What works when working together?: Cross-sector collaboration barriers & facilitators of a built environment Health Impact Assessment in Southern Nevada

ABSTRACT

Purpose

Cross-sector collaboration can improve community health because decisions made across sectors influence health. Health Impact Assessments (HIAs) and other health-focused, cross-sector collaborations encounter challenges. This case study uses a completed HIA to explore factors impeding and supporting health-related cross-sectoral collaboration.

Methods

Semi-structured key informant interviews with 10 of 12 HIA working group participants were conducted and analysed using a content analysis approach.

Results

Analysis generated 48 codes across seven themes in three primary groups: HIA as a collaborative tool; logistical and systemic barriers; and benefits and logistical, interpersonal, and sectoral facilitators. Recognizing the importance of knowledge, analysis, and principles outside of one’s field (n = 62) was the most common facilitator. Limited time was the most common barrier (n = 21). Participants discussed more facilitators (n = 303) than barriers (n = 144); perceived multiple benefits (n = 92), including networking and connecting land use and health; and described facilitators like communication, continuity, engagement, project management, compensation, varying perspectives, and diverse skills. They identified coordination challenges, needs to engage more with stakeholders and the community, limited time, and changes among partners as primary barriers.

Conclusions

Findings can help prepare cross-sector partners about what to expect, aid in mitigating challenges, and further knowledge about what supports and hinders Health in All Policies collaborations.

Health Impact Assessments (HIAs) are practical tools to facilitate multidisciplinary evaluation of potential negative health impacts of decisions and to create opportunities to minimize them (Centers for Disease Control and Prevention [CDC], 2016a). HIAs are in line with other work to advance Health in All Policies (HiAP) (CDC, 2016a). HiAP is a systemic approach to ensure policy decisions from all sectors consider the implications of their decisions on health (CDC, 2016b; National Association of County and City Health Officials, n.d.). HIAs often rely on cross-sector collaboration because HIAs necessitate analysis of plans, projects, and policies (CDC, 2016a; World Health Organization [WHO], 2009) “outside traditional public health arenas, such as transportation and land use” (CDC, 2016a, Para. 5). HIAs offer a multidisciplinary, collaborative process that may involve the community, health workers, government, developers, and others (WHO, 2009). However, the cross-sector collaboration necessary for HIA work remains challenging to implement in practice, despite the overall increasing importance of such collaboration (Lanford et al., 2021).

After completing an HIA focused on the built environment in Southern Nevada, we conducted a qualitative study to better understand the cross-sector collaboration involved in this HIA. Understanding cross-sector collaboration around health is an important area of inquiry. Cross-sector collaboration is a long-standing tool to address community problems such as health disparities (Calancie et al., 2021). Its mechanisms should therefore be thoroughly understood. However, understanding cross-sector collaboration requires assessing its inherent flaws and the problems that may arise from it; cross-collaborative partnerships may not lead to sustained systemic change, and even if they do, outcome measurement can pose challenges (Mattessich & Rausch, 2014; Petiwala et al., 2021). This case study considers ideas beyond the Southern Nevada HIA through which this cross-sector collaboration occurred to extract lessons about collaborations that can promote HiAP work more broadly.

Cross-sector collaboration around health

Cross-sector collaboration is a method by which people from different organizations or sectors work together on a common goal or problem (American Public Health Association, 2020). It can involve cooperation between government entities, the public and communities, and private sector businesses or nonprofit organizations (Bryson et al., 2006). Collaboration can lead to sharing knowledge and resources, as well as better relationships, and it can improve opportunities to promote community health (Calancie et al., 2021; Tung et al., 2018). Cross-sector collaborative approaches have been utilized to address complex social problems such as healthcare costs, access to early childhood education, and inadequate housing (Arkin et al., 2014). Cross-sector collaboration is especially important to public health—a field that crosses disciplines and sectors.

