collaborate Across Sectors and Levels: population health calls for shared responsibility and accountability for health outcomes with multiple sectors and levels whose activities directly or indirectly impact on health or the factors known to influence it    Engage partners early on to establish shared values and alignment of purpose   Establish concrete objectives and focus on visible results   Identify and support a champion   Invest in the alliance building process   Generate political support and build on positive factors in the policy environment   Share leadership, accountability and rewards among partners          27  Key Element  Actions  7. Employ Mechanisms for Public Involvement: population health promotes citizen participation in health improvement, from the development of health priorities and strategies to the review of health-related outcomes  Capture the public’s interest   Contribute to health literacy   Apply public involvement strategies that link to overarching purpose  8. Demonstrate Accountability for Health Outcomes: population health focuses on health outcomes and determining the degree of change that can actually be attributed to interventions   Construct a results-based accountability framework   Ascertain baseline measures and set targets for health improvement   Institutionalize effective evaluation systems   Promote the use of health impact assessment tools   Publicly report results  Note: Reproduction is a copy of the version available at http://www.phac-aspc.gc.ca/ph-sp/pdf/discussion-eng.pdf   Figure 2: Population Health Template (47) Figure 2 below provides a visual of how the elements are related and influence each other.  Note: Reproduction is a copy of the version available at http://www.phac-aspc.gc.ca/ph-sp/pdf/discussion-eng.pdf          28  Up to 70% of people with mental illness report their onset in childhood or adolescence,(30) so intervening early can have the greatest impact by addressing mental health problems before they develop into more severe clinical mental illnesses.(76) There is a need to utilize a population health approach to focus on upstream interventions by to protect mental health, rather than employing curative practices to treat mental illness after it develops.  2.8    Collaboration One Key Element of a population health approach is forming partnerships, both within and across sectors. The DoH that impact mental health lie mostly outside the health sector, so it is pertinent to engage in intersectoral collaboration to effectively combat mental health problems. Collaboration is “a recognized relationship among different sectors or groups, which is formed to take action on an issue in a way that is more effective or sustainable than might be achieved by the PH (or PC) sector acting alone.”(1) A pan-Canadian workshop on “PH and PC Collaboration” called for the PH Agency of Canada to support stronger collaboration between PC and PH to improve the health of populations. Evidence has shown that partnering PH promotion strategies with PC services can result in better access to care, strengthened health promotion through community level efforts, and increased synergy resulting in care that is comprehensive and greater than the sum of its parts.(127–131) 2.8.1    Collaboration Continuum The ways of working together in a collaboration ranges on a continuum, beginning from networking, which is the least formal and requires the least amount of trust in the other partner, to formal collaboration, which is the most complete and requires the most         29  amount of trust.(2,130) Based on work by Himmelman, collaboration is a dynamic process that requires all four strategies/relationships on the continuum: 1) networking: exchanging information for mutual benefit, where resources are generally kept separate; 2) coordination: exchanging information and altering activities for mutual benefit and to achieve a common purpose, where some resources may be shared; 3) cooperation: exchanging information, altering activities, and sharing resources for mutual benefit and to achieve a common purpose), and 4) formal collaboration: exchanging information, altering activities, sharing resources, and enhancing the capacity of another for mutual benefit and to achieve a common goal.(2,132) The level of working together depends on the situation and the degree to which the common barriers to working together – time, trust, and turf (familiar area) – can be overcome.(2) This study focuses on formal collaborations. 2.8.2    Collaborations between PC, PH and other sectors  Focusing on the health sector, it is widely recognized that one way to strengthen primary health care systems is by building stronger collaborations between the PC and PH sectors.(124–129) Formal collaborations between PC and PH for addressing specific purposes are becoming more widely implemented. For example, the Responsive, Intersectoral, Child-Community, Health, Education and Research (RICHER) social pediatrics initiative (133–135) involves multiple PC and PH organizations to deliver health promotion and development for children and their families who are vulnerable due to various social and economic disadvantages. Successful outcomes of the collaboration included increased knowledge skills of the staff and improved accessibility to care for the vulnerable patients.(133) Another example is the Nurse Practitioner         30  Cervical Screening Pilot Project,(136) where a number of health departments in Ontario placed PH nurses in PC offices to expand their utilization in PC offices to increase cancer screening for women.  2.8.3    Need for Collaborations between PC and PH in the Area of Mental Health  Currently, PC and PH play important, and at times overlapping, roles in providing mental health care. For example, one of the most important responsibilities of PH is health surveillance, defined by The National Advisory Committee on SARS and PH as “the tracking and forecasting of any health event or health determinant through the continuous collection of high-quality data, the integration, analysis and interpretation of those data into surveillance products (for example reports, advisories, alerts, and warnings), and the dissemination of those surveillance products to those who need to know.”(20) Increasingly, health surveillance functions (e.g., ongoing analysis of data, disease registries) are performed in PC and use clinical data.(137) However, Tannenbaum et al.,(2009) report, there is a lack of indicators for mental health surveillance in Canada.(138) Mental health surveillance is useful when the indicators also address the underlying root causes of distress, rather than focusing solely on symptomatic outcomes. Comprehensive and timely mental health surveillance requires linking multiple data sources (e.g., health administrative data, self-reported surveys) and tracking the indicators over time in order to effectively “plan and allocate mental health resources, monitor the effectiveness of new policies and programs, and assess the success of mental health reform.”(105, p192)   Monitoring the delivery of service and health outcomes in separate population groups         31  will be important, as certain groups (e.g., high drug users, Aboriginal populations) are at an increased risk of developing mental illness due to an interplay of the DoH. It has been purported that increased screening in the PC setting, particularly for those who are at an increased risk, will increase earlier detection, thus enabling earlier treatment and prognosis.(102) Screening can also take place in schools to detect and treat signs of mental health problems at an early age.(133)  Health promotion (e.g., creating physical and social environments to support health, intersectoral community partnerships to solve health problems) is another example of an interface between PC and PH.(137) However, despite the overlapping responsibilities PC and PH have for mental health services, mental health problems are being predominantly addressed in the PC setting and are not adequately supported in PH; there is not enough focus on prevention and mental health promotion, which are underfunded opposite of curative services in acute care (120,139) and other services.(140) Although effective collaborations between PC and PH have been reported for broad purposes, such as emergency response, environmental health, health promotion, and community surveillance and prevention (141) and for specific issues (e.g., tobacco cessation,(142) immunization (143)), there is a paucity of evidence for collaboration on the delivery of mental health services. Instances of collaborations between sectors and health professionals to improve the delivery of mental health services have generally been between PC providers and mental health specialists. For example, Katon et al.,(144) examined a collaborative care model for patients with depression and heart disease, diabetes, or both. The authors found that collaboration between individual PC practices         32  and a mental health team improved clinical outcomes, such as glycated hemoglobin level and systolic blood pressure. Results from a number of other collaborations between PC providers and mental health specialists have shown benefits such as: improved access to community resources for physicians,(58) increased access to services for patients,(97) increased satisfaction for both patient and provider,(145) improved clinical outcomes,(144,145) and a more efficient use of existing resources.(48,89,91,120) However, there is limited research on collaboration between PC and PH in the delivery of mental health care. Mental health promotion is the responsibility of all sectors as it affects everyone and is influenced by multiple DoH.(67) 2.8.4    Barriers and Enablers to Collaboration  Collaboration between the PC and PH sectors for mental health could reduce duplication and increase efficiency. However, collaboration can be fraught with challenges; there has been a historical disconnect between PH and other health care services and competition for resources that needs to be overcome to ensure a partnership’s success.(125) Convincing PC to engage in population-level based care (137) and similarly convincing PH to engage in individual-level care have been identified as challenges to widespread collaboration.(139) First and foremost, successful collaborations require clarity around the roles and functions of the PC, PH, and other sectors to ensure corresponding action at the policy and community levels.(125,137) This will also support the identification of common goals and objectives.(125)   Mental illness, although most often addressed in the PC setting by a PC provider (physician or NP), is a public health priority as individuals from all backgrounds are at         33  risk of developing mental health problems.(8,147) Due to its epidemiological expertise and long history of focusing on health promotion, two elements that are paramount to a population health approach, PH is viewed as a leader for delivering population health interventions.(139) However, a significant challenge to widespread collaborations between PH and other sectors is the historical disconnect between PH and the rest of the health care system,(148) potentially arising from a history of PH funding being diverted into other health services,(137) particularly into acute care.(139)   Increasingly, individuals are required to navigate a progressively complex system to visit multiple healthcare providers,(148) both due in part to the “excessive specialization” of healthcare providers (149) and also due to increasingly complex health issues that often involve physical, social, and mental health concerns.(150) This has resulted in “fragmented and fragmenting care” (149) that contributes to poor patient experience, an inefficient use of provider and patient resources, and poor patient outcomes.(148) It also results in a lack of continuity of care, defined as the quality of care over time and comprised of informational, management, and relational continuity.(151) It is crucial to engage communities to develop policy and create action according to the needs they identify.(125) As mental health is closely linked with the broader DoH that reside mostly outside the health sector, effective mental health promotion strategies depend on intra- and intersectoral collaboration to provide joint action. The health sector, specifically PH, is seen as the likely candidate to take on a leadership role in population health by engaging with other sectors to improve population mental health status.(115)           34  To our knowledge, no research has specifically examined how increased collaboration between PC providers (PC physicians, PC nurses), PH professionals (e.g. Medical Health Officers, PH nurses), and other organizations (e.g., school boards, community partners) could better meet the complex mental health needs of populations by engaging in mental health promotion and addressing the DoH. Increased collaboration between PC, PH, and other organizations could improve population mental health status through upstream efforts of prevention and mental health promotion to promote mental health, rather than rely on curative services that are currently not able to meet mental health needs.   My research examined the extent to which population health approaches were being utilized in collaborations between PC, PH, and other organizations that addressed mental health by identifying the activities being enacted. My research also examined how PC and PH could consider using a population health approach to better address the DoH that affect mental health by examining the barriers and enablers to conducting activities aligned with a population health approach. This has important implications for policy makers and PC and PH managers and providers, as it will shed light on the enablers and barriers to improving mental health status in collaborations between PC, PH, and other organizations using a population health approach.            35  Chapter 3: Methods 3.1    Overview/Context This thesis is a secondary analysis that uses data collected from a larger program of research. This section will introduce the original program of research, Strengthening Primary Health Care through PC and PH Collaboration, that took place across three provinces of Canada: British Columbia (BC), Ontario (ON), and Nova Scotia (NS).(130) The large interprofessional, geographically distributed research team that included academic researchers, decision-makers, staff and trainees from the three provinces and national leaders in PC and PH. The program of research aimed to: 1) explore the structures and processes required to build successful collaborations between PC and PH, 2) understand the nature of collaborative partnerships that currently exist in the three provinces, and 3) examine the roles that nurses and other providers played in collaborations.  The original program of research used multiple methods, including: 1) a scoping literature review; 2) provincial environmental scans (BC, ON, NS); 3) an interpretive descriptive study using key informant interviews; 4) multiple case studies; and 5) Q-sort methodology. More in-depth information about the program of research can be found elsewhere.(130) Although there were five separate and interrelated components, this Masters thesis is a secondary analysis of focus group data from four of the 10 cases that addressed mental health and/or the DoH.          36  3.2    Multiple Case Studies Examining Collaboration between PC, PH, and other Sectors As part of the program of research, a descriptive case study approach involving multiple case studies were conducted to develop a stronger understanding of the nature of existing collaborations and to examine the mechanisms of successful PC and PH collaborations. A case study approach attempts to examine a phenomenon in its real-life context, and is especially useful when the phenomenon and its context are linked.(152) The cases were either bounded by a specific program or a regional initiative, as long as services were provided through an inter or intra-organizational collaboration. The case may also involve more than one primary care organization (e.g., a group or Family Health Teams) and at least one public health department/unit in the region. The original case study research questions are included in Appendix C. The methods described below provide the context of where the focus group data used for this thesis were collected. 3.2.1    Participants Participants in the case studies included managers, front line professionals, and support staff from the PC and PH (e.g., dietician, social worker) sectors, as well as partners (e.g., hospitals, homeless shelters, community agencies) from other sectors. To protect the confidentiality of the participants, I have not provided the specific participant compositions of the focus groups. During data collection, there were three case studies collected in each of BC and NS and four in ON, in which one was a pilot case study.  Sampling was purposeful; cases were purposely selected for maximum variation for information that fit the needs of the original study.(153) To ensure maximum variation,(154) cases were selected to represent a variety of contexts, including staff mix         37  (e.g., multidisciplinary teams, solo physician practices); PC models (e.g., Family Health Teams, Community Health Centres); PH models (e.g., generalist, specialist); health care professionals involved in the collaborations (e.g., physician, nurse, business administrator); populations (e.g., vulnerable, women) and settings (e.g., rural, urban).(130,155) Additional eligibility criteria included: the collaboration involved a PH and a PC organization that had been in existence for at least one year and had continually worked together to develop and modify strategies to achieve their service delivery goals; collaborations must have begun to act on their plans; services could be provided on a full or part time basis (e.g., 2 or 3 days per week); and the collaboration had to include at least five active participants. Collaborations that involved multiple organizations, in addition to PC and PH, were included 3.2.2    Data Sources Multiple methods for data collection and data sources were used for the case studies, including: 1) the Partnership Self-Assessment Tool,(156) a valid and reliable tool that provided a measurement of the key indicators for successful collaboration and level of synergy; 2) two focus groups; 3) Photovoice,(157) which provides participants with the opportunity to conceptualize their collaborations using photos; and 4) content analysis of documents that were identified by the organizations as providing rich information about the collaborations. For the purpose of this thesis, I used focus group data from 4 of the 10 cases that addressed mental health and/or the DoH. These four cases were from BC and NS. I focused only on the focus group data because the other sources did not capture the topic of interest for my thesis; that is, the PSAT measured the effectiveness of the         38  partnership, the Photovoice captured the images and captions that generally provided evidence on the context of the cases and factors to successful collaboration, and the documents were mostly memorandums of agreement. I might have found some relevant data had I included the other sources, but they would not have been as rich.   3.2.3    Focus Groups There were primarily two types of focus groups that were conducted per case study, although more than one of each type of focus group was conducted, and in one case the two focus groups were combined due to scheduling difficulties. Focus Group A consisted of questions that expanded on the results of the Partnership Self-Assessment Tool. Scores from the Partnership Self-Assessment Tool were shared during the first half hour of the focus group. Afterwards, questions were asked that explored the results in more depth and included:  How does this score resonate with what you perceive about this collaboration?  Why do you think your collaboration received this score?  Focus Group B consisted of questions that further explored the processes and structures at the systemic, organizational, and interactional levels in the collaboration not covered in Focus Group A. Examples of questions included:  Describe any system level factors that are outside of the organizations that have influenced this collaboration.  What impact did PC players, PH players, clients/patients/community members and/or other organizations each have on the development of goals for this collaboration?         39   How do you share feedback between collaboration partners?  Managers, frontline professionals, and support staff from PC, PH, and other sectors were included in the different case study components to obtain information representative of all partners in the collaboration. Where possible, managers were separated from the frontline professionals and support staff for the focus groups, to encourage open and frank discussion. Focus groups were audio taped, anonymized, transcribed, and uploaded to NVivo.   In some cases, a third type of focus group, the Community Member Focus Group, was conducted in cases where community members played a prominent role in the collaboration. Questions asked of the participating community members included:  In what ways if any do you feel community members contributed to the leadership of this collaboration?  How does communication occur with community partners in the collaboration? A complete list of focus group questions can be found in Appendix D. 3.3    Secondary Analysis of Focus Group Data  This thesis draws on focus group data from four of the 10 cases that addressed mental health and/or the DoH to explore my research questions:  1. Do mental health activities, in collaborations between PC, PH and other organizations, incorporate a population health approach?   2. What are the enablers and barriers to conducting activities that incorporate a population health approach, in collaborations between PC, PH and other         40  organizations, in the area of mental health services?  Three cases focused on increasing access to care, specifically for marginalized and street-involved populations, through outreach programs and services. One case focused on communicable disease control and harm reduction that served a street-involved and/or homeless, population. This collaboration was formed by a coalition of community organizations. Another case was an urban outreach case that focused on improving immunization of a street-involved population against influenza and H1N1. The third case focused on urban child health promotion and family outreach and increasing access to services for marginalized populations in a large urban centre. The fourth case focused on improving access to health promotion and illness prevention for specific populations, including those vulnerable to developing mental illness. The emphasis was on improving access to health promotion and illness prevention for children and youth. See Table 2 for a detailed description of the four cases.          41   Table 2: Description of the Four Cases (130) Case Partners involved in collaboration Health issues addressed Goals Case A PC: PC clinics, RNs, PC physician PH: PH units, PHNs, PH physician, addictions worker, mental health, social worker, speech/audiology Other partners: A coalition of community organizations, including community stakeholders and partners, non-governmental organizations, outreach services, HIV-AIDS organization, and home care (e.g., licensed practice nurses) Homeless and/or street-involved population, sex trade workers, DoH. Meet mental health, addictions, harm reductions needs. Improve access to care for underserved populations, provide one-stop shop for care, protection, and outreach.  Case B PC: RNs, family physicians, administrators, managers PH: PHNs, managers, PH physicians Other partners: homeless shelters, needle exchange service, organizations working with sex workers, occupational therapists Immunizations for street-involved population. Informal goals are to improve access to care for street-involved population, prevention, protection, and outreach. Case C PC: PC services, PC physician PH: Health authority, NPs hired by the health authority Other partners: non-profit family support organizations, community centres, day cares, elementary schools, university, pediatricians Child health promotion/ development for those who do not necessarily have a regular source of care. DoH. Create resources to treat children and address DoH, reduce barriers to accessing PC for vulnerable populations, establish relationships with patients, surveillance, and sharing of information resources. Case D  PC: NPs, RNs, LPNs, family physicians, managers, administrators PH: PHNs, nutritionists, managers, youth coordinators, administrators, health educators Other partners: School board, family centre, mental health services, addictions services, and community representativeness Well baby, child, and youth health issues Improve comprehensiveness, including health promotion and illness prevention, of well child and youth health care and enable access to care/services. Note: NP=Nurse Practitioner; PHN=Public Health Nurse; RN=Registered Nurse    42 3.4    Population Health Framework  I used PHAC’s population health framework to explore the focus group transcripts from the original cases that examined the perceptions of PC providers, PH professionals and other sectors. I analyzed data from 4 of the 10 cases where mental health or the DoH were central to the focus. My research examined the extent to which population health approaches were being utilized in collaborations between PC, PH, and other organizations by identifying the activities being enacted. I also examined how PC and PH could consider using a population health approach to better address the DoH that affect mental health by examining the barriers and enablers to conducting activities aligned with a population health approach. 3.4    Analysis  A qualitative descriptive approach in addition to thematic analysis was used. A qualitative descriptive study aims to provide a comprehensive summary of the data organized in a way that best fits the data.(158) It is useful for researchers wanting to know understand the “who, what, and where of events.”(152, p338) Thematic analysis is a qualitative analytic method for “identifying, analyzing and reporting patterns (themes) within data.”(153, p79) Themes are broader than codes and often consist of a cluster of codes to encompass the broader level of meaning. Themes capture important meanings in the data related to the research questions and also patterns within the data.(159) Thematic analysis has been described as the most useful in capturing the complexities of meaning within a “textual data set” (154, p11) and the “most commonly used method of analysis in qualitative research.”(154, p11)   Initially, I familiarized myself with focus group data from one case first in order to immerse myself in the details and their context to examine the overall picture of the focus groups before     43 breaking them down into smaller parts through the process of coding. This is based on the hermeneutical circle,(161) which refers to the notion that the sum of the parts needs to be understood in relation to the whole, and vice versa (161); in other words, contextualizing prior to commencing breaking down of the data into codes is crucial to understanding the meaning of the exemplars. I deductively coded into PHAC’s Population Health Framework to look for alignment between the framework and the activities of PC, PH and other organizations in the collaborations and I inductively coded additional activities that fit the Population Health Framework, but were not explicitly part of the framework, to examine the gaps between the framework and the activities of actual PC and PH collaborations aimed at mental health promotion and/or at addressing DoH. In qualitative description, although researchers begin the analysis with an existing coding framework (i.e., PHAC’s population health framework), the framework is often modified during the course of analysis to provide a final coding framework that best fits the data.(158) While coding, I focused on not just the obvious (what is said) but also searched to find the hidden meanings between words.  With guidance from my committee, a preliminary coding framework was developed based on the PHAC population health framework’s eight Key Elements (16) and additional codes that were identified through reading and re-reading the focus group transcripts from one case. The resultant preliminary coding framework was a combination of the PHAC population health framework and the data itself. I met with my academic co-supervisors on a monthly basis to gather and apply their feedback on the continuously evolving coding structure and development of themes. We outlined a strategy for monitoring and improving intercoder agreement to maintain rigour, wherein my ongoing coding was reviewed and divergences brought up at each meeting. I     44 continued modifying the coding framework based on my co-supervisors’ feedback, specifically adding in new codes until I reached saturation, when there were no new explanations for the data.