November, 2016 - SUPPORT Summary of a systematic review | print this article | download PDF

Does collaboration between local health and local government agencies improve health outcomes?

Partnerships between health and other public services at a local level have been promoted to improve the health of the population. It is not clear whether such collaboration improves health outcomes.

Key messages

Local interagency collaborative interventions may lead to little or no difference in physical health and quality of life compared with standard care.
It is uncertain whether local interagency collaborative interventions decrease mortality or mental health symptoms.
This review did not include any evidence from low-income countries.

Who is this summary for?

People making decisions concerning policies to improve services that need local collaboration between health and other public services

This summary includes:

Key findings from research based on a systematic review
Considerations about the relevance of this research for low income countries

Not included:

Recommendations
Additional evidence not included in the systematic review
Detailed descriptions of interventions or their implementation

This summary is based on the following systematic review:

Hayes SL, Mann MK, Morgan FM, et al. Collaboration between local health and local government agencies for health improvement. Cochrane Database of Systematic Reviews 2012, Issue 10. Art. No.: CD007825.

What is a systematic review?

A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.

SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.

Glossary of terms used in this report

Background references on this topic

Background

The level of health within a given population is affected by factors as diverse as environmental, social, cultural and economic influences. These factors are addressed by many publicly funded organisations, including local government and local health authorities. The recognition of the role that social determinants play in the health of the population makes it clear that health cannot be the responsibility of just one agency. Collaboration and partnerships for health and social development between different sectors have been identified as a priority by several international declarations. However, it is not clear if collaboration developed at the local level results in better health outcomes.

How this summary was prepared

After searching widely for systematic reviews that can help inform decisions about health systems, we have selected ones that provide information that is relevant to low-income countries. The methods used to assess the reliability of the review and to make judgements about its relevance are described here

Knowing what’s not known is important

A reliable review might not find any studies from low-income countries or might not find any well-designed studies. Although that is disappointing, it is important to know what is not known as well as what is known.

A lack of evidence does not mean a lack of effects. It means the effects are uncertain. When there is a lack of evidence, consideration should be given to monitoring and evaluating the effects of intervention, if it is used.

About the systematic review underlying this summary

Type of	What the review authors searched for	What the review authors found
Review objectives: To evaluate the effects of interagency collaboration between local health and local government agencies on health outcomes in any population or age group.
Study designs & interventions	Randomised trials , non-randomised trials, controlled before-after studies and interrupted time series studies that assess any interventions of interagency collaboration and partnership and local government agencies	This review included 16 studies: randomised trials (7), non-randomised trials (4), controlled before-after studies (4) and 1 interrupted time series study. 11 studies were included in the meta-analysis. 7 studies reported on interventions to improve the care or treatment of patients and 9 studies about health education, health promotion or disease prevention
Participants	All population types and all age groups were included	Studies were delivered through community and primary care services (8 studies), in schools (5 studies), and in the wider community (3 studies).
Settings	Any local or national setting	Studies were conducted in UK (7 studies), Denmark (1 study), Sweden (1 study), Norway and Sweden (1 study), the Netherlands (1 study), USA (2 studies), Canada (1 study), Israel (1 study), and Australia (1 study).
Outcomes	Mortality, morbidity and behavioural change	A variety of outcomes were reported, including behavioural changes, morbidity and healthcare process
Date of most recent search: December 2011
Limitations: This is a well conducted systematic review with only minor limitations.

About the certainty of the  evidence (GRADE)

High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.

Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.

Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.

Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.

* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.

† Substantially different = a large enough difference that it might affect a decision.

See last page for more information.

Summary of findings

This review included 16 studies conducted in high-income countries comparing interagency collaboration between local health and local government agencies with standard care or no intervention. Seven studies reported interventions to improve the care or treatment of patients through multidisciplinary team work and 9 studies reported collaborative interventions to improve health education, health promotion or disease prevention in different community settings.

The authors conducted metaanalyses that included 11 studies for which it was possible to combine data. They also conducted a narrative review by type of interventions with studies not included in the metaanalyses. Information from the narrative review has not been included in this summary.

It is uncertain whether local interagency collaborative interventions decrease mortality. The certainty of this evidence is very low.
It is uncertain whether local interagency collaborative interventions decrease mental health symptoms. The certainty of this evidence is very low.
Local interagency collaborative interventions may lead to little or no difference in physical health compared with standard care. The certainty of this evidence is low.
Local interagency collaborative interventions may lead to little or no difference in quality of life. The certainty of this evidence is low.
Local interagency collaborative interventions may slightly improve functional levels in patients with psychiatric disorders. The certainty of this evidence is low.