Health-focused cross-sector collaboration has garnered greater attention as the role of social determinants in health outcomes has become apparent (Lanford et al., 2021). The social determinants of health are upstream factors, such as exposure to psychosocial stressors, physical environments, income, and educational attainment, which shape the conditions in which people live and impact their overall health (Arkin et al., 2014). Research indicates that nearly 70% of the variance in health status is determined by environmental factors, both social and physical (Towe et al., 2016).

Addressing these determinants of health heavily depends on collaborative work between different sectors (de Montigny et al., 2019). The Robert Wood Johnson Foundation (RWJF) Commission to Build a Healthier America argued that a healthier America can only be achieved by creating communities that promote health; this can be accomplished, at least in part, by utilizing collaborative approaches (Arkin et al., 2014).

Past research identified several facilitators of cross-sector collaboration that involve health goals. Cross-sector collaboration between the community development and health sectors is widespread across the United States and is reported as effective in creating opportunities for healthy choices within communities (Arkin et al., 2014; Mattessich & Rausch, 2014). Mattessich and Rausch (2014) assessed collaborations that aimed to improve health through a 2013 web-based survey of 661 professionals working in public health and community development. They reported that common vision and goals, shared respect, skilled leadership, and understanding among partners in different organizations affected the success of cross-sector collaborations (Mattessich & Rausch, 2014).

Other research examining ways to enhance cross-sector collaboration around health suggests that recognizing what expertise is necessary early in the process, ensuring partners have unique but changeable roles, and cultivating the commitment of participating organizations can facilitate such work (Gertel-Rosenberg et al., 2022; van Vooren et al., 2023). A sense of shared ownership and the correct leadership appears also to support partners’ commitment to the project (van Vooren et al., 2023). Previous findings caution, however, that not all partners will have identical priorities over time, and partnerships may have to adjust their shared purposes (Lanford et al., 2021). It is likewise important to reflect frequently and re-examine roles and tasks assigned at the start of a project (van Vooren et al., 2023). Trust is vital, but it is developed over time. Until trust develops, assigning an independent project leader might assist in building “faith in the fairness of the project” (van Vooren et al., 2023, p. 8). Cross-sector collaboration relies on continuous, collective learning (de Montigny et al., 2019; van Vooren et al., 2023). This is essential because it increases motivation for continuous partner engagement, goes hand-in-hand with investment in evaluation of activities and in the decisions made, and informs planning (de Montigny et al., 2019).

The literature also identifies several barriers or challenges to intersectoral collaborations that aim to promote health. Challenges include differences in cultures, values, structure, power, priorities, goals, and languages among partners. They also include power imbalances, lack of sufficient resources and funding, difficulties in measuring outcomes of collaborations, declining participation over time, and insufficient data exchange infrastructure (Carlin & Peterman, 2019; Mattessich & Rausch, 2014; Petchel et al., 2020; van Vooren et al., 2023). When a cross-sector collaboration includes community representation, community voices may be marginalized, with less power allocated to the community (Petiwala et al., 2021). At the same time, community leadership may require the community to take on more active, time-consuming roles (Petiwala et al., 2021). A criticism of many health-promoting cross-sector partnerships to date is that they may be small in scale; this is problematic because addressing health disparities requires moving toward longer-term collaboration to allow for “aligned and sustainable systems” (Lanford et al., 2021).

HIA context & summary

Partners from the public health, transportation, planning, and land use sectors formed a 12-person working group to collaborate on an HIA examining proposed improvements across 0.67 miles of a main arterial road in Las Vegas, Nevada. The arterial roadway includes major medical facilities in the Las Vegas region, with a public hospital, as well as many commercial establishments. The demographics of nearby residents vary; however, residents of adjacent ZIP codes have high levels of inequity along various measures. The HIA was completed through a larger project to integrate health concerns into built environment decisions in the region, completed with funding allocated to the Southern Nevada Health District by the Centers for Disease Control & Prevention (Gakh et al., 2023).