(162)   Once I completed coding for all 20 focus group transcripts from the 4 cases [see Appendix E for the full list of coded focus groups by case], one of my academic co-supervisors reviewed the coding for two transcripts and both my co-supervisors reviewed all coded data; subsequently, my third committee member reviewed all coded data and provided additional feedback at the committee meetings. Feedback from the committee meetings prompted the inclusion of coding at the activities-aspirations and enablers/barriers level. The reason for the activities/ aspirations distinction arose from the realization that much of the coded data was related to a population health approach, but only in aspirational terms (i.e., although participants identified many things related to a population health approach, for some they attributed these to aspirations they had, rather than actual activities being carried out in the collaborations). By incorporating this distinction in the coding framework, enhanced clarity and rigour around coding Research Question One (RQ1) was provided. Similarly, the reason for highlighting the enablers and barriers was to provide increased clarity and rigour around the coding process for Research Question Two (RQ2). Both additions helped serve as an audit trail.   I sorted the various codes into potential themes and subthemes within the Key Elements and followed Patton’s (163) criteria of internal homogeneity and external heterogeneity, where data within themes should be similar and between themes should be different. I considered how the themes fit together, how they fit into the overall picture, and how they related to my research     45 questions.(159) My committee members reviewed the preliminary themes and after incorporating their feedback, we agreed on a final 29 themes and 18 subthemes. For the Key Elements and themes taken directly from PHAC’s population health framework, a definition was provided to enhance clarity,(159) whereas for the additional themes identified from the data, I did not provide definitions as the names of the themes were self-explanatory.    The coding framework was finalized when all the coded data was examined and no modifications to the coding framework were required. This checking process was done to enhance clarity and rigour.(162) The final coding framework consisted of columns listing – from left to right – the original eight Key Elements from PHAC’s population health framework, themes from both the framework and the data, examples of the themes from the coded data, coding related to aspirations/ activities, and coding related to the enablers/ barriers. A sample of the final coding framework is provided below in Table 3 and the coding legend is provided in Figure 3; see Appendix F for the final complete coding framework.  Table 3: Sample of Coding Framework Key Element Theme Sub-theme Examples RQ1   RQ2 1) Focus on the Health of Popula-tions   Assessing health status and health status inequities of the population as a whole, as characterized by geography, age, gender, culture or other defining features, over the lifespan. Measuring population health consistently over time, across jurisdictions, and across health issues.  Specific actions required to mobilize a population health approach:  Determine indicators for measuring health status  Measure and analyze population health status and health status inequities to identify health issues  Assess contextual conditions, characteristics and trends   Focus on populations vs. individuals   We talk a lot about the individual client in primary care, and in public health, we talk about groups, schools, populations, communities as our clients so that can be a slightly different approach as well. [Case A – PH – BA] ASP IND     46 Key Element Theme Sub-theme Examples RQ1   RQ2 Under-standing the larger picture   They’ve been doing enormous work out there for homelessness and things like that, addressing the social determinants of health. So we have the same concept, you still manage the specific communicable disease, issue, or client, or thing, but aware of the broader stuff. [Case A – PH – MD]  ACT E Social justice focus     The values that sit with the people that are now in the senior management at Public Health are social justice values, are the true core public health values. So I think that’s the difference. And they are so hard to even articulate but you know it in your gut. Yes, I know that there are people that don't have that social justice framework and don't rally for the underdog. But that was the group that was most vulnerable [Case A – BOTH – OTH] ASP B Measure and analyze population health status and health status inequities   Well, [name] said it […] in an editorial once. And he said until we really address issues of poverty, the people in [province name] will continue to be not well served by the healthcare system […] it goes back to what [name] is saying about looking at disparities. [Case B – PC – RN] NO B   Figure 3: Coding Framework Legend Finally, I used the coding framework and themes to develop an analytical narrative that told a coherent story of the data related to my research questions.(159,160) For each Key Element, Coding Framework Legend   Grey shading indicates the 8 Key Elements from the original PHAC population health framework   Italicized text indicates the added themes that are not part of the original framework  Bolded text indicates the enablers and barriers   Descriptions are provided for themes from the original framework  The source is identified by [Case – SECTOR – ROLE]; e.g., [Case A – PH – BA] is a business administrator from Case A working in PH   Research Question 1: ACT = activity; ASP = aspiration; BOTH = both an activity and aspiration; IND = indeterminate; -- = neither; NO = activity is not being done  Research Question 2: E = enabler; B = barrier; BOTH = both an enabler and barrier; IND = indeterminate; -- = neither       47 activities and aspirations aligned with a population health approach were described in relation to mental health and enablers and barriers to conducting the activities were identified. Throughout the analysis, the coding framework served both as a data management tool and also as an audit trail, portraying the entire coding process and the final themes. The coding framework helped to keep things “plumb” (164) by facilitating alignment of the coding with the research questions during the analysis stage.   NVivo 11(165) was used for organizing and coding data. Insight and decisions obtained from the meetings were documented in the form of meeting notes and a personal journal. 3.5    Ensuring Trustworthiness and Rigour Four criteria of ensuring rigour developed first by Guba and Lincoln (166) were used: 1) credibility (truth value), 2) fittingness (transferability), 3) auditability, and 4) confirmability.   The first criterion is credibility, which refers to the confidence the researchers have in the truth of the findings as representing reality. Credibility has been argued as the most important criterion for rigour in qualitative research. In contrast to quantitative research, which emphases objectivity, qualitative research values subjectivity. I met regularly with my committee to gather and apply their feedback to help ensure credibility. I also documented an audit trail using a reflexive journal, committee notes, and detailed coding in the coding framework to provide what Yin calls “a chain of evidence”(142, p63).   Fittingness is the second criterion. Fittingness relates to both the degree of similarity between the study findings and contexts outside the study situation and the degree of similarity between the     48 study findings and data sources. When the study findings “fit,” its audience sees the findings as relevant. To facilitate “fit,” the case studies from the original program or research were selected using purposive sampling, which is intended to maximize the range of cases covered. Furthermore, participants from each case were selected to represent the full spectrum of the people involved in PC and PH collaborations.    Auditability is the third criterion and refers to when other researchers can arrive at the same or comparable conclusions using the same processes.(166) I ensured auditability by maintaining a journal to document a clear audit trail of my reflections throughout the data analysis and coding phase in order to keep my own values, assumptions, and potential biases in check.(167) I also used NVivo 11 (165) to create memos that I continuously reflected back on. The documentation in the journal and memos help ensure my analysis is defensible. In addition, my co-supervisors reviewed my coding to examine and address intercoder agreement/disagreement. The final coding framework detailed the coding at the level of my two research questions: 1) activities/ aspirations and 2) enablers/barriers.  The last criterion developed by Guba and Lincoln (166) is that of confirmability. Confirmability is related to neutrality, particularly neutrality in the data.(168) It refers to the researchers being able to confirm the findings using alternate perspectives,(169) indicating the data is neutral by being both truthful and applicable. Detailed records of the study’s methods and procedures are recorded to allow auditing by others. I utilized reflexivity to document my underlying epistemological assumptions that motivated my thinking and data analysis. The reflexivity will provide audiences with background information on how I formulated my research questions and     49 why I presented the findings in the way I did.  In summary, I maintained a reflexive journal to document and analyze my thought processes and perceptions of the data and the data analysis process itself. In it, I documented the relationships between codes and themes and their influences on each other and on the collaborations. I used the journal to guide the development of the codes and the coding structure. In addition, I created memos in NVivo 11(165) to help me reflect further on the coding process. To help facilitate epistemological integrity and representative credibility to prevent against researcher bias, pre-conceived ideas and theories regarding collaboration were noted and constantly checked to ensure they did not cloud my thinking and analysis. As part of the analysis, the themes developed from the descriptive analysis were compared to existing mental health policy in BC and NS. 3.6   Ethical Considerations Ethics approval to conduct the secondary analysis was granted by the Behavioural Research Ethics Board at the University of British Columbia (certificate number H15-01058). This study follows the guidelines outlined in the Tri-Council Policy Statement on Ethical Conduct for Research Involving Humans, revised most recently in 2014.(170) All identifying information was removed from the original interview transcripts and replaced with a unique participant identifier. My secondary dataset was stored on Workspace 2.0, a secure UBC on-campus cloud based file-sharing service that complies with Canadian, Provincial and UBC security requirements.(171) All relevant documents used for the secondary analysis, including my reflexive journal, will be shredded, and my secondary dataset deleted, upon thesis approval. Data from the original program of research will be stored for five years, per UBC policy.       50 Chapter 4. Results A total of 29 themes and 18 subthemes were identified as relevant for carrying out activities related to PHAC’s population health framework and can be found in Table 4. Eighteen of the 29 themes correspond directly with PHAC’s population health framework; that is, they are either a DoH (for Key Element 2) or a specific action required to facilitate and to mobilize a population health approach.(47) Each Key Element includes a number of actions required to mobilize a population health approach.(16) The remaining 11 themes were identified inductively from the coding. All 18 subthemes were identified from the coding. Although the analysis began with PHAC’s theoretical population health framework, the framework was modified during the course of analysis by the identification of themes and subthemes from the data to provide a final framework that best fits the data. All themes and subthemes fit within PHAC’s population health framework.   Bolded text using title case represents the Key Elements from the Population Health Framework, italicized and bolded text represents the themes, and lastly italicized text represents the subthemes. Quotes within paragraphs are encapsulated by quotation marks, while longer quotes are indented. The source of the quotes is identified according to participants’ [Case – SECTOR – ROLE]. For example, [Case A – PH – BA] is a business administrator from Case A working in PH. See Table 5 for a list of the role descriptions. Utterances, such as “ums” and “ahs,” and repetitions that did not contribute to the understanding or tone of the message, were removed to improve readability and clarity of the quotes.       51 Table 4: Final Coding Framework  Note: italicized text are the themes and subthemes that were identified through inductive analysis.   Key Element Theme Subtheme 1) Focus on the Health of Populations:   Determine indicators for measuring health status  Measure and analyze population health status and health status inequities to identify health issues  Assess contextual conditions, characteristics and trends Focus on populations vs. individuals  Understanding the larger picture  Social justice focus    Measure and analyze population health status and health status inequities  2) Address the Determinants of Health and Their Interactions  Determine indicators for measuring the determinants of health  Measure and analyze the determinants of health, and their interactions, to link health issues to their determinants i) Income and social status Address poverty  ii) Social support networks Provide community support services Provide home check-ins for elderly iii) Education and literacy Support education around nutrition and healthy eating iv) Employment/ working conditions  v) Social environments Provide social activities for kids vi) Physical environments Develop more homeless shelters  Ensure care is delivered to the homeless or those living in rooming houses Conduct rooming house visits Work with homeless youth vii) Personal health practices and coping skills  viii) Healthy child development Advocate for children and their families     52 Key Element Theme Subtheme Create extracurricular programs for children  Develop a healthy food program  Support a wraparound approach to providing care for families ix) Biology and genetic endowment  x) Health services Support a one-door policy and hub for health services Lack of communication and service integration  xi) Gender  xii) Culture   3) Base Decisions on Evidence  Use best evidence available at all stages of policy and program development  Explain criteria for including or excluding evidence  Draw on a variety of data  Generate data through mixed research methods  Identify and assess effective interventions  Disseminate research findings and facilitate policy uptake Identify and assess effective interventions   Poor data systems  Public health intervention outcomes take time   4) Increase Upstream Investments  Apply criteria to select priorities for investment  Balance short and long term investments  Influence investments in other sectors Focus on upstream approaches  5) Apply Multiple Strategies  Identify scope of action for interventions  Take action on the determinants of health and their interactions  Implement strategies to reduce inequities in health status Apply a comprehensive mix of interventions and strategies  Provide outreach services      53 Key Element Theme Subtheme between population groups  Apply a comprehensive mix of interventions and strategies  Apply interventions that address health issues in an integrated way  Apply methods to improve health over the life span  Act in multiple settings  Establish a coordinating mechanism to guide interventions Provide referrals  Create programs for youth health   6) Collaborate Across Sectors and Levels  Engage partners early on to establish shared values and alignment of purpose  Establish concrete objectives and focus on visible results  Identify and support a champion  Invest in the alliance building process  Generate political support and build on positive factors in the policy environment  Share leadership, accountability and rewards among partners Identify and support a champion   Invest in the alliance building process  Engage partners early on to establish shared values and alignment of purpose Employ a participatory model  7) Employ Mechanisms for Public / Community Involvement  Capture the public’s interest  Contribute to health literacy  Apply public involvement strategies that link to overarching purpose Apply public involvement strategies that link to overarching purpose Engage stakeholders Build relationships with target population   Focus on the community    8) Demonstrate Accountability for Health Outcomes Specific actions required to mobilize a population health approach:  Construct a results-based accountability framework including a clear statement of roles and responsibilities   Ascertain baseline measures and set targets for health improvement  Institutionalize effective evaluation systems  Promote the use of health impact assessment tools  Publicly report results No formal evaluation mechanisms and accountability structures  Accountability structures and processes      54 Table 5: List of Participant Role Descriptions Acronym  Role BA Business Administrator  HEP Health Educator/Promotor  MD Medical Doctor NP Nurse Practitioner OTH  Other (childhood educator, researcher, developmental specialist)  PHN  Public Health Nurse RN  Registered Nurse  SA Senior Administrator  SP Specialist   Overall, participants indicated that mental health activities in collaborations between PC, PH, and other organizations did incorporate and/or integrate a population health approach. Many participants identified the importance of providing care, using strategies that are aligned with the Population Health Framework. Some of the participants described actual activities that were being carried out in their collaborations, while others described aspirations they had for supporting their goals and did not specify whether these aspirations were being carried out in the form of activities. Participants from across the four cases described the barriers and enablers to conducting activities that incorporate a population health approach, and sometimes described changes that were being enacted to alleviate the barriers.   Results will be presented separately for each of the eight Key Elements of PHAC’s population health framework (47) and further divided according the themes and subthemes of each Key Element. The detailed coding framework, along with the quotes, is presented in Appendix F. Within each Key Element, I will present the relevant literature and then the findings to answer the research questions:  1) Do mental health activities, in collaborations between PC, PH and other organizations, incorporate a population health approach?       55 2) What are the enablers and barriers to conducting activities that incorporate a population health approach, in collaborations between PC, PH and other organizations, in the area of mental health services? Lastly, I end each Key Element with a brief discussion in connection with the literature. Results are presented this way for two pragmatic reasons: 1) to provide clarity by identifying whether each Key Element is being employed in the cases and 2) in qualitative description, no description of the data is free of at least some interpretation.(158)  4.1    Key Element 1: Focus on the Health of Populations  A population health approach “focuses on the interrelated conditions and factors that influence the health of populations over the life course, identifies systematic variations in their patterns of occurrence, and applies the resulting knowledge to develop and implement policies and actions to improve the health and well-being of those populations.”(3, p6) The overall goal of a population health approach is to improve the health of the entire population.(1,115) This is done by focusing actions for health improvement across all levels, from the family and individual levels to the national and provincial levels.(16) The first Key Element: Focus on the Health of Populations from PHAC’s Population Health Framework addressed the importance of understanding the contextual influences of peoples’ lives, of what puts people “at risk of risks.”(5, p3)   Four themes were identified for this key element that were common among participants, three of which came from an examination of the data: 1) focus on populations vs. individuals, 2) understanding the larger picture, and 3) social justice focus, while the last one: 4) measure and     56 analyze population health status and health status inequities, was from the population health framework. See Table 6 for the themes and subthemes for Key Element 1. Table 6: Key Element 1 Themes and Subthemes Key Element Theme Subtheme 1) Focus on the Health of Populations:   Determine indicators for measuring health status  Measure and analyze population health status and health status inequities to identify health issues  Assess contextual conditions, characteristics and trends Focus on populations vs. individuals  Understanding the larger picture  Social justice focus    Measure and analyze population health status and health status inequities   4.1.1    Focus on Populations vs. Individuals  The first theme identified by three participants from three different cases was a focus on populations vs. individuals. This theme emphasized the overarching goal of a population health approach as improving the health of populations (communities, groups of people, etc.,),(45) thus requiring social and political action to target the wide range of determinants that have their impact on the mental health of individuals at least partially at the population level.(110) A registered nurse from Case B mentioned the activity their collaboration carried out around speaking “on the behalf of [collaboration name] and what our experiences are in the community […] Which then hopefully will impact the overall health of [citizens of a province] [Case B – PC – RN].” The nurse recognized the larger goal of improving population health. This focus on populations vs. individuals was echoed in the aspirations described by a participant from Case D, who said:  I’m trying to meet client need. I’m trying to have better access. I’m trying to have better referral for resources and better knowledge about resources. I’m trying to do the upstream, that whole model of upstream to downstream. The whole continuum of prevention and health promotion. So those are my goals. So that at the end of the day, we have a healthier community population [Case D – BOTH – OTH].     57 This participant identified enablers, such as “meet client need,” “have better access,” “better referral for resources and better knowledge about resources,” and address the “whole continuum of prevention and health promotion” to supporting a focus on populations.  4.1.2    Understanding the Larger Picture The second major theme identified by seven participants, mostly from Case A, was understanding the larger picture. This refers to the importance of understanding the complex and dynamic processes through which social and physical factors operate to affect mental health, (50) or “contextualizing risk factors.”(50) This major theme can be summed up by a registered nurse’s exertion “we need to think in a bigger way [Case B – PC – RN].” An individual’s mental health is affected by a multitude of interacting factors’ and improving mental health requires an understanding of the factors that are not immediately apparent.(78)  A physician similarly stated, “so many of our clients have multi needs. They just don’t come to us with one need. […] Maybe they’ve got substance abuse and maybe they’ve got mental health you know [Case A – BOTH – MD].” This participant emphasized the fact that mental health problems do not act in isolation; they are often compounded by other health issues. Similarly, a public health nurse pointed out the collaboration has highlighted the important activity of:  And also to look after their social aspect and things like that. And it’s just nice to have that collaboration and, “outreach staff is doing this part and I’m doing this part”. And if we just kind of touch base once in a while, “so how are things going from your angle?” So you know it’s good that you’re looking at them from different aspects [Case A – PH – PHN].  The enabler to focusing on the health of populations here is “looking at them from different aspects,” since there are a range of factors and conditions that affect mental health. Another     58 enabler a participant discussed was supporting patients “in being able to take that medication on a regular basis as it’s being prescribed,” and not merely “prescribe[ing] the medication [Case A – BOTH – OTH].” A physician working in both PC and PH said the collaboration supported them in the activity of delivering care that factored in the larger context:  working with a team you have the benefit of having a little bit broader perspective on the social issues and housing issues and some of the other, you know, not specifically biomedical issues […] the opportunity to kind of share clients back and forth and build on each other’s strengths is really facilitated by having the multidisciplinary team all on your one corridor [Case A – 05 – BOTH – MD]. Implicit in the above quote is the recognition that the collaborations facilitate mental health activities that are not limited to health services, by emphasizing a “broader perspective” through the enabler of having a “multidisciplinary team on your one corridor.” A public health physician attested to organizations in the collaboration understanding the larger picture by describing the activity “they’ve been doing enormous work out there for homelessness and things like that, addressing the social determinants of health [Case A – PH – MD].”   The focus on understanding the larger picture was further exemplified by a registered nurse discussing how providing care does not merely involve the delivery of health services, it involves “go[ing] where people are, and we kind of get to know them, and you know where they hang out, you know where they eat [Case B – PC – RN].” Incorporating a population health approach into care delivery requires “put[ting] the time in to actually really participate actively in all of the issues that affect the social determinants of health as well as your own particular piece [Case C – PC – NP].” This was identified as key to understanding the larger picture.      59 4.1.3    Social Justice Focus The last major theme that was identified from the data by a participant was a social justice focus. Marmot, chair of the Commission on Social Determinants of Health, et al.,(43) stated that health inequalities are avoidable; therefore, reducing the inequalities is “an issue of social justice.” Marmot et al.,(43) and Link & Phelan (50) emphasized policy change incorporating a social justice focus is paramount to affecting change targeting the conditions that impact health and contribute to health inequalities. Although no participant spoke to activities being conducted that incorporated a social justice focus, a participant from Case B working in the PH sector spoke to aspirations around their senior management team having “social justice values” and the potential enabler of having a “social justice framework” in order to “rally for the underdog [Case A – BOTH – OTH].” 4.1.4    Measure and Analyze Population Health Status and Health Status Inequities The last major theme, measure and analyze population health status and health status inequities, was a required action from the population health framework (46) and was identified by two participants. At its core, population health has a responsibility to measure and analyze population health status, such as current trends in health issues and key health issues, to identify the factors that influence the health of populations,(110) the most pressing health concerns (126) and inform budget allocation among competing priorities.(47,126) Key to supporting this major theme is population-based surveillance and intelligence gathering.(126) Although a business administrator identified surveillance as “one of the approaches we use in PH” to see “that broader picture,” it is conversely something that “we don’t really expect the PC provider to do, that broad surveillance [Case A – PH – BA].” This speaks to surveillance as being viewed traditionally more as a PH responsibility, rather than as a shared responsibility. However,     60 measuring and analyzing population health status, tasks required for “looking at disparities [Case B – PC – RN],” requires joint action by both PH and PC to aptly address the health issues of populations.   4.2    Key Element 2: Address the Determinants of Health and their Interactions It has been increasingly shown that the healthcare system is limited in its contributions to maintaining and improving the health of populations. There is mounting evidence that a number of other factors, termed the DoH, have greater influence over the health and social status of populations.