Interagency collaboration between local health and local government agencies compared with standard care
People: All population types: elderly, children, mothers, patients with psychiatric disorders, etc. Settings: United Kingdom, Denmark, Sweden, United States, Australia and Norway Intervention: Different strategies of local collaboration between primary care, education, local public health, city government, community organizations, etc. Comparison: Standard care
Outcomes	Impact	Certainty of the evidence (GRADE)	Comments
Mortality	We are uncertain of the effect of interagency collaboration between local health and local government agencies.	Very Low	Based on data from 1 cluster randomised trial and 2 non-randomised trials with frail elderly populations
Mental Health	We are uncertain of the effect of local interagency collaboration to improve results in mental health in specific populations.	Very Low	Based on data from 4 studies in patients with different psychiatric disorders and 1 in mothers to prevent postpartum depression
Physical Health	There may be little or no impact of collaborative strategies on health outcomes.	Low	Based on data from 5 studies in different groups of patients: children with asthma, with obesity, adults with musculoskeletal disorders, and mothers to prevent postpartum depression
Quality of life	There may be little no impact of collaborative strategies on quality of life.	Low	Based on data from 3 studies, 2 with patients with asthma and one with elderly patients with dementia
Global Assessment of Function symptoms score	Patients with the intervention had on average a slight improvement compared with the control group (MD-2.63, 95% CI -5.16 to -0.10).	Low	Based on data from 2 studies including patients with psychiatric disorders
GRADE: GRADE Working Group grades of evidence (see above and last page) MD: mean difference CI: confidence interval

Relevance of the review for low-income countries

Findings	Interpretation*
APPLICABILITY
All studies included in this review were conducted in high income countries. The effects of local interagency collaboration on mortality, health outcomes and quality of life are uncertain.	The conditions of local agencies in low-income countries is likely very different from those in high-income countries. Results reported in this review should be applied with caution in low-income settings.
EQUITY
Only two of the 16 studies included in this review focused on deprived populations.	The effects on equity of interventions based on local interagency collaboration will depend on where the intervention is based (schools, primary health centres, community setting). For example, if the intervention is provided in schools, children who don’t attend school will not have access to the intervention, with a detrimental effect on equity for that population.
ECONOMIC CONSIDERATIONS
The studies included no direct evidence of the cost or cost effectiveness of local interagency collaboration.	Coordination between local agencies to develop collaborative interventions could require additional resources that need to be considered before implementing them.
MONITORING & EVALUATION
Good quality data from well-designed studies in low-income countries are not available.	Cluster randomised trials or interrupted time series studies together with process evaluations should be used to evaluate these interventions in low income countries. These studies should assess the effects of local interagency collaborative interventions on relevant patient outcomes. It is also necessary to assess the cost effectiveness of these interventions.
*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low-income countries. For additional details about how these judgements were made see: http://www.support-collaboration.org/summaries/methods.htm

Additional information

Related literature

Smith KE, Bambra C, Joyce KE, et al. Partners in health? A systematic review of the impact of organizational part-nerships on public health outcomes in England between 1997 and 2008. Journal of Public Health 2009; 31:210–21.

Hunter DJ, Perkins N. Partnership Working in Public Health. Bristol: Policy Press, 2014.

This summary was prepared by

Blanca Penaloza, Pontificia Universidad Catolica de Chile

Conflict of interest

None declared. For details, see: www.supportsummaries.org/coi

Acknowledgements

This summary has been peer reviewed by: Sara Hayes, Mala Mann, and David Hunter.

This review should be cited as

Hayes SL, Mann MK, Morgan FM, Kelly MJ, Weightman AL. Collaboration between local health and local government agencies for health improvement. Cochrane Database of Systematic Reviews 2012, Issue 10. Art. No.: CD007825.

The summary should be cited as

Penaloza B. Does collaboration between local health and local government agencies improve health outcomes? A SUPPORT Summary of a systematic review. November 2016. www.supportsummaries.org

Keywords

evidence-informed health policy, evidence-based, systematic review, health sys-tems research, health care, low and middle-income countries, developing coun-tries, primary health care,

inter-agency collaboration, local government, health promotion

This summary was prepared with additional support from:

Pontificia Universidad Catolica de Chile

About certainty of evidence (GRADE)

The “certainty of the evidence” is an assessment of how good an indication the research provides of the likely effect, i.e. the likelihood that the effect will be substantially different from what the research found. By “substantially different” we mean a large enough difference that it might affect a decision. These judgements are made using the GRADE system, and are provided for each outcome. The judgements are based on the study design (randomised trials versus observational studies), factors that reduce the certainty (risk of bias, inconsistency, indirectness, imprecision, and publication bias) and factors that increase the certainty (a large effect, a dose response relationship, and plausible confounding). For each outcome, the certainty of the evidence is rated as high, moderate, low or very low using the definitions on page 3.

For more information about GRADE

SUPPORT collaborators:

The Cochrane Effective Practice and Organisation of Care Group (EPOC) is part of the Cochrane Collaboration. The Norwegian EPOC satellite supports the production of Cochrane reviews relevant to health systems in low- and middle-income countries . www.epocoslo.cochrane.org

The Evidence-Informed Policy Network (EVIPNet) is an initiative to promote the use of health research in policymaking in low- and middle-income countries. www.evipnet.org

The Alliance for Health Policy and Systems Research (HPSR) is an international collaboration that promotes the generation and use of health policy and systems research in low- and middle-income countries. www.who.int/alliance-hpsr

Norad, the Norwegian Agency for Development Cooperation, supports the Norwegian EPOC satellite and the production of SUPPORT Summaries. www.norad.no

The Effective Health Care Research Consortium is an international partnership that prepares Cochrane reviews relevant to low-income countries. www.evidence4health.org

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