In screening, the group decided to complete an HIA focused on a proposed plan to add bike lanes, enhance crosswalks and pedestrian-activated beacons, change signage, add trees and landscaping, narrow vehicle lanes, widen and improve the sidewalk, lower the speed limit, and make other changes to infrastructure in the area. In scoping, the group decided to focus the HIA on potential changes to physical activity (i.e., walking and biking), overweight and obesity, and pedestrian and bicyclist injury. The assessment step consisted of utilizing publicly available secondary data, obtaining some secondary data from HIA partners, conducting a series of literature reviews, and completing an intercept survey of pedestrians and bicyclists in the area to better understand how they viewed walking and biking in the project area. This assessment informed the HIA’s recommendations, which were developed collaboratively and focused on built environment changes that could be “good,” “better,” and “best” for health. The group produced a report discussing the project, containing findings from the assessment, and articulating recommendations with project partners. The group also engaged in a process evaluation of the HIA via a facilitated group discussion and an anonymous survey and established a mechanism to monitor the impact of the HIA and the outcomes of interest (Gakh et al., 2023).

Engagement of stakeholders and the community was utilized throughout the HIA. The HIA was completed by university faculty and students in partnership with and through active guidance from the local health department, the municipal public works department, the regional metropolitan planning organization, and representatives of the statewide minority health and equity coalition. Feedback from the community and stakeholders was also obtained through a feedback session, an intercept survey, and discussions with stakeholders. Additional information about the HIA and its findings and recommendations is available elsewhere (Gakh et al., 2023).

Purpose of study

This study was conducted in the context of the HIA described. Its main aim, though, was not to focus on the HIA itself but rather to use the HIA to explore what factors impede and support cross-sectoral collaboration around health.

Methods

This qualitative study involved conducting and analysing key informant interviews of HIA working group members to identify barriers and facilitators to cross-sector collaboration around health. We utilized an inductive content analysis approach to examine and interpret data from interviews systematically and qualitatively to find patterns. Data were also enumerated once they were split into units (i.e., codes) to facilitate comparison across interviews (Cho & Lee, 2014).

All working group members were contacted and invited to participate in the study. Participants were informed that the goal of the study was a better understanding of cross-sector collaboration around health. Ten of the 12 working group members agreed to participate in this study. All 10 participants verbally consented to participate in the study. All necessary ethics approvals were obtained from the Biomedical Institutional Review Board (IRB) at the University of Nevada, Las Vegas; the IRB reviewed the study and deemed it exempt from full review (protocol number: 1658954–2).

Data collection

Data were collected through 10 semi-structured key informant interviews conducted virtually using WebEx by one member of the research team in October and November 2020. Interview length varied from 20 minutes to just under an hour and usually lasted about 45 minutes. Interviews consisted of 17 open-ended questions, with room for the interviewer to probe and follow-up with additional questions related to the questions in the interview guide.

Participants were asked about their perceptions of what helped and what got in the way of the cross-sector collaboration that occurred through this HIA. Some of the questions included: (1) What were some benefits of this cross-sector collaboration; (2) What were your reservations about the cross-sector collaboration? (3) Was the goal of the cross-sector collaboration achieved? (4) What could have been improved to enhance this cross-sector collaboration? (5) How did the working atmosphere enable cross-sector collaboration? And, (6) How did the working atmosphere inhibit cross-sector collaboration? See Table 1 for a full list of questions. The interview questions were developed by the research team. They were informed by (1) the literature about HIAs, HiAP, and cross-sector collaboration around health; (2) the HIA collaboration; and (3) previous experience by research team members participating in collaborative efforts to improve health.

Table 1.

Interview questions about cross-sector collaboration.

What were some benefits of this cross-sector collaboration? Advantages?

What were some disadvantages of this cross-sector collaboration?

What were you or your organization hoping to get out of the cross-sector collaboration?

What were your reservations about cross-sector collaboration?

How would you have defined success from this cross-sector collaboration?

What facilitated the cross-sector collaboration?

What were some challenges of the cross-sector collaboration?