(41–43,172–174) The 12 DoH identified by PHAC in their Population Health Framework (16,46) as influencing population health are: i) income and social status; ii) social support networks; iii) education; iv) employment/working conditions; v) social environments; vi) physical environments; vii) personal health practices and coping skills; viii) healthy child development; ix) biology and genetic development; x) health services; xi) gender; and xii) culture.(41,44,47) Each of these DoH are important influences on health independently, but they are also interrelated, hence population health has been described as addressing the “patterns” of DoH.(110) In this Key Element the themes are the DoH.   Address the Determinants of Health and their Interactions is the second Key Element that most participants discussed as influencing their care delivery in the collaborations. Measuring and analyzing the full spectrum of determinants – and their interactions – known to influence and contribute to mental health is the hallmark of a population health approach.(110) Reflecting the importance of this Key Element, participants from the 4 cases spoke to 8 of these 12 themes. The order of the eight themes discussed by the participants will be presented in the order outlined in the population health framework,(47) whereas the four themes not mentioned by participants will     61 be summarized at the end of this section. See Table 7 for the themes and subthemes for Key Element 2. Table 7: Key Element 2 Themes and Subthemes Key Element Theme Subtheme 2) Address the Determinants of Health and Their Interactions  Determine indicators for measuring the determinants of health  Measure and analyze the determinants of health, and their interactions, to link health issues to their determinants i) Income and social status Address poverty  ii) Social support networks Provide community support services Provide home check-ins for elderly iii) Education and literacy Support education around nutrition and healthy eating iv) Employment/ working conditions  v) Social environments Provide social activities for kids vi) Physical environments Develop more homeless shelters  Ensure care is delivered to the homeless or those living in rooming houses Conduct rooming house visits Work with homeless youth vii) Personal health practices and coping skills  viii) Healthy child development Advocate for children and their families Create extracurricular programs for children  Develop a healthy food program  Support a wraparound approach to providing care for families ix) Biology and genetic endowment  x) Health services Support a one-door policy and hub for health services Lack of communication and service integration  xi) Gender  xii) Culture    4.2.1    Income and Social Status  The first DoH mentioned by three participants as affecting mental health is income and social status, which has been identified as the most important of the 12 DoH.(41,48) Mental health status is directly related to income and social status, which foremost affects the ability to meet basic needs and make choices in life. Income affects most of the other DoH, such as education,     62 housing, and food security.(41) Lower income and social status has been associated with lower health status,(48) lower life expectancy, and higher mortality rates.(50) The Whitehall study, a major study of British civil servants, showed that health status was positively correlated with job rank (43,44); conversely, lower social status is related to a lower degree of control over life circumstances and consequently increased vulnerability to developing illness due to stress.(49) Lastly, income affects the ability to select and pay for important treatment options that otherwise might not be accessible.(30)   A participant from Case C described a majority of their target population as: dealing with income needs or income for housing, etcetera. So when a kid ends up in ICU because they are living in a basement that’s got three inches of water in it and they can’t breathe because of the mould, etcetera. Well part of that is health because health is ending up paying for the treatment of that child. But the root to changing that or the conditions actually comes into financial support and/or housing [Case C – OT – OT].  A NP from Case C described the enabler of “jointly working to problem solve something that might actually be, fall more accurately if we file things into the social services or income assistance realm [Case C – PC – NP].” The same NP expressed frustration at some other members of the collaboration for not giving up “60 minutes a week” for the weekly meeting the collaboration holds, which influenced the collaboration’s ability to address income. The barrier is then “we don’t have a relationship and you don’t get the income services and you don’t get to be in places where the care is delivered and you don’t get any of what you’re doing [Case C – PC – NP].”        63 A subtheme was address poverty. While it is clear that poverty has a monumental impact on mental health, it is unclear of how to effectively target poverty, due to the multiple cross-cutting sectors and strategies this would involve.(43) Three recommended policies are to employ progressive taxation, increase the minimum wage, and increase assistance levels for those unable to work due to a disability.(41) In an extensive report, the Commission on (Social) DoH put forth a recommendation for governments (provincial and federal) to provide and support a universal comprehensive social protection policy that supports individuals in improving their mental health status.(43,44)   A participant from Case C described an activity that was done, where “a letter was written by a schoolteacher,” that “created a wonderful dialogue about how we don’t get into poverty pornography, but how we actually include families in the discussion about what is it they’re going to need to be successful when their children are in school and it brought a really healthy dialogue [Case C – PC – OT],” The key enabler is to “include families in the discussion,” Aside from this quote, participants did not discuss engaging in activities related to the DoH income and social status and the subtheme address poverty. Poverty and health disparities need to be addressed, which was emphasized by a registered nurse: “Until we really address issues of poverty, the people in [name of province] will continue to be not well served by the healthcare system [Case B – PC – RN].” 4.2.2    Social Support Networks The second DoH is social support networks. Receiving social support from family, friends, and communities is associated with better health status.(48) Strong social support networks serve as a protective factor against developing mental illnesses by helping people solve problems, cope     64 with adversity, and maintain a sense of control over life circumstances.(49) A study conducted in the US found that the more social contacts people have, the lower their premature death rates.(49) This highlights the important benefits of families and friends in providing emotional resources, such as caring, respect, and trust, in addition to tangible resources such as providing basic support in the form of food and housing.(49)  Two participants highlighted social support networks as an area for improvement. By strengthening people’s connections in the community, social support networks can first act as a buffer from developing mental health problems (50) and also help individuals who have experienced mental illness to “transition back into community. Because there’s a real gap there and there’s a little isolation because they haven’t lived in the normal population. And fear judgment, and accessing services [Case A – PH – PHN].”  There were two subthemes identified within the DoH social support networks: 1) Provide community support services and 2) Provide home check-ins for the elderly by two participants. A participant from Case A pointed to the aspiration of “getting [them] more onto regular, normalized community, to be able to have some services there to help them and support them in that transition back into community because there’s a real gap there and there’s a little isolation because they haven’t lived in the normal population [Case A – BOTH – OTH].” The participant pointed to the enabler of community-based services to support patients’ transition back into the community. A family practice nurse pointed to the aspiration of having “a check-in program for elderly people that live home alone with no support systems, just to have someone touch base with them either by phone, to make sure there’s been no falls. And if there has been, someone     65 that can touch base with the doctor [Case D – PC – FPN].” This participant alluded to the enabler of having social support networks, in this case in the form of a check-in program, to support the recovery of patients.   Patients First, a discussion paper initiated by the government of Ontario and incorporating feedback from Ontarians, proposed four key proposals to strengthen patient-centred health care in Ontario, one of which was providing “more consistent and accessible home and community care”(175) by ensuring better integrated care, including services provided by provide community support services and mental health and additions. This is crucial to supporting patients in their transitions from acute and primary care to care in the home and community (175) and supporting their access to mental health and addictions services in the community.(55,70)  4.2.3    Education and Literacy The DoH education and literacy is closely tied to the DoH income and social status.(41) Education is positively correlated with health status through mechanisms such as providing individuals with a sense of mastery and control over life decisions and events,(48,49) education helps increase understanding of and provides resources and options for engaging in mental health promotion, mental illness prevention, and mental illness treatment.(41,50) Higher education and literacy increases opportunities for jobs with higher satisfaction and lower stress, while people with low literacy skills are more likely to be unemployed and have poorer health status than people with higher literacy skills.(176) Education is crucial and starts in early childhood, providing increased life opportunities.(44)       66 Three participants attested to the importance of education. One participant from Case C mentioned that the activity of “just getting that education out there,” emphasizing the “educational piece,” allows the clients to “access so many more resources [Case C – PC – OT].”   In addition, a public health nurse pointed to the first of two subthemes, buying books for the program, indicating “there’s no money for education [so] we could use that money to buy a book [Case C – PH – PHN].” The participant was referring to the honorarium provided to the research participants in cases for participating in the study. The public health nurse spoke to the barrier of having no funding for education and, recognizing the importance of education, elected to use the funds to support education of their clients.   Two participants, one from Case C and the other from Case D, brought up the second of two subthemes, support education around nutrition and healthy eating. They mentioned the activities their collaboration did around supporting this subtheme, including embodying “healthy living [Case D – PC – FPN]” and providing a healthy menu, which is illustrated by the quote below:  We set up the menu and everything and then got the dietician to come in and review it and say what was, what was good about it and what needed twigging. So we did that. And then it took a while for our families to actually, our kids, and the staff, to want to eat these healthy dishes. But now it’s like, great you know we’re eating tofu, beans and couscous or whatever and they all love it, right [Case C – PC – OT]? Support education around nutrition and healthy eating, particularly for young children, is important as eating nutritious foods helps them grow and develop, and provides them with the energy to perform academically and physically. Healthy eating also promote physical health and mental health.(44)     67 4.2.4    Social Environments  Social environments, an extension of social support beyond family and friends to the larger community, is a DoH that is crucial to fostering mental health.(49) The social environment consists of the people, institutions, and organizations surrounding us.(49) Social or community support comprises part of the social environment, and similar to social support networks, can help act as a buffer against mental illness by enhancing an individual’s ability to cope with change and adversity.(176) Health is dependent on healthy communities that promote mental health and support people who have a mental illness.(150) In recognition of this, the BC provincial government provided a $10-million grant in 2008 and established the Community Action Initiative to support communities in their mental health promotion activities, prevent substance use problems, and support treatment when problems occur.(60)   Social environments was discussed by four participants, one of whom spoke to the activity in the collaboration: [we] look after their social aspect and things like that. And it’s just nice to have that collaboration and, “outreach staff is doing this part and I’m doing this part.” And if we just kind of touch base once in a while, “so how are things going from your angle?” So you know it’s good that you’re looking at them from different aspects [Case A – PH – PHN]. The public health nurse mentioned the activity and enabler of looking at the clients from different perspectives, similar to another participant’s description of their collaboration as conducting the activity “addressing the social determinants of health” and the enabler of being “aware of the broader stuff [Case A – PH – MD].” A childhood educator from Case C said, “We’re opening facilities that have a strong model of capacity building and connecting resources [Case C – OT – CD],” describing another activity their collaboration was engaging in.     68  A participant from Case D briefly mentioned the subtheme and activity provide social activities for kids, saying: We had the whole [family resource centre name] beautiful initiative that was driven by community health boards, primary healthcare, public health, where we put a person down there to give those kids other activities to do besides getting drunk and having sex or whatever the heck they do [Case D – BOTH – OTH]. Having a supportive social environment is conducive to personal growth and mental health.(50,60) 4.2.5    Physical Environments Physical Environments, composed of natural factors (e.g., air, water quality) and human-built factors (e.g., housing and design of communities) (49) is one of the key themes many participants discussed. While natural factors are equally important to mental health, I will be focusing on the human-built factors, in particular housing and homelessness, as this is a very pressing issue for people living with mental illness and was discussed by many participants. Up to 200,000 people are homeless in Canada each year.(51) Access to good-quality housing and shelter are basic needs for healthy living.(44) If people’s basic needs are not met, this makes it difficult for them to live a healthy life. Living in unstable and poor housing results in increased levels of stress, while people who are able to afford quality and stable housing are required to devote more of their resources towards this DoH.(41)    To confound the problem, people with mental health problems are at an increased risk of experiencing homelessness or finding stable housing (28,60,150,177) and conversely, being homeless can worsen existing mental health problems.(41,55) As a testament to the importance     69 of stable housing in supporting mental health, a key strategic direction from the Mental Health Commission, in their report Changing Directions, Changing Lives,(55) is to increase the availability of safe, secure, and affordable housing with supports for people living with mental health problems and illnesses. To this end, the federal government, in 2008, invested $110 million for a research project aimed at examining the effectiveness of Housing First (HF), an evidence-based intervention housing model that provides immediate housing and supports for people that were homeless and experiencing mental illness. This study, which took place across five provinces in Canada (Vancouver, Winnipeg, Toronto, Montréal, and Moncton), demonstrated (51) that Housing First is effective at ending homelessness while reducing costs.   Three cases focused on increasing access to care for marginalized and street-involved populations that were influenced by clients’ physical environments, specifically the human-built environment. One participant explained their collaboration as: So [street outreach] sort of spreads themselves over the city in any areas where there’s a higher incidence of number of people who have health issues. That’s sort of the kind of entry point most of the time for [street outreach], is people with inadequate housing. So that’s sort of the bottom line, if you will. And then they’ll see anybody with any kind of issues that happen to exist. It strays a little bit because sometimes there are people that are sort of housed but not necessarily well housed that are isolated. And so they might get involved in that way as well [Case B – PC – MD].  A key strategy to addressing homelessness, outlined above, and which is also the first of four subthemes, is to develop more homeless shelters. Simply put, housing policy must provide affordable housing available for all Canadians, adhering to the Affordable Housing Framework     70 Agreement of 2001and increase funding for social housing programs for low-income Canadians.(41) This was illustrated by a participant who described the aspiration of “one of the goals would be to do some community development to provide some services to the marginalized population, to get better treatment facilities for drug and alcohol addictions and to develop more homeless shelters for this population [Case A – PH – PHN].”  Three participants spoke to the second subtheme of ensure care is delivered to the homeless or those living in rooming houses, including the following aspiration: “There needs to be a broader community development approach to try and make change and build resources for homeless people and for people with drug addictions [Case A – PH – PHN].” This public health nurse identified the enablers of incorporating a broader community development approach and building resources for homeless people. Another nurse, from the PC sector, noted a similar aspiration and enabler of “mak[ing] sure that services are provided. That Public Health has on their radar how we are going to make sure that folks who are homeless or living in isolation in rooming houses and in all those spots, how do they get the public health care, the public health service, health promotion [Case B – PC – RN]?” While the participants identified aspirations, they did not speak to many activities being done to ensure care is delivered to the homeless or those living in rooming houses, aside from a medical doctor’s assertion that the “entry point most of the time [Case B – PC – MD]” for accessing services provided by their collaboration “is people with inadequate housing.” He mentioned, “So that’s sort of the bottom line” and the enabler “they’ll see anybody with any kind of issues.” Providing supportive housing helps keep people off the streets and out of the corrections and criminal justice systems.(150)      71 The last two subthemes, conduct rooming house visits and work with homeless youth, were brought up by two participants as activities in their collaborations in which they were engaging. A registered nurse mentioned the “rooming house visits” they conducted, while a Occupational Therapist (OT) working in the PC sector brought up how their collaboration “shifted form early child development focus to including adolescent health and recruiting the new adolescent health physician who’d worked with homeless youth and had new recruits looking at resiliency and youth [Case C – PC – OT].” However, addressing the issues of housing and homelessness requires changes at the policy level. The provincial governments of BC, ON, and NS recognized the importance of creating inclusive and resilient communities by addressing the issue of homelessness; providing affordable housing was brought up in their first provincial mental health and addictions strategies.(60,150,177) These strategies enable us to take a first step toward addressing one of the key DoH.  4.2.6    Personal Health Practices and Coping Skills  The DoH personal health practices and coping skills relates to the actions individuals take to promote mental health and prevent mental illness. While this is focused at individual level, there is mounting recognition that individual choices and practices are hugely influenced by the other DoH, particularly the social and physical environments and income and social status.(49,178) There is also a need to supplement the development of personal health practices and coping skills with systems level strategies that increase access to goods, products, and services.(178) Coping skills are developed through a sense of mastery and personal growth and enable individuals to take action to support their health and that of their families.(48)       72 This DoH was mentioned briefly by two participants, the first of who spoke to the activity that was conducted by the OT, who “helped work out a system for [the patient] to take his medication [Case B – PC – RN].” The registered nurse elaborated on the beneficial impact the OT had on the patient, saying “that relationship has grown to the point where he now goes with her a little bit and gets food before he spends all his money. And then he was going and getting a bus pass with her, and now he’s gotten to the point where he goes and gets his own bus pass.” Assisting patients with mental health problems by providing guidance on simple, yet important tasks like taking medication, allows individuals to learn to cope with their tasks on their own, thus enabling them to develop a sense of control over their lives.(67)  4.2.7    Healthy Child Development Healthy child development was a theme mentioned frequently; particularly by participants from Case C, a collaboration that focused on child health promotion by creating resources to treat children and to address the DoH. Young children are especially affected by the DoH as they are developing and growing.(49) It is therefore imperative that children grow up in supportive environments with unconditional love, respect for individuality, and healthy relationships.   There were four subthemes identified. The first was advocate for children and their families, which is paramount to supporting good health and growth in children and subsequent success. Early child development affects subsequent life changes through skills development, education, and occupational opportunities, and has large effects for later years.(44) Educational programs and schools are part of the social and physical environment that contribute greatly to building children’s’ capabilities.(44) While this subtheme was only mentioned once, by a participant from Case C, the following quote exemplifies its importance, “I guess what I see my role as is     73 advocating for children and families so that they can be supported in all areas, whether it be financial, health, or just having their voices heard for their families [Case C – PC – OT].”  One way of supporting the development of children is through the second subtheme, create extracurricular programs for children. A participant from Case C described the following activity: “They created an early childhood early learning assessment program through direct service delivery to the children and to the childcare center where they did a music program and a drawing program for kids where they repeated songs around ABC’s, colors and numbers [Case C – OT – CD].” Illustrated here is the understanding that educational programs not limited to the classroom, such as a music program to give children living in lower-income neighbourhoods the opportunity to experience music, can play a vital part in supporting the social and cognitive development of children.(44)  The third subtheme is the application of develop a healthy food program. Good nutrition is crucial, and its importance starts before birth with the nutrition of mothers and continues through childhood, adolescence, and into adulthood and old age.(44)  The last subtheme, mentioned by three participants, is support a wraparound approach to providing care for families. This is related to the larger Key Element: Address the Determinants of Health and their Interactions. A participant from Case C mentioned the activity their collaboration was involved with: “We support not just licensed childcare but the whole wraparound approach to families, which includes supporting food, housing, childcare. […] We’re opening facilities with a very strong, that has a strong model of capacity building and     74 connecting resources [Case C – OT – CD].” Depicted here is the enabler of providing a strong model of capacity building and connecting resources, which is possible through incorporating a wraparound approach. Other participants described aspirations of “if we could engage with them [physicians] and in particular mental health, that if I could call another besides having one representative for community health nursing and sort of that wraparound sort of family approach [Case C – PC – OT],” and “trying to support them in regards to the parenting [Case D – BOTH – OTH].” The enablers to achieving the aspirations described by the participants attest to the importance of implementing a wraparound approach to providing care for families that addresses many aspects of a family’s needs.  4.2.8    Health Services The theme Health services is comprised of services provided by primary care, public health, and specialist health services sector and include the continuum of care from treatment to secondary prevention.(49) Health is viewed as a common good (44) and as a basic human right.(41) Canada created a Mental Health Commission in 2007 to “provide an ongoing national focus for mental health issues.(69)” While the Mental Health Commission of Canada published the first pan-Canadian mental health strategy, “Changing Directions, Changing Lives” in 2012,(55) there is no national mental health policy.(70) This, in addition to a trend toward further regionalization of health care administration,(70) has resulted in a variety of fragmented system of allied mental health services.(56,68) Although Canada has a universal PH insurance program (Medicare), psychologists are generally not covered under this and are instead paid mostly through costly private billings to the patient (68,70) or through private insurance programs.(68)   Furthermore, although individuals have insurance for basic health services, access to other health services such as eye care, dentistry, and prescription drugs are not covered under the universally     75 insured medical care system.(176)   There were two subthemes identified by a large number of participants from all four cases. The first was a one door policy and hub for health services, while the second was a lack of communication and service integration. Oftentimes, mental health services are fragmented as a result of being delivered across many locations by a variety of healthcare professionals (mental health professionals, medical doctors, nurses, etc.,).(55) For individuals experiencing other socioeconomic barriers, it is even more difficult for them to navigate the multi-faceted layers of the mental health care system. As a result, people needing mental health services often do not receive the care they need in a timely manner or do not receive care at all.(179) To help address this widespread problem, the Mental Health Commission of Canada indicated in their national strategy, “Changing Directions, Changing Lives,” that a healthcare goal should be to “have a system in which every door is the right door to meeting people’s mental health needs.”(21, p12) The enabler of every door being the right door allows patients to access the services they need through one place.   