Effectiveness of a systematic approach to promote intersectoral collaboration in comprehensive school health promotion-a multiple-case study using quantitative and qualitative data
The current study had two aims: first to investigate the effectiveness of a systematic
approach to the development of intersectoral collaboration in CSHP and second to open
up the ‘black box’ of the collaborative processes involved. These aspects were investigated
using the data from a two-year DISC-based trajectory. We examined longitudinal quantitative
data from the trajectory to find out whether collaboration had improved in terms of
the DISC factors after participation in the DISC-based trajectory (research question
1), and studied the longitudinal qualitative data to assess whether managerial activities
were employed by regional coordinators in response to the trajectory, and if so which
ones (research question 2). Presenting both results, quantitative and qualitative,
in one paper provides additional understanding of the origins of the observed effects.
As regards our first research question, the quantitative data showed remarkable improvement
(of almost medium effect size) in change management and project management. In addition,
gains of medium magnitude were found on the three subclusters of collaborative support (i.e. perceived consensus, intention to commit, and formalization), as well as on one measure of external factors (i.e. perceived alignment between policies), and on four measures of sustainability (i.e. theoretical vs. practical, research vs. practical, ad-hoc vs. systematic, fragmentation
vs. single service point). These improvements were found despite an increase in organizational problems reported
by stakeholders involved (due to e.g. mergers, reorganization, financial cutbacks).
As regards our second research question, our qualitative data showed that regional
coordinators undertook different activities in response to the DISC-based trajectory,
activities which clustered into five managerial styles and basically addressed (1)
involving stakeholders in the decision-making process, (2) informing them about decisions and progress made, (3) controlling and (4) supporting their task accomplishment, (5) and coordinating the collaborative process.
The improvements that we found in terms of change management, project management, and collaborative support seem to be the result of having encouraged regional coordinators to identify common
grounds with the stakeholders regarding several aspects. These aspects included the
establishment of a common vision, a common collaborative structure, and a suitable
task distribution, while considering stakeholders’ individual interests. In this respect
our qualitative data provide some indications that regional coordinators have created
the necessary opportunities for stakeholders to freely voice their suggestions, doubts,
and wishes regarding these aspects (the involving management style). Similar findings have been reported by others, who found that
creating spaces for negotiation (e.g. brainstorming, discussion) can enhance the consensus
on collaborative goals and necessary actions, and thereby promote the formulation
of commitments in collaborations 35], 20], 36].
The same reasoning seems to apply to the increased degree of formalization we have
found at posttest. We advised regional coordinators to discuss choices at the management
and executive levels. The qualitative data indeed indicate that regions consolidated
agreements in documents at different levels (the coordinating management style). Bohlmeijer et al. 35] reported that written documents can be regarded as the visible results of the negotiations
and are an important indicator of formalization. Koelen et al. 37] showed that such formalization builds employees’ accountability, which acts as an
important driving force for action in Dutch health organizations.
As an adverse development, we have observed that the internal context of the parties
involved deteriorated. It is conceivable that this result is related to the internal
developments (e.g. mergers, reorganizations) that the organizations were going through
during the trajectory, in response to government cutbacks due to the financial crisis
in the Netherlands. In addition, it could be the consequence of the new four-year
public health policy cycle which organizations had entered in 2011 and which obliged
them to translate new national health promotion objectives into concrete strategies
to improve health at local level. We observed that these dynamics often forced collaborating
parties to make choices which were not in interest of the collaboration. Time and
staff were mainly dedicated to the reorientation. Legislation changed, as did organizational
tasks. Some PSSs left the collaboration, others reduced their investments. The reconciliation
of collective and individual interests has been reported by others as a recurring
dilemma in collaborations. While stakeholders achieve collaborative goals, they also
have to fulfil the individual organization’s mission and respond to organizational
developments and problems 20], 21], 37]–42]. This finding may explain the state of the collaboration after three years, where
collaboration shows no improvements in terms of collaborative actions as yet. Even
if agreements were reached, this seemed to require much more time.