Was the goal of the cross-sector collaboration achieved?

What could have been improved to enhance this cross-sector collaboration?

How did the working atmosphere enable cross-sector collaboration? How did it inhibit cross-sector collaboration?

How did participants in this collaboration interact? How effective was this and why?

How were conflicts handled? How effective was this and why?

How did the different values, perspectives, and norms of the various sectors involved impact the collaboration?

What was unique about each partner’s perspective?

How actively involved were the different partners in this collaboration?

What resources enabled this cross-sector collaboration? What additional resources would have been helpful?

How did this experience impact your interest in collaborating with partners in other sectors?

Interviews were recorded and then transcribed verbatim. Recordings were deleted after transcription was complete to maintain anonymity. Transcripts were anonymized by assigning a participant number to the transcript analysis; the participant number was used to attribute quotes so that specific ideas would not be connected to particular participants.

All 10 participants were involved in steering the HIA as project partners who participated in a working group that met regularly and guided the research team in completing the HIA. Five of the 10 participants worked for local or regional government entities, with one participant serving as nonprofit stakeholder and four participants serving on the HIA working group and on its research team. Two-thirds (6 out of 8) project partners who participated in the HIA working group that met regularly and guided the research team and all key members of the research team (4 out of 4) participated in the study.

Data analysis

We used content analysis to examine the transcribed interviews. Content analysis involves grouping and arranging narrative data into categories, where the narrative data in each category shares a meaning (Cho & Lee, 2014). Primarily, a qualitative content analysis approach was used to interpret the transcribed interviews systematically. Consistent with content analysis methodology, this involved identifying units of analysis, classifying statements and ideas into codes, and then categorizing codes that connect to each other into themes. The approach was inductive because the content of the interviews dictated the coding (Cho & Lee, 2014).

We analysed interview transcripts through this process. First, two researchers independently read and re-read the transcripts and created codes and code definitions to capture ideas related to cross-sector collaboration around health. Then, they resolved differences by consensus through discussions. When consensus could not be reached, two additional team members helped resolve differences. Codes and code definitions were maintained in a code book. This process generated a final list of codes and code definitions. Two researchers then re-coded the 10 transcripts using the final codes and code definitions. All 12 working group members were invited to participate in interviews. Ten consented while 2 did not consent. Near the end of the interviews with the 10 participants, no new insights emerged from the data. After analysing the full dataset, we observed that the codes, themes, and concepts were repeating and aligned with the patterns already identified, indicating data saturation.

Through discussions and consultation with the transcripts, four researchers categorized the final codes into themes that organized codes into broader concepts. Finally, codes were tallied across transcripts and across themes to aid the analysis. We counted each instance of a code and aggregated code counts across transcripts. We summed counts for each code within a theme to derive theme counts. We did this to help understand the commonness with which codes and themes emerged. Two researchers also extracted relevant interview quotes representative of each code. Spreadsheet and word processing software were used to complete and track coding. Peer briefings among the research team, in-depth description of the HIA context and study procedures, systematic data collection and analysis, and clearly articulated and iteratively derived codes and themes aimed to ensure trustworthiness.

Results

The interview and coding process generated 48 codes, which were grouped into seven themes. These seven themes can be broadly categorized into three groups: (1) the Health Impact Assessment itself, (2) barriers to cross-sector collaboration around health—which contains the themes of logistical barriers and systemic barriers, and (3) the utility of and facilitators to cross-sector collaboration around health—which contains the themes of benefits, logistical facilitators, interpersonal facilitators, and sectoral facilitators. Each theme is presented below, with its respective codes and illustrative quotes. Across the seven themes the five most common codes were: different perspectives (n = 62), partners’ effective engagement (n = 32), benefits of cross-sector collaboration (n = 30), HIA informing systems change (n = 30), and partners’ interactions (n = 28). These findings and code definitions derived through analysis of interview responses are discussed below.