Six participants from across the four cases spoke to the importance of implementing a one door policy and hub for health services. Half of these were activities being carried out, while the other half were aspirations and most participants described this subtheme as an enabler. Most of the activities in this subtheme were mentioned by participants from Case A. One participant spoke to the enabler of “if they can have it [health services] under one roof, that’s very powerful [Case A – PH – PHN],” since “care for the disenfranchised is fragmented,” resulting in “many barriers for [the patients] to try to access individual pieces of their healthcare.” Similarly, a registered nurse     76 mentioned the activity being carried out: “we do very well I find at cross-referring, again not the formalized referral, but if someone wants to come here mental health services, addiction services or public health nursing specifically […] there’s no barriers [Case A – BOTH – RN].” A public health nurse described how “It’s quite a powerful synergy when you have the primary care and the public health rubbing shoulders together. There’s the interchange of ideas but there’s also a much better experience for the client to be able to access all of those things at in the much more powerful way than if they had to go to separate locations to access these things [Case A – PH – PHN].” The public health nurse confirmed the importance of having a hub for health services, which was similarly described as an activity by a public health nurse from Case D: “they opened the teen health centre. So that was a collaboration with both Public Health and primary healthcare. […] And there’s where your outside agencies certainly came in. Mental Health can come in, and Addictions. So there’s more services [Case D – PH – PHN].”  Participants from the other three cases spoke to aspirations related to this subtheme. For example, a participant from Case C indicated that an important component of the collaboration was to enact a one-door policy and create a hub for health services, to: make it a low barrier system so that if you go into the community center and you need health care, the community center can help you get to the health care. If you go into public health and get immunizations and you need some developmental assessment or you need some kind of maternal, you know, mental health assessment or whatever, you will get linked that way. So it is kind of like every door is a way in [Case C – OT – OT]. Another participant from Case B similarly spoke to the aspiration of “maybe we can’t create a system but maybe we can create doors for that population to get the care that they need [Case B – PC – RN].” The possibility of having a one door policy and hub for health services is enabled     77 by the collaborations providing a “multidisciplinary team [Case A – PH – PHN],” where individuals “can access a whole bunch of services from one place.” The enabler of providing a one door policy and hub for services was mentioned repeatedly by participants.  Although many participants spoke to the subtheme one door policy and hub for health services, there were also a large number of instances of the second subtheme of lack of service integration and communication. This subtheme was described as a barrier; for example, a public health professional said: “there are no formal linkages […] mental health, substance abuse, public health [Case A – PH – OTH],” and a participant working in both PC and PH said “primary healthcare, public health, addiction services, they can’t talk [...] Addiction can’t say what’s Public Health is doing, and Public Health can’t say what addictions is doing. I don’t know. I don’t know what they’re doing [Case D – BOTH – OTH].” Confirming this, a participant from Case C stated: “Public health and mental health and addictions are two different departments under the same health authority [Case C – OT – OT].” However, many of the quotes referred to aspirations and enablers to changing the lack of service integration and communication, such as “we’ve tried to bridge the gap a little bit by using the team leader, a public health nursing team leader, who was able to go in and provide ongoing support and education around the public health activities for the outreach staff [Case A – PH – BA],” and “that’s been an informal working agreement we’ve had since day one, that public health would always be there and be accessible for any education, sharing of policy, sharing of information, able to come to meetings and that sort of thing.” Another participant from Case C indicated that the integration of services requires both a commitment at the frontline level, to avoid thinking along the lines of “it’s your problem, it’s your problem, that’s how it becomes; it’s your problem, or a funding problem [Case     78 C – OT – OT],” and also “at a higher level there needs to be a commitment to integrated frontline service, like supporting the integration of services” to, as another participant pointed out “give people permission to work together [Case C – OT – OT].”    The Patients First discussion paper by the government of ON announced four key proposals to support patient care, one of which was “effective integration of services and greater equity,” while another was “timely access to, and better integration of PC.”(175) The ON government recognized the key to improving mental health service delivery is service integration. Although this discussion paper came out recently, the participants confirmed the relevance and importance of its key proposals.   A PH professional from Case B summarized this DoH nicely, by indicating that “people worked in their own focused area instead of looking at the community as a whole [Case B – PH – OTH],” resulting in “many people [falling] through the cracks, and the services that they really required weren’t offered. They might have been available but they weren’t accessible at all.” The participant “was really excited about the collaboration.” This quote alludes to the potential the collaboration had to change health service delivery. 4.2.9    Culture, Gender, Biology and Genetic Endowment, and Employment/Working Conditions  While participants identified eight of the 12 DoH from Key Element 2: Address the Determinants of Health and their Interactions as being incorporated and/or integrated into their mental health activities, the following four DoH were not mentioned by participants:  1. Biology and genetic endowment: the biology and make-up individuals,     79 2. Culture: the dominant shared knowledge, beliefs, and values that characterize a group of individuals,(112)  3. Gender: the personality traits, behaviours, and power and influence that society assigns to the two sexes, 4. Employment/working conditions: the conditions people work in and whether or not they are employed.   Possible reasons the above DoH were not mentioned by the participants is potentially due to the ubiquitous influence they have on health and because certain DoH, such as gender and culture, are so intertwined into an individual’s being that they are not able to be interpreted or elucidated. As this was a secondary analysis, we did not have the opportunity to explore this further in this research. The original study did not examine research questions related specifically to mental health or the DoH – the participants were never asked direct questions about the DoH. The fact participants spoke to eight of the DoH, even though they were not asked questions related to them, could perhaps be a reflection of the importance and ubiquity of the DoH affecting mental health. I speculate that if the original research questions had asked about the DoH, participants would have mentioned the above four.  4.3    Key Element 3: Base Decisions on Evidence  This Key Element relates to “evidence based decision making,” which is the decisional approach in which an information base or body of information successfully survives a broad, critical review process.(1, p14) Decision making captures evidence on health status, DoH, and effectiveness of interventions.(1) Evidence-based decision making is used at all stages in a population health approach to assess health, identify priorities, and develop strategies to improve     80 health, which includes health status.(1) It has become increasingly important for policy makers and practitioners to plan programs and services using the best available evidence and reasoning.(47) It is furthermore crucial for ongoing research and evaluation to support evidence-based decision making that is shared with the public and used to engage stakeholders.(47) The WHO listed as one of their cross-cutting strategies and principles in meeting their mental health action plan for improving the mental health of the population as basing treatment, prevention and promotion on evidence and best practice.(28) Participants identified three themes within this Key Element: 1) identify and assess effective interventions, 2) poor data systems, and 3) public health intervention outcomes take time. See Table 8 for the themes and subthemes for Key Element 3. Table 8: Key Element 3 Themes and Subthemes Key Element Theme Subtheme 3) Base Decisions on Evidence  Use best evidence available at all stages of policy and program development  Explain criteria for including or excluding evidence  Draw on a variety of data  Generate data through mixed research methods  Identify and assess effective interventions  Disseminate research findings and facilitate policy uptake Identify and assess effective interventions   Poor data systems  Public health intervention outcomes take time    4.3.1    Identify and Assess Effective Interventions  The first theme identified by two participants was identify and assess effective interventions. A population health approach examines all existing interventions targeting modifying specific types of health outcomes, decreasing health inequities, improving the health of the population as a whole or achieving change to the determinants of health, in order to determine the ones that most effective for continued funding and scaling up.(47) Various methods can support this, including expert opinion, trial programs with mid-term evaluations, risk-based assessments, focus groups, and a synthesis and comparison of interventions.(47)      81  One participant from Case C attested to how research and evaluation is an enabler to supporting a population health approach: “this community now will say they will agree is the research is a central part of this partnership, the evaluation […] If we don’t have evaluation to show its effectiveness, we won’t be sustainable [Case C – PC – OTH].” The participant spoke to another enabler of focusing on a “health promotion model” and how they are actively identifying and assessing effective interventions by “looking at what are the factors that work, what are the barriers, predisposing, reinforcing, and facilitating, however you want to look at a health promotion model [Case C – PC – OTH].” This is aided by the “provincial commitment to build it [data systems]” to “firmly [turn] the lens on disparities [Case B – PH – SA].” 4.3.2    Poor Data Systems The National Advisory Committee on SARS and PH identifies health surveillance as one of the most important functions of PH.(180) Health surveillance requires good quality data collection, integration, and analysis system to inform the public of issues, via reports and advisories (180); conversely, countries that have the poorest health also have the weakest data.(44) Effective action on the DoH requires effective and efficient data systems to understand them and their interactions,(44) yet Tannenbaum et al.,(138) pointed out the lack of indicators for mental health surveillance in Canada.   Reflecting this, the theme poor data systems was described by three participants as a barrier to conducting activities that incorporate a population health approach. This was described as the existence of data systems that are “basic [Case B_PH_OTH],” “not a priority [Case B – PH – SA],” or nonexistent. A senior public health administrator emphasized this by stating “It has     82 never been a priority in this province ever. Data collection, data analysis for population health decision-making has never been a priority. So we don't have it [Case B – PH – SA].” However, the senior administrator also notes the enabler that they have “made the provincial commitment to build it,” despite the fact they receive “no funding or support to doing that.” Another participant working in the PH sector pointed out the barrier that they “do not have data systems for PH that are very efficient or effective.” The participant describes the data as being very “basic” because “everything is paper and pencil and then entered [Case B – PH – OTH].” The senior public health administrator reported that, due to the poor data systems, they have been unable to “affect public policy” because they have been unable “to expose and illuminate disparities,” which he/she said is a key to “public health practice [Case B – PH – SA].”   4.3.3    Public Health Intervention Outcomes Take Time To confound the problem, population health initiatives require long term monitoring before results become apparent.(126) This was confirmed by a public health nurse, who pointed out the third theme public health intervention outcomes take time, that “everything that we do takes 8-10 years to evaluate [Case A – PH – PHN].” Additionally, population health issues are difficult to measure   Due to the poor data systems identified by two participants from Case B, and the fact public health intervention outcomes take time, it followed that the other required actions for Key Element 3, Base Decisions on Evidence: (Use best evidence available at all stages of policy and program development; Explain criteria for including or excluding evidence; Draw on a variety of data; Generate data through mixed research methods; and Disseminate research findings and facilitate policy uptake) were not discussed. In summary, PHAC stated that when there is     83 insufficient data, there is a need to turn to other sources, such as expert opinion and trial programs with mid-term evaluations to support evidence-based decision-making.(47) 4.4    Key Element 4: Increase Upstream Investments  The fourth Key Element: Increase Upstream Investments, targets interventions and strategies upstream in order to address the root causes of mental health problems.(47) It involves three specific actions: 1) apply criteria to select priorities for investment, 2) balance short and long term investments, and 3) influence investments in other sectors. Health Canada described the potential impact a population health approach has on mental health status as being greater the more upstream the actions are taken.(181) There was one theme, focus on upstream approaches, mentioned by participants. See Table 9 for the themes and subthemes for Key Element 4.  Table 9: Key Element 4 Themes and Subthemes Key Element Theme Subtheme 4) Increase Upstream Investments  Apply criteria to select priorities for investment  Balance short and long term investments  Influence investments in other sectors Focus on upstream approaches     While this theme was infrequently mentioned directly by participants, addressing mental health problems using a population health approach tackling the DoH and incorporating mental health promotion are themselves upstream approaches to care.(182) Mental health promotion aims to target the risk factors that are the root causes of mental health problems – including the DoH – early on, prior to the onset of mental health problems.(67) In the year 2013, WHO developed a comprehensive mental health action plan with goals “to promote mental well-being, prevent mental disorders, provide care, enhance recovery, promote human rights and reduce the mortality, morbidity and disability for persons with mental disorders.”(27, p9) In the action plan,     84 WHO indicated one of their four objectives was to implement strategies for promotion and prevention in mental health.  Two participants from across two Cases spoke to aspirations of using an upstream approach, including one participant’s assertion “I’m trying to do the upstream, that whole model of upstream to downstream. The whole continuum of prevention and health promotion. So those are my goals [Case D – BOTH – OTH],” and another participant’s statement:  Upstream I guess for me is thinking of […] So instead of trying to spread one person to provide the direct service in 3 or 4, you know, [name] is the expert who could mentor future leaders somehow so here time could be spent in that way. And I hope that in the future that we can get there to see that you know, she could someone who could be really moving some of that piece and helping to build capacity for more sustainability there. Because if there’s no money, like so much, what other options are there? And that’s an upstream approach [Case D – PH – OTH].  These two participants spoke to various enablers of supporting an upstream approach, such as “whole model of upstream to downstream [Case D – BOTH – OTH],” “mentor future leaders,” and “build capacity [Case D – PH – OTH].”   4.5    Key Element 5: Apply Multiple Strategies  A tenet of a population health approach is its employment of multiple strategies (e.g., media campaigns, community-based prevention programmes) by various individuals (e.g., psychiatrist, physician, nurse), across sectors (e.g., PC, PH) and levels (e.g., individual, community), and throughout the health care continuum (e.g., prevention, promotion).(16,47,178) The World Health Organization proposed, in their “Mental Health Action Plan,” the delivery of mental health services using a multisectoral approach (28) because many of the determinants affecting mental health lie outside the health services sector.(83) Treating many mental illnesses is     85 possible, but this depends on a timely diagnosis and access to appropriate care. Appropriate care involves linkages with and provision of care by other sectors, such as housing, social, judicial, and employment services.(28,66)    Apply multiple strategies was the Key Element that was mentioned most frequently, perhaps as a reflection of its importance. Thirteen participants from across all four cases discussed this. Four themes were identified inductively, through an examination of the data: 1) apply a comprehensive mix of interventions and strategies, 2) provide outreach services, 3) provide referrals, and 4) provide programs for youth health services. This corresponds with fragmented and fragmenting services identified in the literature, resulting in decreased continuity of care and patient outcomes.(148) See Table 10 for the themes and subthemes for Key Element 5. Table 10: Key Element 5 Themes and Subthemes Key Element Theme Subtheme 5) Apply Multiple Strategies  Identify scope of action for interventions  Take action on the determinants of health and their interactions  Implement strategies to reduce inequities in health status between population groups  Apply a comprehensive mix of interventions and strategies  Apply interventions that address health issues in an integrated way  Apply methods to improve health over the life span  Act in multiple settings  Establish a coordinating mechanism to guide interventions Apply a comprehensive mix of interventions and strategies  Provide outreach services  Provide referrals  Create programs for youth health    4.5.1 Apply a Comprehensive Mix of Interventions and Strategies The first theme identified by three participants was directly related to the Key Element. A physician from Case A described the rationale for applying a comprehensive mix of interventions and strategies:      86 Because of course so many of our clients have multi needs. They just don’t come to us with one need. They’ve got a number of areas that all need help. And only one piece of it is going to be the medical and only one piece of it is the TB piece. Maybe they’ve got substance abuse and maybe they’ve got mental health you know [Case A – BOTH – MD]. The participant indicated the barrier to delivering effective care being that many of their clients have multiple needs. Another participant described the various strategies their collaboration used:  There were things like haircuts, as I said, clothing, conference kits, a hot lunch. There was a wellness centre, like they would check up, diabetes screening, blood testing, vision care, nutrition counselling, mental health, addictions. There was some financial services there, education and employment services was there, local shelter [Case B – PH – OTH].  The quote above illustrates the number and variety of strategies across multiple sectors required to successfully address mental health problems. In addition, a participant from Case C described the aspiration and enabler of “we’re open to always have all of the different specialties come in, and we’re wanting them to come in as often as possible and I think we would like to see a collaborative way of just having an evening and having people coming or having come around more often [Case C – PC – OT].” This quote demonstrates the recognition of the importance of synergistic action, of involving many individuals across a variety of sectors in order to effectively tackle mental health problems.(83)   4.5.2    Provide Outreach Services The remaining three themes describe the specific strategies used by the collaborations. The first of these strategies, provide outreach services, was mentioned by six participants. Outreach services include “resources in the community [Case C – OT – CD],” and “supporting clients on the street [Case A – PH – MD].” A central component of provide outreach services is the     87 relationship healthcare professionals build with the client population, which is illustrated in the following two quotes describing activities the collaboration is engaged in:  We ran to a light and they said hello to six of the people. I was impressed with the [name of organization] folk that they remember these people by first name having never met them, but knew all their file stuff. It just showed me how connected the system was on supporting clients on the street [Case A – PH – MD]. And “We go where people are, and we kind of get to know them, and you know where they hang out, where they eat, that’s really all we’re doing [Case B – PC – RN].”    The physician and registered nurse mentioned the enablers “supporting clients on the streets [Case A – PH – MD],” and “get to know them [clients] [Case B – PC – RN].” Additional enablers described by the participants were “having relationships built with the downtown street population [Case A – PH – PHN],” and “meet with the young parents in the community [Case C – OT – CD].” Lastly, a NP attested to the importance of outreach services, even though the corresponding barrier is that their work isn’t delivered on site:  And often they want us to be based in the hospital or organizational setting and the work we do can sometimes be a bit invisible because we’re not on site. And I wish it, there was a way that management could better understand the work we do and how we truly impact the community, the people, the nurse practitioner, or a physician, or say public health, in these roles or the services we give [Case C – PC – NP].  4.5.3    Provide Referrals Referrals were another strategy brought up by two participants. A participant working in both PC and PH indicated that another member of her collaboration had “been referring some clients into there and that, so we’ve had some actual good feedback from public health [Case A – BOTH –     88 OTH],” while the other participant, similarly working across both PC and PH, spoke to her aspiration of “I’m trying to have better referral for resources and better knowledge about resources [Case D – BOTH – OTH].”  4.5.4    Create Programs for Youth Health Services The last strategy and theme for Key Element Apply multiple strategies acknowledged was create programs for youth health services. It has been shown that intervening early, during childhood and youth, has a higher potential to influence subsequent health and well-being.(48) Two participants from Case D, a collaboration that aimed to improve comprehensiveness of well child and youth health care, described the activities of their collaboration. The first participant, a public health nurse, said: One other thing I thought of meeting the needs of the community was the [town name] school, there was a lot of issues going on with the high school. So the DHA and primary healthcare and Public Health all came together, the school board, the Department of Education to see what they could do to help the school and the students. And they opened the teen health centre. So that was a collaboration with both Public Health and primary healthcare. […] Mental Health can come in, and Addictions. So there’s more services [Case D – PH – PHN].   The public health nurse added, “We’re still striving ahead with that open door and how we get in. So a year ago, I had my first conversation with the principal. Today, we have had at least 4 consultations with the kids.” Key enablers in the above two quotes are “opening the teen health centre” and having “consultations with kids.” The second participant from Case D explained the process of engaging youth:  Public Health was in there building the relationships, doing the consultations, asking the kids what they need. We got those kids, two kids on the Community Health Board. That was just an     89 amazing thing where we all went in there together. Oh, and addictions, I can’t forget Addictions. They have put a counselor down there too. So it’s been beautiful. And Mental Health goes down on a satellite basis. And they’ve been involved. So it was a true collaboration [Case D – BOTH – OTH]. The key principal for this theme is engaging the youth. This is congruent with research showing that when designing health interventions targeting youth, it is critical to engage the youth to incorporate their feedback and develop programs and services tailored to their needs.(183)   4.6.    Key Element 6: Collaborate Across Sectors and Levels  This Key Element, Collaborate Across Sectors and Levels is closely related to the previous Key Element: Apply Multiple Strategies. Applying a population health approach to health delivery requires collaboration across multiple sectors and levels (47,181) to effectively address mental health problems because most of the determinants affecting mental health fall outside the purview of the health services sector.(48) Furthermore, the responsibility for providing mental health care does not reside solely in the health sector.(55) The Patients First discussion paper presented four key proposals, the first of which was “effective integration of services and great equity through sub-regions,”(175) and another which was “stronger links [for PC] to pop & public health.”(175) Key here is the recognition that intersectoral collaboration with organizations outside the health care sector (e.g., housing, employment) is necessary to supporting mental health promotion.(78)  Three themes were brought up by many of the participants: 1) identify and support a champion, 2) invest in the alliance building process, and 3) engage partners early on to establish shared values and alignment of purpose. These correspond with the specific actions required to mobilize     90 Key Element 6 from PHAC’s Population Health Framework.(47) See Table 11 for the themes and subthemes for Key Element 6. Table 11: Key Element 6 Themes and Subthemes Key Element Theme Subtheme 6) Collaborate Across Sectors and Levels  Engage partners early on to establish shared values and alignment of purpose  Establish concrete objectives and focus on visible results  Identify and support a champion  Invest in the alliance building process  Generate political support and build on positive factors in the policy environment   Share leadership, accountability and rewards among partners Identify and support a champion   Invest in the alliance building process  Engage partners early on to establish shared values and alignment of purpose Employ a participatory model   4.6.1    Identifying and Supporting a Champion The first theme, identifying and supporting a champion, was mentioned by four participants, two of whom spoke to it in aspirational terms. The WHO indicated strengthening leadership and governance as their number one objective in their “Mental Health Action Plan.”(28) It has been proposed that it is the role of the health sector to lead collaborative initiatives (115). Within the health sector, PH has been purported to be a logical leader due to their focus on improving population health by engaging with other sectors to address the DoH and health promotion and expertise in access, surveillance, and analyses of data.(139,175)  A business administrator working in the PH sector said:  one of the things we have done despite having sort of separate structures, is that we’ve tried to bridge the gap a little bit by using the team leader, a public health nursing team leader, who was able to go in and provide ongoing support and education around the public health activities for the outreach staff […] that’s been an informal working agreement we’ve had since day one, that     91 public health would always be there and be accessible for any education, sharing of policy, sharing of information, able to come to meetings and that sort of thing [Case A – PH – BA]. However, two participants from Case C pointed out that in a collaboration “everybody has a role in, in terms of being a leader [Case C – PH – BA],” and “there is no one leader […] in a project. It’s a collaborative approach [Case C – OT – CD].”  4.6.2    Investing in the Alliance Building Process  The literature shows that trust and personal relationships are key factors for successful collaborations.