Next to the effort to reconcile individual and collective interests, our qualitative
and quantitative data strongly suggest that regional coordinators recognized relevant
policies for intersectoral collaboration and tried to influence them to promote collaboration.
Regional coordinators used the ‘windows of opportunity’ 43] that emerged from the dynamic context for this purpose. They placed the HSA and the
collaborative structure on the agenda of meaningful internal and external meetings
(the informing management style). They made connections and opportunities visible to relevant actors
(the coordinating management style). They developed supporting policies and financial agreements between
municipal authorities and PHSs (the supporting management style). Our quantitative data confirm greater alignment between health
policies, school policies, and the HSA after the trajectory (external factors). De Leeuw 27] reported comparable skills by ‘social entrepreneurs’ who were able to influence policy
agendas. These social entrepreneurs had the abilities to obtain an overall view of
the various perspectives of stakeholders, to broker commitments of stakeholders into
networks and to reflect on their own position and that of the stakeholders. They influenced
the policy agenda by bringing problems, solutions, and the right stakeholders together.
By contrast, our study shows that directive behaviors, which focus on task performance,
such as planning and control systems (the controlling management style) were less commonly employed, and when they were used, it was mostly
in organizations that fall under one umbrella organization. This probably indicates
the difficulty of employing this type of behavior in collaborations lacking formal
authority 35], 41].
Finally, it is encouraging to find that stakeholders expressed more favorable judgments
about the sustainability of the collaboration at posttest (i.e. more systematic, more
practical, more demand-driven practices). Although the absence of comparable studies
makes it difficult to compare our findings, there are studies that support the view
that a systematic, step-wise approach to change can give direction and transparency
35], 44]–46]. A study involving the provision of professional support for school staff to implement
the CSHP acknowledged that professional support can enhance the acquisition of organizational
knowledge and its translation into practice 47]. Lastly, the finding that school health promotion developed from fragmentation towards
a single service point for health promotion (i.e. demand-driven practices) provides
additional evidence that collaborative efforts start to pay off and contribute to
collaborative goals.
Based on the above interpretations, it is plausible to postulate that regional coordinators
employed managerial activities in response to the DISC-based trajectory, which have
contributed to the observed improvements in terms of the DISC factors. In this respect
the combination of the qualitative and quantitative data was an important strength
of our study. It allowed data triangulation and a combined study of effects and processes.
This in turn provided important insights into the causes of the observed effects.
This strength partly offsets the weakness of the quantitative results based on a pretest-posttest
design, which as such limited the opportunities to draw causal inferences due to possible
history and maturation biases and Hawthorne effects 48]. In addition, data source and investigator triangulation, as well as the member check
of analyzed minutes contributed to the objectivity (i.e. confirmability) and credibility
of our findings. Furthermore, studying multiple cases gave us the opportunity to collect
qualitative data from various cases, which differed in several characteristics and
staring situations, and thereby increased the transferability of our conclusions.
Finally, we tried to enhance readers’ judgments about the dependability of qualitative
findings through a thorough description of the inquiry process and interpretation
of findings against the context of the studied collaboration 49], 50]. Nevertheless, some limitations to our study should be considered. Despite being
based on multiple cases, our quantitative research suffered from a small sample size,
due to the small number of stakeholders involved. In addition, drop-out affected our
sample size, though we minimized its detrimental effects by applying suitable analysis
techniques (i.e. including all available cases in the analysis). Furthermore, selection
bias may have affected our data because of the voluntary participation of PHS regions
in the DISC-based trajectory and because the stakeholders were not randomly selected.
In addition, regional coordinators decided to give priority to a particular sector
in the collaboration. The desire to achieve their own organizational goals (e.g. youth
health promotion) may have led their choices. Finally, the data gathered for the purpose
of support may not necessarily capture all managerial activities that the regional
coordinators employed, so our overview might not be exhaustive and might need further
elaboration. In addition, the stage of the collaboration limited the number of managerial
activities that could be studied, activities which can help manage the transition
from formalization to collaborative action. These activities will thus need special
attention in follow-up studies.