Group 1: the Health Impact Assessment

Theme 1: the Health Impact Assessment as a collaborative tool

This theme consisted of six separate codes, which collectively appeared 65 times across the 10 transcripts. These codes captured participants’ ideas about the HIA goals and process as well as what the HIA could achieve or contribute. Within this theme, by far the most prevalent code was “HIA informing systems change,” which appeared 30 times across the transcripts and was defined as using the HIA process and its outcomes to enhance broader systems-change work. In the words of one participant:

We also hope that [the HIA] would lead to the development of future tools that could be used in working with … transportation-related departments.

This theme also included a code capturing the definition of cross-sector collaboration (n = 17), working with or getting to know people from different agencies and different sectors by addressing a common problem. We included this code in the HIA theme because this HIA was a precursor to a larger, cross-sector project that aimed to design a prospective tool for integrating health concerns into land-use decisions. As one participant explained:

When I think of cross sector collaboration, I think more about the professional aspect of trying to jointly solve a problem, or think through an issue, rather than the community engagement piece, which is also very important.

Within this theme, participants also discussed the HIA process (n = 9), defined as a six-step systematic process that is also flexible. It begins by selecting a project and then becomes an iterative process of feedback and questions. As one participant described:

… The structure that the HIA provided, that was overlaid onto the monthly meetings, was also helpful in kind of keeping us moving and keeping us focused on a specific agenda and specific questions and products and steps.

Also mentioned were changing the built environment (n = 4), or physical alterations to urban design features, objectives of the grant (n = 3), which entail meeting the grant deliverables and fulfilling partner contracts, and an incremental approach (n = 2), that is, describing a method of starting a project small and building upon it to set out a larger project with greater collaboration.

Group 2: barriers to cross-sector collaboration around health

Participants expressed their thoughts about many of the challenges hindering or blocking this cross-sector collaboration around health. Thirteen different codes captured these perceptions and ideas. Of the 13, six codes involved logistical barriers and seven codes involved systemic barriers.

Theme 2: logistical barriers

We defined logistical barriers as perceived impediments to cross-sector collaboration around health that were operational or organizational in nature or barriers that involved project planning. This theme emerged 87 times across the interviews and through seven unique codes. Insufficient resources in the form of time and money were by far the most prevalent logistical barriers conveyed by participants.

The most common code was more time, defined as needing more time to conduct this project or time as a constraint for the HIA (n = 21). As one participant explained when discussing deficits within the HIA process:

… Probably more time along the same lines of maybe having more time to get through the process that we were trying to do in the amount of time that we were trying to do it.

Participants also articulated practical challenges of coordination (n = 18), which captured comments focusing on complications related to working together. Comments illustrating this code often focused on the difficulties of coordinating schedules. In the words of one participant:

I would say, in particular [to] this group, one of the struggles was probably … when you get that many people together it’s hard to find a time when everyone can meet and everyone make this a priority. And so that’s probably one of the disadvantages to having … the amount of people in the group that we did, and that kind of cross-sector collaboration.

Partners’ limited time (n = 17), described as the participants not working on a full-time basis on this project, limiting the time put into this project, and competing interests stalling project progress, was also a common code. As one interviewee described:

I didn’t have a team that was able to be dedicated to the project. So finding that might have been … our biggest challenge, is having enough people. To really be dedicated to it full time … it would have been nice to have been able to spend more time on the project …

Change in partners (n = 12), which includes lack of continuity of partners, partners that did not participate in the whole project, and partners that were replaced during the project, focused on events such as staffing changes and resulting inconsistencies in participation.

Participants also discussed as barriers the need for more financial resources or having more money available for this project (n = 8) and the need to narrow the project scope (n = 8) to better define roles, goals, and perspectives for the project to put every team member at the same level of understanding of the project. As one participant described:

I think a lot of people can use their own … professional language sometimes, that not everyone is completely familiar with, so there’s a lot of level setting that has to happen with cross-sector collaborations. A lot of defining of terms.