(125) Trust is developed over time; therefore, it is imperative to invest in the alliance building process to ensure “goals identified [Case A – PH – BA]” are “still heading the same direction we envisioned it heading.” Four participants touched upon this theme. A business administrator from Case A mentioned following activity being carried out in their collaboration:  We have actually had the coordinator of outreach urban health attending the mental health team leader meetings, for I think, well I don’t know, most of this year, I think. […] But that’s helped too, because there’s such an overlap between mental health services and outreach urban health services [Case A – PH – BA]. Illustrated in the above quote is the enabler of dedicating time for working together. Related to this, a participant from Case C pointed out “It’s those relationships that we have and, and keeping that trust [Case C – OT – CD],” which similarly requires time and effort to build. An example of an outcome from investing time is described by a senior administrator: “I love the fact that we can just pick up the phone and sort of say, okay, so how do I handle this [Case B – PH – SA]?”       92 4.6.3    Engage Partners Early on to Establish Shared Values and Alignment of Purpose Lastly, a few participants from Case B and C discussed the third theme engage partners early on to establish shared values and alignment of purpose. A clear and mutual understanding of the collaboration’s objectives is necessary to ensure success.(125)   A registered nurse from Case B described the sole activity associated with this theme:  Our relationship is with individuals but we’ve created a relationship with Public Health […] Public Health has recognized our connection and our relationship to that community. And so therefore have taken away any barriers that one might face as a nurse delivering care in the community and said, okay, how do we work with you since you’re going to do this? What can we do to make your job easier but also to increase the components around prevention, treatment and care in the community [Case B – PC – RN]? The registered nurse referred to the enabler of the relationship building process and the ensuing result of encountering fewer barriers when delivering care in the community. A NP described an agreement “that was signed by the whole team, with the community non-profit agencies, just outlining what we brought to the collaboration, what they bring to the collaboration and that we’re working together to meet the needs of the community [Case C – PC – NP],” but did not specify whether members of the collaboration were actively working together. Another participant from Case C mentioned an aspiration of engaging the various partners, but similarly did not indicate whether this was being carried out:  I think we’re open to always hav[ing] all of the different specialties come in, and we’re wanting them to come in as often as possible and I think we would like to see a collaborative way of having people coming or having come around more often. I think its great that the practitioners     93 can come in and be there […] It’s making those connections every once in a while has helped to build that strength [Case C – PC – OT].  4.7    Key Element 7: Employ Mechanisms for Public / Community Involvement Engaging the community is key to a population health approach as most of the DoH exert their influence at the community level.(53) A criticism of population health is its lack of engaging communities to identify local needs and develop bottom-up strategies to target these needs.(118) This research provided evidence on a number of strategies, reported by multiple participants across the four cases, related to this Key Element: Employ Mechanisms for Public / Community Involvement that both support and address the criticism. There are three themes related to this Key Element: 1) apply public involvement strategies that link to overarching purpose, 2) build relationships with target population, and 3) focus on the community. See Table 12 for the themes and subthemes for Key Element 7.  Table 12: Key Element 7 Themes and Subthemes Key Element Theme Subtheme 7) Employ Mechanisms for Public / Community Involvement  Capture the public’s interest  Contribute to health literacy  Apply public involvement strategies that link to overarching purpose Apply public involvement strategies that link to overarching purpose Engage stakeholders Build relationships with target population   Focus on the community     4.7.1    Apply Public Involvement Strategies that Link to Overarching Purpose Firstly, the data indicate the importance of apply[ing] public involvement strategies that link to overarching purpose, including the engagement of stakeholders. Most of the quotes related to this Key Element were actual activities being carried out in the collaborations. For instance, a participant identified an activity of the collaboration as “the first time you’ve asked us what we needed, not deciding what you wanted to study [Case C – PC – OT].” Inherent in this quote is the fact the participant viewed participatory processes as something that was not always existent. Another activity was the engagement of youth, through processes such as “spending some time     94 with the youth [Case D – PH – OTH],” and “consultations with the kids [Case D – BOTH – OTH].” One of the two quotes from the subtheme engage stakeholders provided an effective summary this Key Element: “Always really intended to be quite a grass roots movement and I think the involvement of the community partners was a very central, essential component […] I think the priority was absolutely the community capacity for this [Case C – BOTH – BA].” The enabler of involving the community partners is tantamount to a population health approach.(126)  4.7.2    Build Relationships with Target Population  The importance of the theme build relationships with target population was described by four participants, three from Case A and one from Case B. This theme was particularly relevant for Case A, which had a focus on homeless and/or street-involved population. An enabler for the collaborations was identified as the “built relationship with the client population [Case A – PH – PHN].” The extent and strength of the relationships were exemplified in a quote from a doctor working in PH describing the following activity:  We ran to a light and they said hello to six of the people. I was impressed with the [name of organization] folk that they remember these people by first name having never met them, but knew all their file stuff. It just showed me how connected the system was on supporting clients on the street [Case A – PH – MD]. This showed the collaboration as carrying out strategies aligned with a population health approach of engaging with the target population at the community level.  4.7.3    Focus on the Community  The last theme for this Key Element is focus on the Community, which is related to the previous theme. Four participants from Cases B and C attested to the enabler of focusing on the community, describing examples such as “working with communities [Case B – PC – RN],” “looking at the community as a whole [Case B – PH – OTH],” and “having resources in the community [Case C – OT – CD].” Although focus on the Community was identified as an enabler, only one activity was mentioned in relation to this: “our presence is in the community, our relationship is with the individuals [Case B – PC – RN],” whereas the remaining quotes described aspirations, such as “thinking around a community perspective [Case B – PC  RN].”      95 Overall, participants recognized the importance of engaging and empowering communities to take control of their own health and spoke to both aspirations and activities to supporting this. 4.8    Key Element 8: Demonstrate Accountability for Health Outcomes  The last Key Element: Demonstrate Accountability for Health Outcomes, is closely related to Key Element Base Decisions on Evidence. It was mentioned infrequently by participants, and only by participants from Cases A and B. For example, a participant from Case B described the importance of making sure that services are provided, and posed the question “How do we make sure that that happens [Case B – PC – RN]?” Additionally, no activities were described. This could be due to the composition of the participants in the collaboration, as the collaborations did not include any policy makers. Policy makers are the people responsible for designing evaluation methods to demonstrate accountability for health outcomes. Literature supports the importance of demonstrating positive health outcomes resulting from population health strategies through accountability measures.(110,181) Had the original study involved policy makers, there might have been more positive mention of this Key Element. As this was a secondary analysis, we were not able to explore this further. Two themes, no formal evaluation mechanisms and accountability structures and accountability structures and processes, describe this Key Element. See Table 13 for the themes and subthemes for Key Element 8.  Table 13: Key Element 8 Themes and Subthemes Key Element Theme Subtheme 8) Demonstrate Accountability for Health Outcomes Specific actions required to mobilize a population health approach:  Construct a results-based accountability framework including a clear statement of roles and responsibilities   Ascertain baseline measures and set targets for health improvement  Institutionalize effective evaluation systems  Promote the use of health impact assessment tools  Publicly report results No formal evaluation mechanisms and accountability structures  Accountability structures and processes   4.8.1    No Formal Evaluation Mechanisms and Accountability Structures A senior administrator spoke to an activity related to accountability that was not being done in their collaboration: “I’d be challenged with how to do an evaluation without formal mechanisms     96 and accountability structures in place […] So are we evaluable at this time? No, I would say no, we’re not. We don’t have those items organized enough to be able to evaluate [Case B – PH – SA].” The senior administrator pointed out “we don’t really have any formal tools in our relationship with [street outreach],” while a registered nurse provided a related possible explanation for this, indicating “I think sometimes we’re not critical enough around doing evaluation [Case B – PC – RN].”  4.8.2    Accountability Structures and Processes  A participant from Case A described accountability in specific relation to outreach urban health, indicating that while it appears they do not have any accountability structures and processes, they “have internal checks and balances and people aren’t just going rogue [Case A – BOTH – OTH].” Another participant from Case B questioned how they were ensuring PH services and health promotion were being enacted and emphasized the important thing is to “make sure that services are provided.”  Despite no activities being discussed for this Key Element, Millar et al.,(139) described the engagement of individuals and communities as being an accountability mechanism. We can therefore interpret activities being carried out in collaborations related to the previous Key Element, Employ Mechanisms for Public/Community Involvement as an accountability mechanism.        97 Chapter 5. Discussion Discussion specific to the eight Key Elements has been described in Chapter 4. Below I provide an overall integrated summary of the research findings and a discussion of how they are relevant to mental illness. 5.1    Summary of Findings I used the PHAC population health framework to explore the focus group data from the four cases that were collaborations between PC, PH, and other organizations (e.g., government, communities). There are eight Key Elements to a population health approach (46,47): 1. Focus on the health of populations 2. Address the determinants of health and their interactions 3. Base decisions on evidence  4. Increase upstream investments  5. Apply multiple strategies  6. Collaborate across sectors and levels 7. Employ mechanisms for public involvement 8. Demonstrate accountability for health outcomes 5.1.1    Mental Health Activities and Aspirations in Collaborations using a Population Health Approach Participants mentioned aspirations for all eight of the Key Elements from PHAC’s population health framework (47) and described actual activities being carried out for six of them in the collaborations. Actual activities were not mentioned in Key Elements Increase Upstream Investments and Demonstrate Accountability for Health Outcomes. Participants across the four cases mentioned some of the Key Elements more frequently (e.g., Address the     98 Determinants of Health and their Interactions, Apply multiple strategies), while others were mentioned less often (e.g., Increase Upstream Investments, Demonstrate Accountability for Health Outcomes). There were more descriptions of activities for certain Key Elements, such as Address the DoH and their Interactions, Apply Multiple Strategies, and Employ Mechanisms for Public/Community Involvement. This could be due to the inherent actionability of these Key Elements, rather than the concept-driven nature of some of the other Key Elements.  5.1.2    Enablers and Barriers to Effective Mental Health Promotion using a Population Health Approach Key enablers brought up by participants included working in a multidisciplinary team, addressing the DoH by thinking in a bigger way, engaging the community, applying multiple strategies, and creating a hub for health services. Key barriers included poor data systems, a lack of service integration, a lack of action on demonstrating accountability for outcomes and infrequent mention of providing funding for upstream investments. These enablers and barriers are aligned with PHAC’s framework and provide further support that improving mental health status requires a population health approach. There were some quotes that could be interpreted as both and an enabler and a barrier, such as “at a higher level there needs to be a commitment to integrated frontline service [Case C – OT – OT].” The enabler is a commitment to integrated frontline services, while the barrier is a lack of commitment. Such quotes were not descriptive enough for a definitive interpretation of whether they were a barrier or enabler. Participants described more enablers than barriers, although sometimes the enablers were mentioned in relation to aspirations, rather than activities, so we are not able to conclude whether they would remain relevant for activities. For example, a participant from Case A discussed the enablers of     99 “mentor future leaders [Case D – PH – OTH],” and “build capacity for more sustainability there,” related to aspirations for “the future.”   While there were many enablers for specific themes, such as support a one-door policy and hub for health services that were common across cases, there were other enablers that were mentioned primarily by participants from one case, perhaps a reflection of the central focus of the cases. For example, enablers were mentioned the most frequently for the theme healthy child development by Case C, which focused on health promotion for children and their families. Similarly, there were many barriers for specific themes, such as lack of communication and service integration, common across most cases (Cases A, B, and C), but there were other barriers that were brought up only by participants from one case (e.g., “the work we do can sometimes be a bit invisible because we’re not on site [Case C – PC – NP]). For some Key Elements, such as Collaborate Across Sectors and Levels and Employ Mechanisms for Public/Community Involvement), participants only cited enablers. For other Key Elements, such as Base Decisions on Evidence and Demonstrate Accountability for Health Outcomes, participants described a mixture of enablers and barriers.   5.2    Contributions to the Literature Most of the findings were consistent with previous literature in the area of mental health and population health. Findings addressed several key the criticisms of population health.  5.2.1    Widespread Influence of Population Health in Collaborations between PC, PH, and other Organizations in the Area of Mental Health:  Participants across the four cases collectively brought up all Key Elements, even though no single case captured all eight. This shows that the collaborations were incorporating population     100 health elements, but only in part. Some Key Elements, such as Base Decisions on Evidence, Increase Upstream Investments, and Demonstrate Accountability for Health Outcomes, were mentioned infrequently, perhaps because the original research questions did not ask about these and could also be due to the composition of the collaborations (i.e., no policy makers). As this was a secondary analysis of original data that did not incorporate a population health focus, the fact the participants discussed all eight Key Elements is indicative of the widespread influence of population health, even though it is a relatively new concept.(45,112) This is representative of the literature depicting the prominence of population health as a viable approach to reducing health inequities, reducing health expenditures on health and social problems, and improving the health of populations by first and foremost addressing the DoH.(44,48,110) 5.2.2    Population Health Approach as an Actionable Approach using PHAC’s Framework One of the challenges to the widespread implementation of population health is its perceived complexity and lack of actionable strategies for its uptake.(123,124) Although participants did speak more often to aspirations, rather than activities, findings show that PHAC’s population health framework, which provides a specific set of actions for each Key Element, helps guide the implementation of population health strategies, going beyond merely providing a concept of health.(45) Participants spoke to activities being carried out in their collaborations aligned with a population health approach, along with barriers and enablers to conducting the activities. Nonetheless, most of the data pertain to aspirations for delivering care using a population health approach, rather than actual activities. This is consistent with literature criticizing population health as being nebulous, hard to define, and even harder to implement due to its shortcomings in providing specific guidance for its mobilization,(45,124) that it “provides a model of research,     101 not of change.”(7, p193) Due to shortcomings in its operationalization,(184) there is a “lack of agency and action at the meso- and microlevels.”(124) This research contributes new literature showing that certain Key Elements of the PHAC population health framework are more actionable than others in the area of mental health, thus identifying areas for the framework’s further development. 5.2.3    Not all DoH are Equally Relevant to Mental Health  Research on the factors that influence health demonstrates that certain DoH, such as income and social status and social environments are more important for health status.(122) Findings show that some DoH (e.g., income and social status, healthy child development, physical environments – specifically housing and homelessness) were mentioned more frequently than others (e.g., education and literacy, personal health practices and coping skills) as these were the areas that were addressed in the collaborations. Income and social status and housing have been described as key influences on mental health.(48,51) Healthy child development has also been cited by PHAC and population health articles as a crucial DoH that has potential for great improvement if acted upon early enough.(44,48) The more frequent mention of these three DoH could also be due to the context and focus of the collaborations in the four cases; mental health was central to the focus for three cases (e.g., one case addressed addictions and homelessness), while one focused on child health promotion and the DoH.   Four DoH: 1) employment/working conditions; 2) biology and genetic endowment; 3) gender; and 4) culture were not mentioned in the data. This could be due to the obvious and ubiquitous influence they have on health, so participants did not mention them. Another explanation is that DoH such as gender and culture are so intertwined into an individual’s being that they cannot be     102 elucidated. Culture exerts its influence on mental health through multiple channels, including: 1) positive or negative lifestyle behaviours; 2) health beliefs and attitudes; 3) reactions to being sick; 4) communication patterns; and 5) status.(112) Healthcare providers need to provide culturally competent care that takes into account the cultural backgrounds of the individuals.(112) Gender similarly influences health through multiple channels, such as differences in individual susceptibility to particular mental health risks and health-seeking behaviours.(185) In fact, in recognition of the important influence of gender on health status, the “Chief PH Officer’s Report on the state of PH in Canada, 2012” focused on sex and gender influences on the health of Canadians and argued for the integration of sex and gender into research.(185) As this was a secondary analysis, we did not have the opportunity to explore the reasons for their absenteeism further in this research. 5.2.4    Poor Data Systems that do not Provide Accountability for Population Health  Participants rarely mentioned activities or aspirations for Key Element Base Decisions on Evidence. When they did, it was in a critical tone, citing poor data systems that are basic or nonexistent. This is congruent with previous work that shows health data systems are not capable of providing the information required for quality improvement and providing accountability for population health strategies.(139) The uptake of population health is dependent on practitioners and policy makers being able to demonstrate its effectiveness.(120,123) Part of this might be due to historical perceptions of poor data systems, and part of this might be due to the roles of the participants – had participants in other roles been asked specific questions related to this, we might have received different responses. More recent evidence indicates significant increases in evidence-based research and practice. For example, the Institute of Medicine has devoted significant attention and resources to strengthening the credibility and utility of using summary     103 measures for measuring population health.(186) This was a secondary analysis so we were therefore not able to further explore the perceptions of the participants. Regardless, it is imperative for population health to continue to demonstrate accountability and transparency.(110) 5.2.5    Engaging the Public/Communities is Paramount in a Population Health Approach  Findings from this research, in particular from Key Element Employ Mechanisms for Public/Community Involvement, demonstrate the importance of engaging the public and communities in mental health service delivery. The importance of community-based mental health services, which place the community at the centre of the system and enables them to carry out tailored mental health strategies linked to local needs (8,82) was emphasized by the participants. These data help address the criticism that the field of population health does not sufficiently engage and empower individuals and communities and instead focuses on action created and implemented at the policy level.(115,124) This top-down approach, with its emphasis on expert knowledge, has been cited as placing knowledge creation in the hands of social scientists and not providing autonomy to individuals and communities, the people that are able to provide the most informed input.(118)   Data identify the presence of a bottom-up approach to mental health service delivery at the community level that emphasized “involvement of the community partners [Case C – BOTH – BA]” as “a very central, essential component.” There was a focus on communities by building relationships with the target population and listening to their needs, which has been cited as being more effective to a population health approach than an emphasis on expert knowledge.(118,123) The Executive Steering Committee for the Standards Modernization in     104 Ontario met in August 2016 to discuss the inclusion of mental health promotion in the Ontario Public Health Standards (OPHS), which guides the delivery of PH programs and services by Ontario’s 36 boards of health,(187) and the role of PH in mental health promotion.(188) The OPHS will next focus on developing a consultation strategy with a focus on increasing transparency and accountability in health services. This is a reflection of the increasing emphasis on participatory processes for health interventions.(115)  5.2.6    Collaboration is Necessary for Improving Population Health  In line with current health care agendas calling upon the renewal of primary health care as key to addressing the health challenges of the 21st century, including the increasing prevalence of mental illnesses,(27,108,109) data from my research show the importance of building a strong primary health care system through increased collaborations between the PC, PH, and other sectors (e.g., government, communities). Most of the data related to this is from Key Element Collaborate Across Sectors and Levels. As mental health is closely linked with the broader DoH that reside mostly outside the health sector, effective mental health promotion strategies depend on intra- and intersectoral collaboration to provide joint action for addressing fragmented and fragmenting care.(120) Mental illness, although most often addressed in the PC setting by a PC provider (physician or NP), is a public health priority as individuals from all backgrounds are at risk of developing mental health problems.(8,147) Kindig & Stoddart (110) identify the main strength of population health as providing measures of outcomes across all DoH, rather than independent measurements of the individual DoH. To ensure this, inter- and intra-organizational action is required.       105 Furthermore, due to deinstitutionalization, most individuals living with mental illness live and receive support in the community,(89) where they are required to navigate a progressively complex health care system to visit multiple healthcare providers.(148) There is a need for improved coordination of care between the various healthcare providers – PC-PH collaborations could facilitate this through improved communication and care management. This research provides clarity on the distinction between PH and population health as there has been confusion between the two.(112,118) Historically, PC and PH have been separate entities with different purposes.(139) However, due to the changing health challenges of the 21st century, in particular the rapid rise in mental illnesses, it is imperative for PC and PH to collaborate on tackling the broad cross-cutting DoH that impact mental health. Public health is viewed as a leader for population health given its emphasis on health promotion and epidemiological expertise, elements that are key to a population health approach.(139) A significant challenge to widespread collaborations between PC and PH is a history of PH funding being diverted into acute care. Governments need to address funding priorities and allocations to encourage PH participation in collaborations.   5.3    Strengths of the Research Approach To my knowledge, this is the first research that has been done using PHAC’s population health framework for mental health, and more specifically, in collaborations between PC, PH, and other collaborations. One of the legacies of population health is the emergence of intra- and intersectoral collaborations to address the health challenges of the 21st century, including mental illness.(8,139) This research is relevant to the emerging collaborative processes by providing support for the viability and applicability of using a population health approach in collaborations that address mental health and/or the DoH. As Pollett (67) emphasized, everyone is responsible     106 for mental health promotion because mental health is determined by multiple factors. Despite this being a secondary analysis of data from a larger study that did not use a population health approach, focus group data from the four cases demonstrate the tangible benefits of incorporating population health strategies, notably through collaborations. Interestingly, Collaborate Across Sectors and Levels is a Key Element of PHAC’s population health framework – the simple fact the data were obtained from participants in the collaborations is a testament to the prevalence of a population health approach.   During the analysis stage, it became apparent that while participants spoke to all Key Elements, many descriptions were aspirations they had, rather than activities they did or were doing. In response to this, my coding framework was modified to separate the aspirations from the activities. Resultantly, I was able to more critically examine my Research Question 1, specifying that while strategies aligned with a population health approach were being reported in the collaborations, much of it was in fact aspirations. This is not a limitation, however, as it showed the participants had ambitions to carry out more activities aligned with a population health approach. This implies they saw shortcomings in service delivery in the collaborations, which they believed could potentially be filled by employing population health strategies, although these would need to be further refined. Part of the reason for the high ratio of aspirations to activities could be due to the participants not be specifically asked questions related to a population health approach, but another reason could be due to the limited number of actions for each Key Element. Results from this analysis provide valuable perspective on the actionability of the Key Elements, and points to gaps in the framework that could be further developed to enhance its applicability and operationalization.      