Recommendations for Effective Intersectoral Collaboration in Health Promotion Interventions: Results from Joint Action CHRODIS-PLUS Work Package 5 Activities

The burden of chronic disease in Europe continues to grow. A major challenge facing national governments is how to tackle the risk factors of sedentary lifestyle, alcohol abuse, smoking, and unhealthy diet. These factors are complex and necessitate intersectoral collaboration to strengthen health promotion, counter-act the social determinants of health, and reduce the prevalence of chronic disease. European countries have diverse intersectoral collaboration to encourage health promotion activities. In the Joint Action CHRODIS-PLUS success factors for intersectoral collaboration within and outside healthcare which strengthen health promotion activities were identified with a mixed method design via a survey of 22 project partners in 14 countries and 2 workshops. In six semi-structured interviews, the mechanisms underlying these success factors were examined. These mechanisms can be very context-specific but do give more insight into how they can be replicated. In this paper, 20 health promotion interventions from national programs in CHRODIS PLUS are explored. This includes community interventions, policy actions, integrated approaches, capacity building, and training activities. The interventions involved collaboration across three to more than six sectors. The conclusion is a set of seven recommendations that are considered to be essential for fostering intersectoral collaboration to improve health-promoting activities.

Political support is a prerequisite to get resources allocated for the implementation and the sustainability of health-promotion programs. In order to gain political support, collaboration goals should be aligned with key policies How?
• Ensure that the planning documents contain the references to important policies • Align with health system goals 2 Define a shared vision of the problem to be solved aligned with organizational goals Why?
Commitment of all partners is crucial for successful collaboration. Agreeing on the problem to be solved and defining a shared vision of how to solve the problem helps to create this commitment and results. Furthermore, such a discussion allows professionals from different organizations, and possibly sectors, to develop a common language to talk about the main issues and potential solutions. How? • Appeal to a shared sense of urgency to solve a problem or to shared interests • Agree on intersectoral collaboration as one of the solutions of the problem • Achieve actual mutual understanding of norms, values, and roles and create trust • Use a visionary leader who is accepted by all parties • Engage an experienced facilitator/coordinator Example: Healthy Overvecht, Integrated medical and social care, the Netherlands (2006-ongoing) The collaboration was originally developed in a deprived neighbourhood in Utrecht (Utrecht Overvecht), in response to the needs of primary health care professionals in this neighbourhood (e.g., general practitioners, physiotherapists, midwives, Youth Health Care Services, Municipal Public Health Services team, and district nurses).
They felt a great deal of work pressure and indicated that the situation was not sustainable. There was a shared feeling of urgency among professionals, the municipality, and other organisations to solve this problem together. Confindustria Lombardia (associations of companies), trade unions and the regional healthcare system at its different organizational and structural levels. Also, the community and target groups were involved from the start in the collaboration process and the programme implementation at the workplaces. A manual for companies that join the network recommends involving employees and other key roles from the beginning, to plan their programmes and select good practices based on their specific needs. Other partners can be involved at different levels: associations of professionals, non-profit organizations (with special reference to social/sport activities promotion associations or with expertise on specific health issues such as smoking cessation), municipalities, scientific societies and universities. Due to the collaboration project, the healthcare system gained more skills in interacting with other sectors of society (e.g., companies), recognising its own limits in influencing certain multi-faceted determinants of health.

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Build bridges between sectors and disciplines through effective leadership Why?
Leadership is essential and closely tied to strong working relationships and a transparent process for collaboration. Effective leadership fosters trust and good working relationships between collaboration partners. How?
• Identify a local champion who can be the leader or can support the leader • Use different types of leaders or leadership for different phases of the collaboration • Recruit a dedicated person with leaderships and coordination qualities: • who understands the language of 'others' • with good project and process management skills • who uses information systems and technologies to ensure effective communication and information exchange Example: The process towards a smoke-free Hungary -Tobacco control in practice (2011-̶ ongoing) The Prime Minister of Hungary is dedicated to the anti-tobacco cause. He was adamant that signing international legislations is not enough, it also need to be implemented. Since then, guidelines, protocols and recommendations were disseminated to provide guidance on tobacco control, such as the Framework Convention on Tobacco Control of the WHO. There is also a dedicated person, who possesses the necessary information and expertise in the field to act as a coordinator. This person, who despite the high turnover of professionals in the field, has been present for 30 years and has been the one constant in tobacco control. He serves as the coordinator between the supporting departments, ministries and non-governmental organizations.
He has been working as a health promotion programme manager of the national health programme and coordinates activities in Hungary in connection with smoking prevention and cessation. As Head of the Hungarian Focal Point for Tobacco Control, his main tasks include: making plans in the short, medium and long term related to tobacco control, making professional, methodological guidelines, and making recommendations on public health and health development. He is responsible for elaborating professional programmes' methodologies, creating and maintaining a database of laws and provisions, and of instructions for their use; supervising the collection of social, economic and health indicators related to tobacco consumption; conducting research; fulfilling organisational tasks and coordination.
In addition, he is the creator and leader of the Smoking Prevention Programme for Kindergarten Children (age 3-6), which has been introduced in one third of all the kindergartens in Hungary, and the Smoking Prevention Program for Primary School Children (age 6-10), which has been running in one quarter of the elementary schools in the country. In connection with these programmes, he leads the activities of producing and developing special health education materials. He is also one of the leaders of the professional co-ordination of the activity of the national network of the National Public Health and Medical Officer's Service in connection with smoking.
This collaboration has strengthened other health promotion activities beyond tobacco control.