The impact of the COVID-19 pandemic (n = 3) also appeared in responses, as it meant going from in-person to online meetings, which decreased engagement and participation, and the overall partners’ interactions.

Theme 3: systemic barriers

Many of the barriers identified by interviewees focused on broader, interpersonal, and systems-level challenges. These barriers were a product of the systems and relationships within which participants work and operate. This theme consisted of six codes that together appeared 57 times across interviews.

Engaging with more people was the most prominent code (n = 13). It was defined as including more people from represented agencies or with different expertise in the project from the beginning to learn what they do and to enable them to share information about this project with others. The second most prominent code within this theme was the need for more community engagement (n = 11), which focused on involving more community members in the project, rather than relying only on stakeholders to communicate with community members.

Slow change, or the patience that is needed to see the status quo change, was mentioned 10 times, with one participant saying:

I think it’s gonna take time and effort and work before the real changes in how land is used will take place. It’s going to be slow …

Other codes included hierarchical inclusion (n = 9), that is, having more decision makers and leadership at the table, or at least educating them on the work that was being done in this project. As one participant stated:

A little more buy-in from people who were making decisions about what was actually going to happen in those areas from the start, I think that would have been valuable.

Decision making (n = 7) was defined as the limited influence of this project on the renovation plan. This includes the ideas that the project was structured to enable making recommendations and that recommendations were made accordingly, though final decision-making rested outside of the project team. Discussions of contribution to the project, either by the participants themselves or others, was also demonstrated (n = 7). This was defined as the contribution or buy-in of some partners or sectors, or the fear of not being able to contribute to the project as much as other partners.

Group 3: utility of & facilitators to cross-sector collaboration around health

Interviewees often described what they saw as the benefits of cross-sector collaboration and the ideas that facilitate such work. These perceptions generated 29 codes and four themes, one focused on benefits of such collaboration and three related to forms of facilitators—logistical, interpersonal, and sectoral.

Theme 4: benefits

Participants described benefits of cross-sector collaboration, the results of which were divided into seven codes mentioned 93 times throughout the interviews. The code describing the benefits of participation, that is—each partner benefiting or enjoying the project and cross-sector collaboration, was the most prevalent (n = 30), with at least one mention in each of the 10 interviews. As one participant described:

I think there were win-wins for everybody at their respective organizations, in terms of the kind of outputs that they needed and what they’re measured on and evaluated on. So, I think that … was good.

The code centring on connecting health and land use (n = 23), defined as practice, research, discourse, or other action that encourages a shift in thinking about the relationship between public health and the built environment, also appeared often in interviews. One participant shared about witnessing such a shift during the collaboration process:

… We got to teach them about or make them aware of looking at the health aspects of what they’re doing and some of them flat out said, “We’ve never thought of this.” It’s just a different way of looking at things.

Also discussed were codes regarding networking (n = 19), or building or strengthening good relationships with other partners or the community to collaborate on future or long-range work, as well as enhanced interest (n = 10), defined as a positive experience of collaboration on the project, ultimately heightening a partner’s interest in cross-sector collaboration.

I will say that because it did go well and because we did build good relationships through the process … I am going to continue to work across sectors … in general.

The remaining codes garnered fewer mentions. These included student learning opportunity (n = 4), a project or activity that provides students the chance to learn about a topic or to see how it is completed in practice, as well as community (n = 4), defined as the bidirectional relationship of learning and education between the project team and the community.

Mentions of innovation (n = 3), or using cross-sector collaboration to push boundaries for the common good, discussed the inventiveness of potential outcomes from this collaboration. As one participant stated:

I think cross-sector collaboration fundamentally is an opportunity to kind of think beyond the status quo.

Theme 5: logistical facilitators

Participants also focused on logistical facilitators of cross-sectoral collaboration, with 65 mentions across five codes. The code appearing most frequently in this theme involved partner compensation (n = 27), defined as funding or other resources made available to workgroup members to compensate for their resources and energies spent on the project. This code appeared at least twice in each interview, with several mentions of the grant funding that enabled this project and what it meant to the participants and the project. As one interviewee stated:

I think having [the health department] … helped bring everyone around. Because when you have the person who got the money, and is giving out the money, at the table then it makes people come to the table to give their input and those sorts of things.