107 Lastly, this study draws upon qualitative approaches, which seek to understand the nature of the phenomenon through the perspectives and experiences of the participants,(189) allowing researchers to understand the gaps to applying a population health approach. This helps address a criticism of population health that it is top-down, as opposed to participatory. Qualitative research attempts to explain things from the view of the participants and to provide insight into the views of participants by allowing them to report in their own way responses to the research questions. This is particularly helpful for research on population health because population health data collection and analysis require a long and complicated process involving multiple interrelated indicators (e.g., the DoH). Qualitative research seeks to understand the phenomenon under study in its natural context, where responses can be assumed to be most natural and real. Furthermore, qualitative research allowed for the unique examination and separation of the aspirations from activities, and enablers and barriers.  5.4    Limitations of the Research The findings of this research are subject to three limitations, the first of which arise from my research being a secondary analysis. The original research questions did not address mental health or illness and were not informed by a population health approach, so the data are not as rich as they might have been. However, there were three cases where mental health was central to the focus (e.g., one case addressed addictions and homelessness) and the fourth focused on child health promotion and the DoH. While aspirations were mentioned across all eight Key Elements, activities were mentioned in only six (and sparse in a number of other Key Elements). We were not able to confirm whether this was because the collaborations were not engaging in the activities, whether they were but participants did not report on this because they were not asked, or whether it was due to a lack of actionable items in PHAC’s population health     108 framework. We were not able to explore ambiguities with participants, nor were we able to validate the classifications I had attributed to the various aspirations and activities. Despite the original study not using a population health framework, the prominence of Key Elements from PHAC’s population health framework in the data highlight the prevalence of population health. The research provides an important perspective on the level of population health integration in collaborations between PC, PH, and other organizations in the area of mental health service delivery.  The second limitation arises from this research being a qualitative study based on people’s perspectives. The results are the participants’ representations of reality, rather than the objective reality. As this was a secondary analysis, member checking or validation was not possible. Furthermore, the results represent the interpretations of myself and my committee members. Although we incorporated reflexive bracketing, a method used to bypass our personal assumptions and preconceptions to objectively report the views of the participants, we must admit full objectivity is not possible in qualitative research (190) – the results include any biases we may have arising from our varied epistemological backgrounds. This may be particularly relevant in my interpretations of data attributing the views of participants as activities or aspirations and enablers or barriers, particularly for those that were more ambiguous without sufficient supporting context. However, my committee helped provide guidance throughout the data analysis and write-up process, helping to ensure my own personal objectives were recognized and its influence on the interpretation of the data minimized.       109 The last limitation is related to the fact the original study did not include perspectives of the individuals receiving the care, so we are not able to understand whether the collaborations were helpful from their perspective. The perspectives obtained through the focus groups were of the frontline staff and managers and may reflect any biases in what they considered to be important, not necessarily reflective of the views of the receivers of the care. There was, however, a range in the level of partners in the collaboration, which included governmental, non-governmental organizations, community partners, and mental health and addictions services and a range in the roles of participants, which included frontline staff, business administrators, and senior managers. The involvement of a vast array of partners helps provide a comprehensive perspective of care delivery in the collaborations and addresses the concern that population health does not do enough to seek input from communities.(124) Suggestions to address these limitations in future research are described in Section 5.6 below.  5.5    Recommendations The findings from this study provide perspective on some of the barriers and challenges for improving mental health. The promising PHAC population health framework has resonance, providing a useful template for guiding some aspects of mental health service delivery, despite its limitations of not providing sufficient actionable strategies for some of the Key Elements (e.g., increase upstream investments, demonstrate accountability for health outcomes). This supports a criticism of population health that, despite offering a deeper understanding of the DoH, is too broad (122) because it sees health as the product of ‘anything and everything’(191) and is not easily implemented. In order to transform population health from being merely a concept of health to something that can be widely implemented, PHAC might consider further clarification and development of their sophisticated and advanced population health framework     110 to enhance its “uniformity of use,”(16, p381) making it more applicable to those working in the field. This could potentially be done through engagement of practitioners to develop a more comprehensive repertoire of actionable items for some of the Key Elements in their framework.   Glouberman and Millar (122) reported large increases in funding for population health initiatives in the late 20th and early 21st centuries (e.g., Canadian Population Health Initiative received $20 million in 1999 to fund research over a 4-year period) and the Canadian Institutes for Health Research created an Institute of Population and Public Health “to support research into the complex biological, social, cultural and environmental interactions that determine the health of individuals, communities and global populations.”(192) The Canadian Institutes for Health Research also included population health as one of its 4 “pillars” of research in addition to biomedical, clinical, and health services research.(122) Recently, interest in population health has decreased, in part due to its criticisms mentioned in Chapter 2.(149,184) Based on a review of the PHAC website, the population health framework is not prominent, despite calls from governments and advocates for an increasing emphasis on population health.(184) The population health page is situated within the “Health Promotion” page, perhaps adding further confusion around the distinction of population health from health promotion; furthermore, an additional three clicks is required to arrive at the population health framework document. Given the potential population health has on improving health status, it is timely and important to update the PHAC population health framework and to conduct further research evaluating its applicability and effectiveness in practice. Also, PHAC might consider placing an increased emphasis on mental health promotion (which is similarly situated within the “Health Promotion” page on PHAC’s website), as mental illness is a leading cause of the global burden of disease     111 (193) and a PH priority.(21,194) Increased attention to amalgamating mental health promotion and a population health approach efforts could be considered by PHAC.  5.6     Directions for Future Research  While this thesis contributes new knowledge showing that certain elements of PHAC’s population health framework are more actionable than others in the area of mental health, future research is much needed. Future research should aim to focus on collaborations that more explicitly examine population health in collaborations focused on mental health. This could be done using a participatory longitudinal mixed-methods study design within existing collaborations, using a combination of standardized measures administered to individuals (e.g., demographics, diary, Patient Health Questionnaire (PHQ)(94)) and interviews with community partners and practitioners. The research could incorporate theory, in addition to the findings obtained through this research. Baseline measures could be taken, and then measures would be repeated at three additional time points (e.g., 6 months, 1 year, 2 years). Interviews would be conducted at baseline, consisting of questions asking about their expectations and experiences with a population health approach and their expectations for delivering care using this approach, and then again at the end of the study to explore their feelings and experiences with the implementation of the framework. Outcomes could be assessed by the change in PHQ scores, evaluation of the diaries, and examination and comparison of the interviews. Additional research could also further explore findings from this research. For example, whether participants think gender and culture are important DoH impacting mental health. Additionally, the research could explore questions related to data systems and accountability for health outcomes, questions that we were not able to explore further in this thesis. This might require the participation of collaborations that involve policy maker partners. Focused research questions on PHAC’s     112 population health framework could provide further clarity on the existing framework in relation to mental health and whether additional actions might have been reported in this study, had the original research questions examined this topic.   The original study did not include perspectives of the communities and individuals, so we were not able to perform member checking to validate whether the strategies aligned with a population health approach were impactful from their perspective. A criticism of population health is that it does not seek to learn what individuals and communities identify as problematic and how others can support them in creating their own healthy communities.(124) Moreover, a literature review by D’Amour et al.,(195) identified an absence of the individuals’ perspective in defining collaborations, even though they are the reason collaborative care is integral in the first place.  There is a paramount need for future research to involve communities in the design and development of population health strategies to foster participation and respect, and a deeper understanding of the context of the DoH.(115,118,124) This could be done through the creation of a community advisory group to co-develop research questions, methodologies, and participate in the interpretation of findings. Most importantly, they could participate in the uptake of population health strategies, should the additional research demonstrate their effectiveness. Using participatory processes also tackles the criticism that population health is “context stripping”(118) in that it conducts large scale studies that attempt to identify general DoH, rather than identifying the specific DoH relevant for individual communities. Insight from this study could inform the effectiveness of using a population health approach in collaborations focused on mental health promotion at the community level.       113 5.7    Conclusion  Despite the original research not focusing on a population health approach or mental health, my secondary analysis shows that participants from the PC-PH collaborations are considering, and in some cases using, strategies aligned with a population health approach. Working with a subset of cases, of which mental health was central to the focus for three and the fourth focused on child health promotion and the DoH, my results provide evidence that collaborations between PC, PH, and other organizations were incorporating population health strategies. Notably, participants spoke to numerous activities and aspirations for addressing the DoH. While participants more frequently mentioned aspirations for providing mental health services aligned with population health strategies, other times they described specific actions being carried out. These findings suggest the population health approach has resonance and could be useful to incorporate into policy and practice going forward, despite a lack of guidance on specific ways to take action for a number of the Key Elements. In conclusion, this research provided clarity for thinking about how population health strategies are being implemented into mental health service delivery; that is, population health was thought about more often than acted upon, suggesting that if population health strategies, including resource allocation, were considered from the outset, then improvements in mental health service delivery would be more likely to occur. While many of the Key Elements lent themselves to being actionable, more might be done if we could further develop a repertoire of specific actions related to each of the Key Elements in PHAC’s population health framework, supporting its widespread applicability and uptake.   Mental illness, one of the most pressing concerns facing society today, is not being adequately addressed, resulting in many individuals not receiving the appropriate treatment they require.     114 There is a need to incorporate mental health promotion using a population health approach. This research identified a number of barriers and enablers to conducting activities that incorporate a population health approach, including the acknowledgement that care is fragmented, stemming from a lack of service integration between PH and mental health services. Mental health problems are currently being addressed predominantly in PC and are not adequately supported in PH; prevention and promotion are largely ignored in funding opposite of curative services in acute care.(120,139) Given the limitations of current mental health services, there is a need to address the DoH, the root causes of mental illness that lie mostly outside the health sector, and to employ participatory actions that supports mental health promotion at the community level. Mental health promotion strategies are grounded in a population health approach and are dependent on intersectoral collaboration, in particular between the PC and PH to potentially reduce duplication and increase efficiency for screening and diagnosis. The health sector, specifically PH due to its expertise in population health and clinical care, is envisioned to take a leadership role.   Mechanic and Aiken (1986) argue that the main contribution of social science research to social change is through its influence on the way policymakers and the general public think about social and health problems. Findings from my research could motivate additional research to further develop PHAC’s population health framework tailored to the unique mental health needs of communities and might support increased resource allocation on upstream investments. Population mental health can only be realized if sufficient resources are invested across sectors to support joint action to address the DoH that impact mental health.      115 References  1.  Public Health Agency of Canada. Glossary of Terms [Internet]. 2010 [cited 2016 Feb 16]. Available from: http://www.phac-aspc.gc.ca/php-psp/ccph-cesp/glos-eng.php 2.  Himmelman AT. Collaboration for a change: Definitions, decision-making models, roles, and collaboration process guide. Minneapololis, MN; 2010.  3.  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Government of Canada Statistics Canada. Canadian Community Health Survey - Mental Health (CCHS) [Internet]. 2013. Available from: http://www23.statcan.gc.ca/imdb/p2SV.pl?Function=getSurvey&SDDS=5015        141 Appendices Appendix A: Determinants of Health  The 12 DoH, along with their brief descriptions and examples (49)   Determinant Description Example 1 Income and social status Income can affect mental health because it affects the ability to meet basic needs and make choices in life. A higher income provides options and opportunities that are otherwise unavailable, which is important for individuals with mental illness.(48) Income is also positively associated with social status. A higher income and social status enhance an individual’s sense of control and the discretion to act. The percent of people who perceived their mental health as poor or fair was highest among the lowest income group, and decreased with each increase in household income bracket.  2 Social support networks Having a rich social support network helps act as a buffer from developing mental illnesses through many mechanisms such as: allowing them to develop trusting relationships, fostering a more meaningful purpose in life, enhancing sense of self and mastery, and providing support during stressful times. Single parents were more likely to report their mental health as poor or fair compared to married/cohabiting individuals who either had a child or did not.  3 Education and literacy Education is positively associated with health status. Education provides individuals with knowledge and skills to problem solve and deal with adversity. Furthermore, education helps individuals gain employment and opportunities for income, which in turn provides a sense of control over life circumstances. These are “key factors that influence health”.(47, p11)  Mental health status improves with each level of education attained.  4 Employment/ working conditions Unemployment and underemployment are associated with poorer mental health as it leads to diminished self-worth and increased stress. However, with employment come stresses related to the demands of the job (e.g. unrealistic deadlines) and working conditions (e.g. health and safety violations, authoritarian management). High levels of unemployment or overemployment are associated cause mental health problems, not only in the individuals but also in their families and the community     142  Determinant Description Example 5 Social environments Social environments (e.g. family, friends, workplace) can add or detract from individuals’ health depending on the amount and quality of support, nurturing, and cohesion that is provided. A healthy lifestyle is composed of the individual in connection with the surrounding social environments. In the 1990 Health Promotion Survey done by Health and Welfare, 48% of people said the support of friends and family was an important factor in making healthy decisions.  6 Physical environments The physical environment, composed of natural factors (e.g. air, water quality) and human-built factors (e.g. housing, design of communities), are important influences in an individual’s mental health. It can facilitate or hinder social cohesion, cooperation, and trust, all of which are important to mental health. Neighbourhoods with boarded windows, abandoned buildings, and heavy graffiti may imply vandalism and criminal activity, which can lead to fear and social isolation.  7 Personal health practices and coping skills Personal health practices and coping skills refer to the deliberate decisions and actions by which individuals cope with challenges, deal with challenges, and make choices that enhance health. For instance, regular exercise is extremely beneficial to mental health twofold: 1) it releases brain chemicals that help reduce stress and 2) it helps people maintain a healthy body weight, thus decreasing risks associated with being overweight (e.g. heart disease, diabetes).(30) However, it is widely recognized that personal decisions are greatly influenced by individuals’ socioeconomic environment. People who are physically inactive were more likely to report their mental health as poor or fair compared to those who were active.  8 Healthy child development  All of the health determinants greatly affect young children as they are developing and growing. Furthermore, resiliency, which provides an important buffer against developing mental illness, is developed in childhood. Therefore, it is imperative that children grow up in supportive environments with unconditional love, respect for individuality, and healthy relationships. Engaging in risky behavior (e.g. alcohol and drug use, drinking and driving) is highest among young people, particularly young men.      143  Determinant Description Example 9 Biology and genetic endowment An individual’s biology and genetic endowment provide the predispositions to the way they respond to external stimuli and life events. Genetic endowment interacts with the external environment (environmental, physical, culture) to produce a cumulative response. Drug and/or alcohol use during pregnancy can result in poor health outcomes in the babies.  10 Health services Health services include services provided by the primary care, public health, and specialist health services sector. The health services continuum of care encompasses treatment and secondary prevention. Although Canada has a publicly funded health care system, many low to medium income families experience difficulty accessing mental health care.  11 Gender Gender refers to the array of society-determined roles, personality traits, attitudes, behaviours, values, relative power and influence that society ascribes to the two sexes on a differential basis. “Gender”, unlike the biologically determined “sex”, is socially constructed and heavily influenced by the norms, values, and attitudes of society. “Gendered” norms influence the health system’s practices and priorities. Although women, on average, live longer than men, they experience higher rates of depression, often due to competing responsibilities at work and at home.  12 Culture  Canada is a multicultural country, with many immigrants from all continents. Culture influences an individual’s coping style and the method of providing/receiving social support. Being a part of a cultural group different from the dominant one can be associated with discrimination, racism, and poverty. The highest rate of suicide occurred in the Inuit population, compared to all other ethnic groups.  Note: many of the examples are taken from the Canadian Community Health Survey – Mental Health (CCHS – Mental Health),(197) which collects data related to mental health care access, utilization, and support in Canadians from the 10 provinces and three territories of Canada over 15 years of age.         144 Appendix B: Population Health Framework  Definition and Rationale for Key Elements and Actions that Define a Population Health Approach (47)  Key Element  Definition and Rationale Actions  1. Focus on the Health of Populations A population health approach assesses health and health status inequities over the lifespan at the population level. The approach captures not only illness and injury, but the positive dimensions of health. It links health measures of health status with measures of DoH to show how they interact.  Determine indicators for measuring health status   Measure and analyze population health status and health status inequities to identify health issues   Assess contextual conditions, characteristics and trends  2. Address the Determinants of Health and Their Interactions  A population health approach measures and analyzes the entire range of individual and collective factors and conditions and their interconnectedness that have been shown to be correlated with health status. Commonly referred to as the DoH, these factors include: social, economic and physical environments, early childhood development, personal health practices, individual capacity and coping skills, human biology, and health services.   Determine indicators for measuring the  determinants of health   Measure and analyze the determinants of health, and their interactions, to link health issues to their determinants  3. Base Decisions on Evidence  Evidence on health status, the determinants of health and the effectiveness of interventions is used to assess health, identify priorities and develop strategies to improve health. In a population health approach, evidence-based decision making is used at all stages of the policy/program development cycle. Evidence-based decision making refers to a decisional approach in which an information base or body of information successfully survives a broad, critical review process.    Use best evidence available at all stages of policy and program development   Explain criteria for including or excluding evidence   Draw on a variety of data   Generate data through mixed research methods   Identify and assess effective interventions   Disseminate research findings and facilitate policy uptake  4. Increase Upstream Increasing efforts and investments “upstream” to maintain health and address the root causes of health and illness will help create a  Apply criteria to select priorities for investment      145 Key Element  Definition and Rationale Actions  Investments  more balanced and sustainable health system. A population health approach directs investments to these areas that have the greatest potential to positively influence health. It also seeks to maximize the potential for health-related cost savings.   Balance short and long term investments   Influence investments in other sectors  5. Apply Multiple Strategies  Current understandings indicate the health of populations is correlated with factors that fall outside as well as inside the health system. A population health approach integrates activities across the wide ranges of interventions that make up the health continuum: from health care to prevention, protection, health promotion and action on the broader DoH.   Identify scope of action for interventions   Take action on the determinants of health and their interactions   Implement strategies to reduce inequities in health status between population groups   Apply a comprehensive mix of interventions and strategies   Apply interventions that address health issues in an integrated way   Apply methods to improve health over the life span   Act in multiple settings   Establish a coordinating mechanism to guide interventions  6. Collaborate Across Sectors and Levels   A population health approach calls for shared responsibility and accountability for health outcomes with multiple sectors and levels whose activities directly or indirectly impact on health or the factors known to influence it. “Intersectoral collaboration” is the joint action between health and other government sectors, as well as representatives from private, voluntary and non-profit groups, to improve the health of populations. This is based on the understanding that health is determined by multiple, interrelated factors, and that creating and maintaining health requires action from those sectors whose work aligns with the various DoH.  Engage partners early on to establish shared values and alignment of purpose   Establish concrete objectives and focus on visible results   Identify and support a champion   Invest in the alliance building process   Generate political support and build on positive factors in the policy environment   Share leadership, accountability and     146 Key Element  Definition and Rationale Actions  rewards among partners  7. Employ Mechanisms for Public Involvement  A population health approach engages citizens through the public involvement process, from the development of health priorities and strategies to the review of health-related outcomes. Involvement refers to the level of participation along a continuum. Three activities span the public involvement continuum:  1) communication, 2) consultation, and 3) citizen engagement.   Capture the public’s interest   Contribute to health literacy   Apply public involvement strategies that link to overarching purpose  8. Demonstrate Accountability for Health Outcomes  Population health focuses on health outcomes and determining the degree of change that can actually be attributed to interventions. An emphasis is placed on accountability for health outcomes and determining the degree of change that can actually be attributed to interventions. In making decisions on the best investment of resources, strategies that have the potential to produce the greatest health gains within acceptable resource limits will be given priority. Outcome evaluation, which examines long-term changes in both health status and the DoH, is essential in a population health approach.   