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Keep collaboration partners in all sectors engaged Why?
Crucial for the success of the collaboration is keeping the partners engaged by informing, motivating, and entrusting them, thus sustaining commitment of all partners. How? • Formalize the collaboration by making clear agreements about roles and responsibilities of the partners • Create a win-win situation for partners in the collaboration (mutual and joint benefits) • Form designated communication liaisons, e.g., to provide information to participants of the collaboration, arrange meetings, manage a website, and/or create regular newsletters • Give professionals ownership, via a bottom-up approach • Motivate the professionals involved, e.g., by offering feedback on progress towards shared vision • Celebrate smaller short-term advancements while aiming for long-term, sustainable success • Organize face-to-face meetings when possible to allow people from different sectors and disciplines to get to know each other also on an informal and personal level Example: VESOTE project, Finland (2017-2018 The VESOTE programme reinforces and develops effective and target-based lifestyle guidance in social and health care. The development activities emphasise physical activity, nutrition and sleep. The final goal of the programme is for Finns to be more physically active, sit less, eat a varied and healthy diet and sleep better. The municipalities of Northern Ostrobothnia signed a joint plan for strengthening cooperation between social and health care actors and between social and health care and other actors. The primary target group was those of working age -obese adults and arterial patients -as well as those at high risk for developing arterial disease. The project created new cooperation groups and strengthened the activities of existing ones. Active communication was a success factor. At the beginning of the project, a communication plan was developed, which received the approval of the development manager in the hospital district. Communication was goal-oriented. Project leaders sought out the tools and the help of communication experts. Visibility in regional media was obtained; in fact, there were several different media channels including a local magazine and Facebook. The project resulted in new perspectives and expertise for health professionals. It is hoped that cooperation will continue in the future. Many different actors have promised to participate in the longlasting partnership, and their will to act has strengthened. The initiative to set up a lifelong learning Centre has been established.

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Use a planned/systematic approach suitable for all partners Why?
Using a systematic approach based on scientific evidence and on experiences from the past will improve the implementation of the collaboration in each sector. Moreover, this systematic approach should allow all partners to combine their health-promotion efforts and enhance the effectiveness of the program. JOGG is a program based on a previous project in France (EPODE), but has evolved since then. The objective of JOGG is to allow children to grow up in good health using an integrated approach at both the national and local level to target overweight. JOGG advocates a local approach in which parents and health professionals, shopkeepers, companies, schools and local authorities join forces to ensure that young people remain at a healthy weight. The Dutch JOGG approach consists of five pillars: political and governmental support; cooperation between the private and public sector (public private partnership); social marketing; scientific coaching and evaluation; linking prevention and health care.
Although the programme has some pre-determined (five pillars) elements, it can be adapted to the local context. Over 140 municipalities and 30 social organizations and companies have joined JOGG. JOGG is a learning organisation and maintains contact with its partners to discuss the progress of the collaboration. In addition, an independent institute monitors what efforts JOGG has undertaken to commit towards their objectives.

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Ensure there are sufficient resources to sustain the collaboration Why?
To establish a sustainable collaboration, it is important that resources, such as dedicated time, qualified personnel, and funding, are and remain available. The distribution of these resources should be transparent and fair to all partners. Filha had an initial project idea, and, when the appropriate funding mechanism became available (a government programme to disseminate good practices), it enabled the project to start. The project sought to identify what had been done in hospital districts on the subject of tobacco cessation among mentally ill patients and patients with substance abuse problems in order to develop regionally-appropriate activities. The ultimate goal was to improve to quit smoking for mentally ill smokers and patients with a history of substance abuse received to quit smoking. Hospital districts developed their own models where collaboration has occurred between primary and secondary care, as well as with NGO's: The part-time regional facilitator, who was especially assigned to this project in every participating hospital district, discussed with and trained the staff in different departments together with Filha. He also collaborated with local NGO's, who had contacts with experts by experience. Courses were organised in the hospital districts and a 2-hour on-line course was available. It was agreed that staff would attend these courses. The regional facilitator visited the different departments in secondary as well as primary care in the hospital district and convinced the workers to attend the courses. He discussed practical issues with the workers around providing tobacco cessation services and helped them resolve issues that arose.
Some hospital districts recognise the value of this project and are allocating their own resources to fund a regional facilitor now the initial program has ended.