Also appearing frequently was the code for project management (n = 26), or effective and thoughtful management of the project by the leading team with specific timelines and goals to achieve, thus keeping the work on track. Interviewees emphasized the collaborative approach taken and the interpersonal skills of leadership.

… We received meeting notes quickly after the meeting, and we received [the] agenda. I thought it was very organized. I thought I knew exactly where we were in the project and what was coming up next. I thought it was very well managed.

The other, less-often-discussed codes within this theme were logistical resources (n = 6), or the availability and management of tangible resources such as meeting rooms, network, food, technical support, as well as preliminary work (n = 4), and the academic or professional resources that complement or relate to the project, known as existing literature (n = 2).

When describing preliminary work, that is, the work done by project partners before the start of the HIA that enabled its completion and feasibility, one interviewee stated about the local health district:

They tend to really approach their work very cross-sector … They’ve been working around public health … and the built environment for a really long time, and so they had very good relationships and trust and kind of political capital built up with the city.

Theme 6: interpersonal facilitators

In interviews with project participants, interpersonal facilitators resulted in creation of nine codes with a total of 129 mentions, the most of any theme. The most common was partners’ effective engagement (n = 32), defined as participants’ involvement and willingness to do their tasks, communicate, provide feedback, highlight issues and provide recommendations. As one participant characterized it:

I think it was like very collegial environments, you know. I think people would just bounce ideas off each other. I mean, I think a lot of it was … like being each other[‘s] soundboard.

The second most common code was partners’ interactions (n = 28), or the way project interactions were set up so everyone could speak freely and be heard, and have their opinion respected and the implications of these interactions on building relationships, trust, and keeping the group on track for the work. Participants mentioned willingness to engage and hold conversations. As one stated:

The fact that people were willing to talk to each other, and they were willing to listen to our ideas about how … their decisions might influence health, that definitely facilitated the whole process.

Other codes within this theme included partners’ communication (n = 23), defined as the way participants engaged with each other through meetings, phone calls, emails, and other modes of communication, as well as limited conflicts, meaning there were few project-related conflicts among partners related to the project (n = 14).

Previous collaborations with the group (n = 10), or knowing and collaborating with some partners prior to this particular project, was also viewed as a facilitator by participants. One interviewee highlighted this:

… We were brought in because we have been long-time partners with the health district. So I actually think it was that specific kind of convening actor that already had a lot of trust built up in each of the collaborating sectors that really helped facilitate the entire project.

A suitable team (n = 8), defined as having the right people and the right number of people at the table with the right background and expertise in this cross-sector collaboration, was raised as a facilitator. Resolution dialogue (n = 7), or dialogue among people who have different ideas or conflicts about a project-related question that may involve contributions from others, was another facilitator. An interviewee described:

I think if we did have a conflict … we would just kind of table that issue for … a little bit and then come back to it. You know … bring in someone who could speak on that … I don’t feel like we have conflict.

The two codes that garnered the fewest mentions in this theme were project expectations (n = 4), and partners’ continuity (n = 3). “Expectations” in this context means having a sense of what was going to happen in this project before the project started. “Continuity” the same partners are at the table from the beginning to the end of the project.

Theme 7: sectoral facilitators

Many participants in this HIA raised issues pertaining to sectoral facilitators aiding cross-sector collaboration, resulting in eight codes with 109 mentions. By far the most common code was different perspectives (n = 62), defined as the knowledge, analysis, vocabulary, and principles outside of an individual’s field and how that work connects to the HIA. This code was mentioned at least twice in every interview. As one participant described:

… I think it was like, everyone had a very, very unique point of view from the engineering perspective and from a project management perspective. And so I think those are definitely highlighted more when we were in the groups.