Construct a results-based accountability framework   Ascertain baseline measures and set targets for health improvement   Institutionalize effective evaluation systems   Promote the use of health impact assessment tools   Publicly report results         147 Appendix C: Original Research Questions  Note: underlined are the questions I am specifically interested in.   Research questions for the case studies from the larger program of research (130) 1. Under what contexts are collaborations occurring? (setting; population served; history; systems drivers; goals; power; funding models; functions).  2. For what health issues does working together make sense?  a. How do partners work together (i.e. cooperation, coordination, collaboration, integration) for various health issues?  3. What are the precipitators and motivators of collaboration?  4. What structures and processes lead to the development as well as help to maintain collaborations?  5. What roles do various players have in collaborations?  6. What are the intended outcomes (process as well as other outcomes- short-, intermediate-, and long-term outcomes) of collaborations and how well are these reached?  7. What risks are inherent in building and maintaining collaborations and how are these managed?  8. How, if at all, is the community engaged in the collaboration?         148 Appendix D: Original Focus Group Questions  Note: underlined are the questions I am specifically interested in.   Focus Group A Questions (130) As you are aware, people from the agencies involved in your collaboration completed the Partnership Self- Assessment Tool. For this focus group, first we will present results (as mean scores) to you about your collaboration. This will include your response rate, your partnership’s synergy score which is a key indicator of how well your partnership’s collaborative process is working. We will also report on your partnership’s strengths and weaknesses in areas that are known to be related to synergy: (1) the effectiveness of your partnership’s leadership; (2) the efficiency of your partnership; (3) the effectiveness of your partnership’s administration and management; and (4) the sufficiency of your partnership’s resources. This information can help your partnership identify what it is doing well and what it needs to focus on to improve the success of its collaborative process. Next we will report results on your partners’ views about their own participation in the partnership. This describes their views about the decision-making process in the partnership, benefits and drawbacks they are experiencing as a result of participating in the partnership, and their overall satisfaction with the partnership.   After presenting you with the results, we will be asking you to comment on the results from your collaboration in the focus group so that we can get a better understanding about your results.  1. How do your scores resonate with what you perceive about this collaboration?  2. What struck you about the results? 3. Why do you think your collaboration received this score? We will present one section at a time and allow you to respond to each.    Focus Group B Questions (130) Support for Innovation 1. What programs/services are delivered in this collaboration and how are they delivered? a. What is different about how you deliver services to this population now compared to before this collaboration existed? Goals 2. What drove the development of this collaboration?  3. What do you think are the goals of this collaboration? 4. How were the goals defined?  Client/Community Engagement 5. What impact did primary care players, public health players, clients/patients/community members and/or other organizations each have on the development of goals for this collaboration? Centrality 6. Describe any formal systems or organizational structures and processes that guide action towards maintaining and sustaining the collaboration?  Information Exchange 7. Describe the information structures or processes that exist which facilitate or create barriers for the exchange of information between partners in your collaboration?  8. What type of information is shared between individuals in the organizations as well as between organizations in the collaboration?     149 9. What mechanisms are in place to share feedback between collaboration partners?  Financial and Non-Financial Resources 10. What financial and non-financial resources facilitate or create barriers in your collaboration?  11. How were you able to obtain these resources? What barriers did you have to overcome and how did you overcome them? 12. Are there any incentives (financial or other) tied to performance in the collaboration? (e.g. financial incentives for high screening rates). If so, how are the incentives managed and by whom? 13. What do you think about these incentives? Mutual acquaintanceship 14. How were roles and scope of practice of various primary care and public health players in the collaboration determined? (managers / directors only) 15. How was your role or scope of practice in the collaboration determined? (Front line only) Formalization Tools 16. For professionals participating in collaborations/partnerships, it can be important to know what is expected of you and what you can expect of others. What formalized tools exist that helped to clarify roles and activities in your collaboration?  17. How were these tools created? By whom? 18. What do you perceive are the benefits and drawbacks of these tools? Mutual acquaintanceship cont. 19. Primary care and public health have different approaches to working with patients/clients/groups and populations. a. How do you think your approaches differ and how do these differences impact on your collaboration?  b. How are these differences managed? 20. Describe any activities that occur among people working in this collaboration that help to build knowledge of one another’s worlds?  Connectivity 21. Describe in general how you work together in your collaboration.  Trust 22. Tell me about your relationship with your collaborative partners since your collaboration began. How has your relationship with staff members in your collaborative partner organizations changed since the collaboration began? 23. How do you perceive trust is built and maintained between partners in this collaboration? In your view, how well is this working? 24. What threatens trust in your collaboration and how do you deal with this threat? 25. How are conflicts in the collaboration addressed? Systems Factors 26. Describe any system factors (outside of the organization) that have influenced this collaboration.  Evaluation 27. How many clients are reached through your collaborative programs and services? 28. What, if any, evaluations have been conducted of this collaboration? a. How often do such evaluations occur and what and who do they involve?        150 Appendix E: List of Coded Focus Groups   Case  Focus Group/ Individual Interview Case A Focus Group A_BOTH Focus Group_A_BOTH Focus Group B_BOTH Case B Focus Group_A_FL Focus Group_A_MAN Focus Group_A_MAN_2 Focus Group_B_FL Focus Group_B_FL_2 Focus Group_B_MAN Focus Group_B_MAN_2 Case C BOTH_FL BOTH_MAN_1 BOTH_MAN_2 BOTH_MAN_3 Case D Focus Group_A_FL Focus Group_A_FL2 Focus Group_A_MAN Focus Group_B_FL Focus Group_B_FL2 Focus Group_B_MAN     151 Appendix F: Final Coding Framework  The following themes and subthemes are central to a Population Health Approach.(16) I coded deductively for activities-aspirations and enablers-barriers by examining the extent to which the participants depicted the eight Key Elements from PHAC’s population health framework and the specific actions to mobilize them are being addressed. I also coded inductively for related information related to the population health framework.   Key Element Theme (Definition) Subtheme Examples RQ1   RQ2 1) Focus on the Health of Populations   Assessing health status and health status inequities of the population as a whole, as characterized by geography, age, gender, culture or other defining features, over the lifespan. Measuring population health consistently over time, across jurisdictions, and across health issues.  Specific actions required to mobilize a population health approach:  Determine indicators for measuring health status  Measure and analyze population health status and health status inequities to identify health issues  Assess contextual conditions, characteristics and trends                       Focus on populations vs. individuals   We talk a lot about the individual client in primary care, and in public health, we talk about groups, schools, populations, communities as our clients so that can be a slightly different approach as well. [Case A – PH – BA] ASP IND  We talk. And I know to make sure that [name] has heard my voice around that so that when she’s at a table that she can kind of echo and feel free to speak on the behalf of [collaboration name] and what our experiences are in the community […] Which then hopefully will impact the overall health of [citizens of a province]. [Case B – PC – RN] ACT E  I’m trying to meet client need. I’m trying to have better access. I’m trying to have better referral for resources and better knowledge about resources. I’m trying to do the upstream, that whole model of upstream to downstream. The whole continuum of prevention and health promotion. So those are my goals. So that at the end of the day, we have a healthier community population. [Case D – BOTH – OTH] ASP E Understanding the larger picture   They’ve been doing enormous work out there for homelessness and things like that, addressing the social determinants of health. So we have the same concept, you still manage the specific communicable disease, issue, or client, or thing, but aware of the broader stuff. [Case A – PH – MD]  ACT E  working with a team you have the benefit of having a little bit broader BOTH E     152 Key Element Theme (Definition) Subtheme Examples RQ1   RQ2        perspective on the social issues and housing issues and some of the other, you know, not specifically biomedical issues […] the opportunity to kind of share clients back and forth and build on each other’s strengths is really facilitated by having the multidisciplinary team all on your one corridor [Case A – BOTH – MD]  And also to look after their social aspect and things like that. And it’s just nice to have that collaboration and ‘outreach staff is doing this part and I’m doing this part,’ and if we just kinda touch base once in a while, ‘so how are things going from your angle?’ so you know it’s good that you’re looking at them from different aspects [Case A – PH – PHN] ACT E  Because of course so many of our clients have multi needs. They just don’t come to us with one need. They’ve got a number of areas that all need help […] Maybe they’ve got substance abuse and maybe they’ve got mental health you know. [Case A – BOTH – MD] -- --  Well it’s one thing to prescribe the medication, it’s another thing to support them in being able to take that medication on a regular basis as it’s prescribed, right? So it’s kind of like working on that part, like this is the ideal ‘how do we get you as close to that ideal as possible recognizing you know that you don’t have stable housing you might have some substance use or mental health issues?’ and, and that, I think it’s just like a larger scope altogether that really defines the difference in the roles. [Case A – BOTH – OTH] ASP E  We need to think in a bigger way [Case B – PC – RN] ASP E  The nurse practitioner will have a larger parents’ kind of view, which is fine because, I don’t necessarily need that and that’s okay. Even if sort of a mom’s having an awful lot of issues that will help her now, helps me understand why she may not be home or following through on some things with the child. [Case C – PH – SP] IND E  Unless you’re willing to put the time in to actually really participate actively in all of the issues that affect the social determinants of health as well as your own particular piece, trust is hard to establish. [Case C – PC – NP] ASP E Social justice focus     The values that sit with the people that are now in the senior management at Public Health are social justice values, are the true core public health values. So I think that’s the difference. And they are so ASP B     153 Key Element Theme (Definition) Subtheme Examples RQ1   RQ2 hard to even articulate but you know it in your gut. Yes, I know that there are people that don't have that social justice framework and don't rally for the underdog. But that was the group that was most vulnerable [Case A – BOTH – OTH] Measure and analyze population health status and health status inequities   That broader picture, so doing some of the surveillance for example […] that is one of the approaches we use in public health that we don’t really expect the primary care provider to do, that broad surveillance [Case A – PH – BA] BOTH  BOTH  Well, [name] said […] in an editorial once. And he said until we really address issues of poverty, the people in [province name] will continue to be not well served by the healthcare system […] it goes back to what [name] is saying about looking at disparities. [Case B – PC – RN] NO B 2) Address the Determinants of Health and Their Interactions Measuring and analyzing the full spectrum of factors – and their interactions – known to influence and contribute to health. These factors are commonly referred to as the determinants of health. Specific actions required to mobilize a population health approach:  Determine indicators for measuring the determinants of health  Measure and analyze the determinants of health, and their interactions, to link health issues to their determinants  i) Income and social status   (Income is positively associated with health status. Income can affect mental health because it affects the ability to meet basic needs and make choices in life.)   Do they just see collaboration as sharing information back and forth? Or do they see collaboration as the [name of collaboration] model envisions, as truly spending one hour a week sitting at the table, sometimes not always talking about something that actually you’re even interested in but that just happens to be what is put on the table that day, and jointly working to problem solve something that actually might be, fall more accurately if we file things into the social services realm or into income assistance realm [Case C – PC – NP] -- E  Which is frustrating because without that [weekly meeting] we don’t have a relationship and you don’t get the income services and you don’t get to be in places where the care is delivered and you don’t get any of what you’re doing if you don’t give up that 60 minutes a week. [Case C – PC – NP] NO B Address poverty   Well, [name] said […] in an editorial once. And he said until we really address issues of poverty, the people in [province name] will continue to be not well served by the healthcare system [Case B – PC – RN] NO B  A letter was written by a schoolteacher at [elementary school name] [...] ACT E     154 Key Element Theme (Definition) Subtheme Examples RQ1   RQ2 it created a wonderful dialogue about how we don’t get into poverty pornography, but how we actually include families in the discussion about what is it they’re going to need to be successful when their children are in school and it brought a really healthy dialogue, so that by the time we’re having this open forum at the library, the community, there were parents who didn’t feel comfortable sticking up their hands, it was too intimidating but they felt represented by the people that were chosen on the panel to discuss what was healthy for the community [Case C – PC – OT]  A lot of our families are dealing with income needs or income for housing, etcetera. So when a kid ends up in ICU because they are living in a basement that’s got three inches of water in it and they can’t breathe because of the mould, etcetera. Well part of that is health because health is ending up paying for the treatment of that child. But the root to changing that or the conditions actually comes into financial support and/or housing. [Case C – OT – OT] -- E                    ii) Social support networks   (Having a rich social support network helps act as a buffer from developing mental illnesses through many mechanisms such as fostering a more meaningful purpose in life and providing support during stressful times.)   So just developing some of those on a community support thing, activities, or what not. To really help them get more engaged back into the community […] Because that is definitely a barrier and that does make people slip back. [Case A – BOTH – OTH] ASP E Provide community support services   Thing about also being interesting, to develop something to help people that are… you know kind of getting more onto regular, normalized community, to be able to have some services there to help them and support them in that transition back into community boecause there’s a real gap there and there’s a little isolation because they haven’t lived in the normal population. And fear judgment, and accessing services. [Case A – BOTH – OTH] ASP E Provide home check-ins for elderly  It was mentioned here a while ago how we’d like to have a check-in program for elderly people that live home alone with no support systems, just to have someone touch base with them either by phone, to make sure there’s been no falls. And if there has been, someone that can touch base with the doctor. [Case D – PC – FPN] ASP E iii) Education and literacy    Just getting that education out there. That they are able to access so many more resources [Case C – PC – OT] ACT E  So again it’s that whole educational piece and having them come [Case IND E     155 Key Element Theme (Definition) Subtheme Examples RQ1   RQ2                                    (Education is positively associated with health status. Education provides individuals with knowledge and skills to problem solve and deal with adversity.)  C – PC – OT]  Somebody said well there’s no money for education we could use that money to buy a book. [Case C – PH – PHN] -- B Support education around nutrition and healthy eating  We set up the menu and everything and then got the dietician to come in and review it and say what was, what was good about it and what needed twigging. So we did that.s And then it took a while for our families to actually, our kids, and the staff, to want to eat these healthy dishes. But now it’s like, great you know we’re eating tofu, beans and couscous or whatever and they all love it, right? [Case C – PC – OT] ACT E  You guys are very lifestyle and preventive as well. You know, healthy living that you guys do. And that providers that we have in our clinic right now, they are very lifestyle...  [Case D – PC – FPN] ACT E iv) Employment/ working conditions  (Unemployment and underemployment are associated with poorer mental health as it leads to diminished self-worth and increased stress.)   Nothing coded    v) Social environments  (Social environments (e.g. family, friends, workplace) can add or detract from individuals’ health depending on the amount and quality of support,   And also to look after their social aspect and things like that. And it’s just nice to have that collaboration and, “outreach staff is doing this part and I’m doing this part”. And if we just kind of touch base once in a while, “so how are things going from your angle?” So you know it’s good that you’re looking at them from different aspects [Case A – PH – PHN] ACT E  They’ve been doing enormous work for homelessness and things like that, addressing the social determinants of health. So we have the same concept, you still manage the specific communicable disease, issue, or client, or thing, but aware of the broader stuff. [Case A – PH – MD] ACT E  We’re opening facilities that have a strong model of capacity ACT E     156 Key Element Theme (Definition) Subtheme Examples RQ1   RQ2   nurturing, and cohesion provided.) building and connecting resources [Case C – OT – CD] Provide social activities for kids  We had the whole [family resource centre name] beautiful initiative that was driven by community health boards, primary healthcare, public health, where we put a person down there to give those kids other activities to do besides getting drunk and having sex or whatever the heck they do. [Case D – BOTH – OTH] ACT E vi) Physical environments  (The physical environment, composed of natural factors (e.g. air, water quality) and human-built factors (e.g. housing, design of communities), are important influences in an individual’s mental health.) Develop more homeless shelters   one of the goals would be to do some community development to provide some services to the marginalized population, to get better treatment facilities for drug and alcohol addictions and to develop more homeless shelters for this population. [Case A – PH – PHN] ASP E Ensure care is delivered to the homeless or those living in rooming houses  There needs to be a broader community development approach to try and make change and build resources for homeless people and for people with drug addictions [Case A – PH – PHN]  ASP E  What is really important is that we make sure that services are provided. That Public Health has on their radar how are we going to make sure that folks who are homeless or living in isolation in rooming houses and in all those spots, how do they get the public health care, the public health service, health promotion? How do we make sure that that happens? [Case B – PC – RN] ASP E  So [street outreach] sort of spreads themselves over the city in any areas where there’s a higher incidence of number of people who have health issues. That’s sort of the kind of entry point most of the time for [street outreach], is people with inadequate housing. […]And then they’ll see anybody with any kind of issues that happen to exist. It strays a little bit because sometimes there are people that are sort of housed but not necessarily well housed that are isolated. And so they might get involved in that way as well. [Case B – PC – MD] ACT E Conduct rooming house visits  No. [street outreach] is a primary care, Health Promotion and Prevention program that offers care specifically to populations and individuals who are either homeless or street-involved or whose lives are, you know, in chaos due to addictions or mental health. And also people who are pretty insecurely housed. We do a lot of rooming house visits. Lots actually. [Case B – PC – RN] ACT E Work with homeless  I was just having that exact conversation this morning with a grief counselor around accessing services for [homeless] youth with mental ASP B     157 Key Element Theme (Definition) Subtheme Examples RQ1   RQ2 youth health issues and the amount of youth that are coming, that are kind of coming up through right how that are really suffering from mental health issues and, and how to figure out how the system works and you know, that’s a challenge for us. [Case C – PH – BA]  it shifted form early child development focus to including adolescent health and recruiting the new adolescent health physician who’d worked with homeless youth and had new recruits looking at resiliency and youth. [Case C – PC – OT] ACT E vii) Personal health practices and coping skills  (This refers to the deliberate decisions and actions by which individuals cope with challenges, deal with challenges, and make choices that enhance health. These impact lifestyle choices through personal life skills, stress, culture, social relationships and belonging, and a sense of control.)   So [occupational therapist name] helped work out a system for him to take his medication. That relationship has grown to the point where he now goes with her a little bit and gets food before he spends all his money. And then he was going and getting a bus pass with her, and now he’s gotten to the point where he goes and gets his own bus pass. [Case B – PC – RN] ACT E  And that providers that we have in our clinic right now, they are very lifestyle […] They do a lot of prevention as well. Teaching. They’ll send off to, you know, a dietician and all that before a pill, a medication is ever ordered, if it can be. [Case D – PC – FPN] ACT E viii) Healthy child development  (All of the health determinants greatly affect young children as they are developing and Advocate for children and their families  I guess what I see my role as is advocating for children and families so that they can be supported in all areas, whether it be financial, health, or just having their voices heard for their families. [Case C – PC – OT] ASP E Create extra-curricular programs  They created an early childhood early learning assessment program through direct service delivery to the children and to the childcare center where they did a music program and a drawing program for kids where they repeated songs around ABC’s, colors and numbers. [Case C ACT E     158 Key Element Theme (Definition) Subtheme Examples RQ1   RQ2 growing. It is imperative that children grow up in supportive environments with unconditional love, respect for individuality, and healthy relationships.) for children  – OT – CD] Develop a healthy food program   I noticed it too cause we have a lunch program and we got the dietician. We set up the menu and everything and then got the dietician to come in and review it and say what was good about it and what needed twigging. [Case C – PC – OT] ACT E Wrap-around approach to providing care for families  We support not just licensed childcare but the whole wraparound approach to families, which includes supporting food, housing, childcare. […] We’re opening facilities with a very strong, that has a strong model of capacity building and connecting resources [Case C – OT – CD] ACT E  It’s not just about children’s and women’s, it’s about health care for families in the inner city. [Case C – OT – CD] ASP --  If we could engage with them [physicians] and in particular mental health, that if I could call another besides having one representative for community health nursing and sort of that wrap around sort of family approach that we were looking forward to. That it would be the addition of someone representing community mental health and how we better connect with existing programs [Case C – PC – OT] ASP E  I think they feel that they are talking to their families about the Enhanced Home Visiting program or about [family resource centre name]. They’re trying to support them in regards to the parenting. And there’s so much of it that it’s much more on the social paradigm than on the clinical paradigm. [Case D – BOTH – OTH] ASP E ix) Biology and genetic endowment  (An individual’s biology and genetic endowment provide the predispositions to the way they respond to external stimuli and life events. Genetic endowment interacts   Nothing coded       159 Key Element Theme (Definition) Subtheme Examples RQ1   RQ2 with the external environment (environmental, physical, culture) to produce a cumulative response.) x) Health services  (Health services include services provided by the primary care, public health, and specialist health services sector. The health services continuum of care encompasses treatment and secondary prevention.) Support a one-door policy and hub for health services  When care for the disenfranchised is fragmented there, it’s so much more difficult, it just puts up so many barriers for them to try to access individual pieces of their healthcare. And if they can have it all under one roof, that’s very powerful [Case A – PH – PHN] -- BOTH  we do very well I find at cross-referring, again not the formalized referral, but if someone wants to come here mental health services, addiction services or public health nursing specifically […] there’s no barriers. [Case A – BOTH – RN] ACT E  they really have a multidisciplinary team, so people can go to outreach urban health and they can access a whole bunch of services from one place. Which probably wasn’t available prior to outreach urban health being established [Case A – PH – PHN] ACT E  It’s quite a powerful synergy when you have the primary care and the public health rubbing shoulders together. There’s the interchange of ideas but there’s also a much better experience for the client to be able to access all of those things at in the much more powerful way than if they had to go to separate locations to access these things [Case A – PH – PHN] ACT E  I think with Public Health shifting to a different focus, working in the community more, I think the opportunities are endless. Whereas the way our structure was previously, I think it caused huge barriers. People worked in their own focused area instead of looking at the community as a whole. And so many people fell through the cracks, and the services that they really required weren’t offered. They might have been available but they weren’t accessible at all. So I think this is... I was really excited about the collaboration. [Case B – PH – OTH] ASP B  We have a system that’s kind of created around, you know, for what some have defined as the majority, right. And anyone who kind of is ASP BOTH     160 Key Element Theme (Definition) Subtheme Examples RQ1   RQ2 outside of that, really you need to sometimes ask yourself, okay, maybe we can’t create a system but maybe we can create doors for that population to get the care that they need. [Case B – PC – RN]  make it a low barrier system so that if you go into the community center and you need health care, the community center can help you get to the health care. If you go into public health and get immunizations and you need some developmental assessment or you need some kind of maternal, you know, mental health assessment or whatever, you will get linked that way. So it is kind of like every door is a way in. [Case C – OT – OT] ASP E  they opened the teen health centre. So that was a collaboration with both Public Health and primary healthcare. […] And there’s where your outside agencies certainly came in. Mental Health can come in, and Addictions. So there’s more services. [Case D – PH – PHN] ACT E Lack of commu-nication and service integration   I don’t know if you would call it an activity so much, but one of the things we have done despite having sort of separate structures, is that we’ve tried to bridge the gap a little bit by using the team leader, a public health nursing team leader, who was able to go in and provide ongoing support and education around the public health activities for the outreach staff […] that’s been an informal working agreement we’ve had since day one, that public health would always be there and be accessible for any education, sharing of policy, sharing of information, able to come to meetings and that sort of thing. [Case A – PH – BA] ASP E  They touch on very, many, many, many departments. They touch on home care nursing, they touch on public health, they touch on CD, and there are no formal linkages […] mental health, substance abuse, public health…what else do they belong to…long term care [Case A – PH – OTH] -- B  Public health and mental health and addictions are two different departments under the same health authority […] One public health and one not. When the health problems that people are dealing with, many people have two problems. […] So there are multiple layers here, that’s why it’s so amazing that we can make it work at the front line [Case C – OT – OT] -- B     161 Key Element Theme (Definition) Subtheme Examples RQ1   RQ2  Well I would say having a mechanism to bring them together and commit to, you know, supporting change at the front line. […] Instead of people saying it’s your problem, it’s your problem, that’s how it becomes; it’s your problem. But a funding problem. That’s your problem. Can everybody say, if this family has a problem because they don’t have housing and funding and their kid’s sick and their mother has got a mental health issue […] So I would just say at a higher level there needs to be a commitment to integrated frontline service, like supporting the integration of services. [Case C – OT – OT] ASP BOTH  But I think mostly giving people permission to work together, right? […] But don’t you think it would be best to engage with those other people who are involved to come up with creative solutions? If people have permission to do that and the skills to have the conversation instead of saying, well, I’m not doing that and you know blah blah blah. I may be mischaracterizing it, but my sense is that there is disconnect. [Case C – OT – OT] ASP BOTH  And one community program, even if it’s in Health, so primary healthcare, public health, addiction services, they can’t talk [...] Addiction can’t say what’s public health is doing, and public health can’t say what addictions is doing. I don’t know. I don’t know what they’re doing. [Case D – BOTH – OTH] -- B xi) Gender  (The array of society-determined roles, personality traits, attitudes, behaviours, values, relative power and influence that society ascribes to the two sexes on a differential basis.  Gendered norms influence the health   Nothing coded       162 Key Element Theme (Definition) Subtheme Examples RQ1   RQ2 system’s practices and priorities.) xii) Culture   (Culture influences an individual’s coping style and the method of providing/receiving social support. Being a part of a cultural group different from the dominant one can be associated with discrimination, racism, and poverty.)   Nothing coded   3) Base Decisions on Evidence Using “evidence-based decision making”. Evidence on health status, the DoH and effectiveness of interventions is used to assess health, identify priorities and develop strategies to improve health. Specific actions required to mobilize a population health approach:  Use best evidence available at all stages of policy and program development  Explain criteria for including or excluding evidence  Draw on a variety of data  Generate data through mixed research methods  Identify and assess effective interventions Disseminate research findings and facilitate policy uptake  Identify and assess effective interventions    An interesting piece of the partnership in this community now will say they will agree is the research is a central part of this partnership, the evaluation […] If we don’t have evaluation to show its effectiveness, we won’t be sustainable [Case C – PC – OTH] --  E  We’re actually looking at what are the factors that work, what are the barriers, what are the, you know predisposing, reinforcing, and facilitating, however you want to look at a health promotion model that we we’re actually looking at. Outcomes and processes [Case C – PC – OTH] ACT E     163 Key Element Theme (Definition) Subtheme Examples RQ1   RQ2  We’ve made the provincial commitment to build it [data systems]. That’s what I was talking about – firmly turning the lens on disparities. And we are getting no funding or support to doing that. And yet that is what Public Health should be doing. That’s the work that we should be doing. [Case B – PH – SA] --  BOTH  Poor data systems   Data and information, I mean we do not have data systems for Public Health that are very efficient or effective. So data and information, I could see why that score is somewhat low. I would expect it to be lower because everything is paper and pencil and then entered. [Case B – PH – OTH] --  B  It has never been a priority in this province ever. Data collection, data analysis for population health decision-making has never been a priority. So we don't have it […] We’ve made the provincial commitment to build it. That’s what I was talking about – firmly turning the lens on disparities. And we are getting no funding or support to doing that. And yet that is what Public Health should be doing. That’s the work that we should be doing. [Case B – PH – SA] --  BOTH  We don’t have the data. So in those other jurisdictions, all of those medical officers of health can come to the table with here is the data [Case B – PH – SA] --  B  The data is very basic at this time. As I explained to you earlier, what data I’m keeping track of and how we are trying to share with [street outreach], similar data to try and understand the population we’re serving. [Case B_PH_OTH] ASP BOTH  I firmly believe public health practice is about our ability to expose and illuminate disparities. But we have not done that. We can’t affect public policy if we don’t do that and we haven’t done it. So it doesn’t surprise me at all. [Case B – PH – SA] NO --  Public health intervention outcomes take time    And the acute care just sits there and [noise of rubbing hands together], at the end of the year says good, we’re lost our deficit, so we’ve lost our money that way because of the type of work that we do, and the fact that everything that we do takes 8-10 years to evaluate. [Case A – PH – PHN] --  B 4) Increase Upstream Directing increased efforts and investments “upstream” to maintain health and to address root causes of health and illness. This will help to create a more balanced and sustainable health system.     164 Key Element Theme (Definition) Subtheme Examples RQ1   RQ2 Investments Specific actions required to mobilize a population health approach:  Apply criteria to select priorities for investment  Balance short and long term investments  Influence investments in other sectors  Focus on upstream approaches   But for communicable disease control, for health promotion and some of the upstream efforts that we really need to be doing, I think with public health shifting to a different focus, working in the community more, I think the opportunities are endless. [Case B – PH – OTH] ASP E  I’m trying to do the upstream, that whole model of upstream to downstream. The whole continuum of prevention and health promotion. So those are my goals. [Case D – BOTH – OTH] ASP E  But you can’t have a health centre coordinator permanently based doing 3 health centres because it’s going to collapse somewhere. It's not going to be consistent. [Case D – PH – OTH] IND B  And the upstream/downstream piece is big even with not just with like the health promotion types but with the nurses […] the standards are telling us we’re going exclusively upstream. How far upstream is another issue. [Case D – PH – HP] IND BOTH  I think too it’s also that traditional approach of what they would see in terms of prevention or their responsibility or role in prevention or upstream approaches. […] it’s old...It's traditional, older kind of ways of thinking about that. And that’s, I guess, partly maybe our role to try to help them understand that better or, you know, work with them closer to understand that. [Case D – PH – OTH] ASP E  Upstream I guess for me is thinking of […] So instead of trying to spread one person to provide the direct service in 3 or 4, you know, [name] is the expert who could mentor future leaders somehow so here time could be spent in that way. And I hope that in the future that we can get there to see that you know, she could someone who could be really moving some of that piece and helping to build capacity for more sustainability there. Because if there’s no money, like so much, what other options are there? And that’s an upstream approach. [Case D – PH – OTH] ASP E 5) Apply Multiple Integrating activities across the wide range of interventions that make up the health continuum: from health care to prevention protection, health promotion and action on the broader DoH.     165 Key Element Theme (Definition) Subtheme Examples RQ1   RQ2 Strategies Specific actions required to mobilize a population health approach:  Identify scope of action for interventions  Take action on the determinants of health and their interactions  Implement strategies to reduce inequities in health status between population groups  Apply a comprehensive mix of interventions and strategies  Apply interventions that address health issues in an integrated way  Apply methods to improve health over the life span  Act in multiple settings  Establish a coordinating mechanism to guide interventions                           Apply a comprehensive mix of interventions and strategies   Because there were things like haircuts, as I said, clothing, conference kits, a hot lunch. There was a wellness centre. Like they would check up, diabetes screening, blood testing, vision care, nutrition counselling, mental health, addictions. There was some financial services there. Education and Employment Service was there. Local shelter. [Case B – PH – OTH] ACT E  Because of course so many of our clients have multi needs. They just don’t come to us with one need. They’ve got a number of areas that all need help. And only one piece of it is going to be the medical and only one piece of it is the TB piece. Maybe they’ve got substance abuse and maybe they’ve got mental health you know. [Case A – BOTH – MD] -- B  I think we’re open to always have all of the different specialties come in, and we’re wanting them to come in as often as possible and I think we would like to see a collaborative way of just having an evening and having people coming or having come around more often. I think it’s great that the practitioners can come in and be there and they have a spot [Case C – PC – OT] ASP E Provide outreach services   having relationships built with the downtown street population and also knowing who these people are and, again yesterday when we had that positive skin test with somebody that had very high risk behaviour, we were able to phone outreach and see if this gentlemen was known to them. It was helpful. [Case A – PH – PHN] ACT E  we have public health staff who are working out of the outreach urban health office and, in fact, that’s where so much of the daily collaboration is happening between primary care and public health. [Case A – PH – BA] ACT E     166 Key Element Theme (Definition) Subtheme Examples RQ1   RQ2                                     The word is out there on the streets that the nurse practitioners and the mental health physician meet with the young parents in the community and nobody’s out there on the streets [Case C – OT – CD] ACT E  We ran to a light and they said hello to six of the people. I was impressed with the [name of organization] folk that they remember these people by first name having never met them, but knew all their file stuff. It just showed me how connected the system was on supporting clients on the street. [Case A – PH – MD] ACT E  it’s really not anything new, it’s actually very old work. We go where people are, and we kind of get to know them, and you know where they hang out, where they eat, that’s really all we’re doing. [Case B – PC – RN] ACT E  And often they want us to be based in the hospital or organizational setting and the work we do can sometimes be a bit invisible because we’re not on site. And I wish it, there was a way that management could better understand the work we do and how we truly impact the community, the people, the nurse practitioner, or a physician, or say public health, in these roles or the services we give. [Case C – PC – NP] IND B  you need to be able to trust that it’s a safe environment and by having resources in the community and fellow members in the community actually take them and introduce them. [Case C – OT – CD] IND E Provide referrals   I know that [name’s] been referring some clients into there and that, so we’ve had some actual good feedback from public health. [Case A – BOTH – OTH] ACT E Create programs for youth health    And then now we’re discovering that for our youth mental health concerns that there’s a wonderful program like connecting to the roving leaders program and that the community has some solutions that are, maybe we can work with instead of creating a parallel system. [Case C – PC – OTH] BOTH E  One other thing I thought of meeting the needs of the community was the [town name] school, there was a lot of issues going on with the high school. So the DHA and primary healthcare and Public Health all came together, the school board, the Department of Education to see what they could do to help the school and the students. And they opened the teen health centre. So that was a collaboration with both Public Health ACT E     167 Key Element Theme (Definition) Subtheme Examples RQ1   RQ2        and primary healthcare. […] Mental Health can come in, and Addictions. So there’s more services. [Case D – PH – PHN]  Public Health was in there building the relationships, doing the consultations, asking the kids what they need. We got those kids...two kids on the Community Health Board. That was just an amazing thing where we all went in there together. Oh, and addictions, I can’t forget Addictions. They have put a counsellor down there too. So it’s been beautiful. And Mental Health goes down on a satellite basis. And they’ve been involved. So it was a true collaboration. [Case D – BOTH – OTH] ACT B  We’re still striving ahead with that open door and how we get in. So a year ago, I had my first conversation with the principal. Today, we have had at least 4 consultations with the kids. We’ve done a walk through alcohol land where the province came up and talked to the kids about why is alcohol such an issue. [Case D – BOTH – OTH] ACT E 6) Collaborate Across Sectors and Levels Intersectoral collaboration is the joint action among health and other groups to improve health outcomes. This is required because a population health approach calls for shared responsibility and accountability for health outcomes with multiple sectors and levels. Specific actions required to mobilize a population health approach:  Engage partners early on to establish shared values and alignment of purpose  Establish concrete objectives and focus on visible results  Identify and support a champion  Invest in the alliance building process  Generate political support and build on positive factors in the policy environment  Share leadership, accountability and rewards among partners            Identify and support a champion    I don’t if you would call it an activity so much, but one of the things we have done despite having sort of separate structures, is that we’ve tried to bridge the gap a little bit by using the team leader, a public health nursing team leader, who was able to go in and provide ongoing support and education around the public health activities for the outreach staff […] that’s been an informal working agreement we’ve had since day one, that public health would always be there and be accessible for any education, sharing of policy, sharing of information, able to come to meetings and that sort of thing. [Case A – PH – BA] ASP E  That depends on how you view leadership… I mean everybody has a role in, in terms of being a leader. [Case C – PH – BA] --  IND     168 Key Element Theme (Definition) Subtheme Examples RQ1   RQ2                                     There is no one leader in a, in a project. It’s a collaborative approach. [Case C – OT – CD] -- E  [name] is the expert who could mentor future leaders somehow so here time could be spent in that way. And I hope that in the future that we can get there to see that you know, she could someone who could be really moving some of that piece and helping to build capacity for more sustainability there. Because if there’s no money, like so much, what other options are there? And that’s an upstream approach. [Case D – PH – OTH] ASP E Invest in the alliance building process   Well I know there were goals identified in the guiding document when it originated which covered all the goals were talking about so. It’s kind of nice to see that it’s actually still heading the same direction we envisioned it heading [Case A – PH – BA] IND E  But we have actually had the coordinator of outreach urban health attending the mental health team leader meetings, for I think, well I don’t know, most of this year, I think. […] But that’s helped too, because there’s such an overlap between mental health services and outreach urban health services. [Case A – PH – BA] ACT E  So that, I think, is the crux of many relationships that [street outreach] has. And it’s unique because you know, you identify your allies because the system isn’t always an ally to you but there are individuals within it that are. And because the system has not kind of really thought about how to create itself in a way that is  free. But there are individuals within the system that are really embracing that. [Case B – PC – RN] IND BOTH  So for example, a memorandum of understanding can give parties an excuse not to do something because it’s not in the MOU, instead of giving them an opportunity to do something or permission to do something or do things. And so I think some degree of formalization is a good idea, and I love the fact that we can just pick up the phone and sort of say, okay, so how do I handle this? [Case B – PH – SA] IND E  Having community includes people that have been in community a long time […] It’s those relationships that we have and, and keeping that trust [Case C – OT – CD] -- E Engage partners   Our relationship is with individuals but we’ve created a relationship ACT E     169 Key Element Theme (Definition) Subtheme Examples RQ1   RQ2          early on to establish shared values and alignment of purpose  with Public Health […] Public Health has recognized our connection and our relationship to that community. And so therefore have taken away any barriers that one might face as a nurse delivering care in the community and said, okay, how do we work with you since you’re going to do this? What can we do to make your job easier but also to increase the components around prevention, treatment and care in the community? [Case B – PC – RN]  You identify your allies because the system isn’t always an ally to you but there are individuals within it that are. [Case B – PC – RN] IND BOTH  That was signed by the whole team, with the community non-profit agencies, just outlining what we brought to the collaboration, what they bring to the collaboration and that we’re working together to meet the needs of the community and so that is signed [Case C – PC – NP] IND E Employ a participatory model   I think we’re open to always hav[ing] all of the different specialties come in, and we’re wanting them to come in as often as possible and I think we would like to see a collaborative way of having people coming or having come around more often. I think its great that the practitioners can come in and be there […] It’s making those connections every once in a while has helped to build that strength. [Case C – PC – OT] ASP E 7) Employ Mechanisms for Public / Community Involvement Promoting citizen participation in health improvement wherein they are provided opportunities to contribute to the development of health priorities and strategies and the review of health-related outcomes. Mental health promotion focuses at the community level, where needs of the community are understood and strategies can be tailored to address those needs. Specific actions required to mobilize a population health approach:  Capture the public’s interest  Contribute to health literacy Apply public involvement strategies that link to overarching purpose          Apply public involvement strategies that link to overarching purpose   It’s the first time you’ve asked us what we needed, not deciding what you wanted to study and so that it was working with us at what we had identified as the issues, not being fixed on what you wanted to look for. And so I would say that this has been a employ a participatory model [Case C – PC – OT] ACT E  There has been a multitude, and I can say that freely, of major tragedies down there that had pulled people, including youth health coordinators […] going down and spending some time with the youth. We did some focus groups and collaborated that way as well. And even [the ACT E     170 Key Element Theme (Definition) Subtheme Examples RQ1   RQ2                   family resource centre], the local agency here, to go down and talk to the youth about what their wants are and what their needs are [Case D – PH – OTH]  We’re still striving ahead with that open door and how we get in. So a year ago, I had my first conversation with the principal. Today, we have had at least 4 consultations with the kids. We’ve done a walk through alcohol land where the province came up and talked to the kids about why is alcohol such an issue. We have the party program. [Case D – BOTH – OTH] ACT E  Engage stakeholders   And so we’re identified as kind of stakeholders or key players in that, and invited to that table [Case B – PC – RN] ACT E  Always really intended to be quite a grass roots movement and I think the involvement of the community partners was a very central, essential component […] I think the priority was absolutely the community capacity for this [Case C – BOTH – BA] ASP E Build relationships with target population    It’s built relationships with the client population and also it’s really firmly established us with the community partners who also are dealing with the similar populations. So that’s been really advantageous to have those established invoke relationships. So that really has changed how we do our own work now, because now we’re able to work through other organizations as well [Case A – PH – BA] ACT E  Having relationships built with the downtown street population. [Case A – PH – PHN] IND E  We ran to a light and they said hello to six of the people. I was impressed with the [name of organization] folk that they remember these people by first name having never met them, but knew all their file stuff. It just showed me how connected the system was on supporting clients on the street. [Case A – PH – MD] ACT E  I said ‘you know what, it’s really not anything new,’ it’s actually very old work. We go where people are, and we kind of get to know them, and where they hang out, where they eat, that’s really all we’re doing. [Case B – PC – RN] ACT E Focus on the community     It’s a collaboration that’s working with communities. It’s listening to community around where the needs are, what needs to happen, and so help is huge from infants all the way up to the parents who’ve got ASP E     171 Key Element Theme (Definition) Subtheme Examples RQ1   RQ2 schizophrenia and we’ve got mental health at that table. There’s a large gap around mental health services within the community if they weren’t at that table [Case C – OT – CD]  People worked in their own focused area instead of looking at the community as a whole. And so many people fell through the cracks, and the services that they really required weren’t offered. They might have been available but they weren’t accessible at all. So I think this is... I was really excited about the collaboration. [Case B – PH – OTH] --  BOTH  In some ways we are what Public Health used to do years ago in that the way we do it now is that our presence is in the community, our relationship is with individuals but we’ve created a relationship with Public Health […] Public Health has recognized our connection and our relationship to that community. And so therefore have taken away any barriers that one might face as a nurse delivering care in the community and said, okay, how do we work with you since you’re going to do this? What can we do to make your job easier but also to increase the components around prevention, treatment and care in the community? [Case B – PC – RN] ACT E  Community centers, you know, they are a prime example of you need to be able to trust that it’s a safe environment. And by having resources in the community and fellow members in the community actually take them and introduce them. [Case C – OT – CD] IND E  But it’s about thinking around a community perspective [Case B – PC – RN] ASP E 8) Demonstrate Accountability for Health Outcomes Focusing on health outcomes and on determining the degree of change that can actually be attributed to interventions. This has an impact on planning and goal-setting processes as well as on the choice of interventions or strategies employed. Specific actions required to mobilize a population health approach:  Construct a results-based accountability framework including a clear statement of roles and responsibilities   Ascertain baseline measures and set targets for health improvement  Institutionalize effective evaluation systems  Promote the use of health impact assessment tools  Publicly report results  No formal evaluation mechanisms and   I’d be challenged with how to do an evaluation without formal mechanisms and accountability structures in place. So there is a piece of those forms, I think, that would have to be in place before we NO B     172 Key Element Theme (Definition) Subtheme Examples RQ1   RQ2 accountability structures would be in a position to evaluate. So are we evaluable at this time? No, I would say no, we’re not. We don't have those items organized enough to be able to evaluate. [Case B – PH – SA]  And I guess my point is that I think sometimes we’re not critical enough around doing evaluation [Case B – PC – RN] -- B  So we don't really have any formal tools in our relationship with [street outreach]. I think the benefit of formalization is around accountability. I think it can create an accountability structure. But is it important? I don’t know. [Case B – PH – SA]  -- BOTH Accountability structures and processes   There is the perception, I think, of outreach urban health being a little cowboy…I think so. There are processes, like we have internal checks and balances and people aren’t just going rogue. But it’s just like kind of the perception because there isn’t maybe the formal structure, but there are definitely structures in place and there’s accountability for everything that happens there, and it’s you know very open and what not to our management leads. So just to kind of put that, it’s just not quite as formalized as public health and that’s mostly because I think of the nature of the clientele that we service, and the amount of community partners etcetera [Case A – BOTH – OTH] --  BOTH  That creates an accountability for [street outreach] within the reporting structures of [the district health authority]. But the relationship existed long before that reporting structure was in place and the funding model was in place. [Case B – PH – SA]  IND E  I think that what is really important is that we make sure that services are provided. That Public Health has on their radar how we are going to make sure that folks who are homeless or living in isolation in rooming houses and in all those spots, how do they get the Public Health’s care, the public health service, health promotion? How do we make sure that that happens? […] I think they’ve taken some strides to make sure of that through including that in policy. But how tight do you make a relationship can sometimes tighten what you can do in a relationship. [Case B – PC – RN] ASP E    

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