Other codes in this theme were far less common. They included interest in the project (n = 11), defined as the overall interest that partners and other people in their agencies had in the intersection between land use and health, in the HIA, or in improving equity. As a participant said:

… There were folks who, I think, beyond the core group that worked on this HIA at the different agencies … were interested in this collaboration and the outcomes because they were interested in the issues, meaning the intersection of land use and health. And so, I think having that interest at the leadership level was also really helpful because it provided a way to justify participation by the folks who were part of the working group and … this project.

Also mentioned by interviewees was the public health perspective (n = 9), factors at the intersection of land use and health, that were brought by the public health partners. These include data, theory, and analysis; the lack of some data or studies specific to health and land use; and health equity.

Other codes within this theme were: (1) existing cross-sector collaboration experience (n = 8), defined as previous participation in projects that involved cross-sector collaboration, and (2) the city’s perspective (n = 8), describing renovation plans, how they work, and how they fit into the agency’s structure and how language is used in the city government. As one interviewee stated:

I would say … their expertise in traffic and public works and the process … was an interesting perspective, because there’s a lot of things that we didn’t know about that they were able to shed light on …

Prior knowledge of partners (n = 4), knowing and understanding the perspectives of the partners before starting the project, was among the other codes in this theme, as was transportation perspective (n = 4), which involves learning about how land use decisions are made and how these are affected by local and regional governments, and the interest that governments had in including health in their decisions more often. Diversity of skills (n = 3), a code encompassing the different skills that the team members had, such as data analysis and access to specific data, was also seen as a sectoral facilitator by some.

Discussion

HIAs can function as key forms of cross-sector collaboration to minimize the potential for negative and maximize the potential for positive community health effects stemming from decisions. HIAs usually address decisions with impacts on the social determinants of health (WHO, 2009). To succeed, such processes often require effective collaboration between professionals in multiple fields (de Montigny et al., 2019). This study involved in-depth key informant interviews with cross-sector team members who collaborated to complete an HIA related to the built environment. Participants identified many benefits and facilitators of cross-sector collaboration that they noticed through this HIA, including the addition of different perspectives, effective engagement of partners, compensation of partners, and the enjoyment of participation in the project itself. They also identified limitations of this and other cross-sector collaborations around health, including those related to resources, coordination, and who is engaged.

The literature indicates that HIAs are well-suited to cross-sector collaboration. Cross-sector collaboration is bolstered by HIAs, and HIAs may directly affect decisions made in non-health fields (Bourcier et al., 2015). Broad HIAs that emphasize community participation, as opposed to narrow HIAs that focus on quantifying health effects, are thought to be useful to intersectoral partnerships (Kang et al., 2011). This study further supports findings that HIAs can promote cross-sector collaboration through in-depth responses from interviewees who articulated the benefits of this collaborative HIA. Such benefits included discussions about the relationship between health and land use among participants from various fields, new or stronger relationships that will be useful in the long term, and enhanced interest in future collaborations.

The interviewees’ perceptions related to barriers to cross-sector collaboration around health often reflected or related to barriers highlighted in the literature. Participants articulated a lack of continuity among partners and the presence of partners who did not participate in the whole project as a logistical barrier. This idea echoes other findings emphasizing the importance of active and continuous participation by collaborators. Staff turnover may affect continuity of participation (Petchel et al., 2020), and, over time, active participation in cross-sector collaboration projects by partners may decrease (van Vooren et al., 2023). This ties in with a frequent theme that emerges from literature considering cross-sector collaboration around health: the need for more resources to support it (Carlin & Peterman, 2019; Towe et al., 2016). Participants in this study frequently mentioned limited resources, primarily in the form of limited time and money, as a barrier to the collaborative effort. They also highlighted the effect of the COVID-19 pandemic on the cross-sectoral collaboration. Three participants mentioned that as meetings shifted from in-person to online participation, engagement in the HIA waned. Although the literature suggests that outcome measurements can be challenging (Mattessich & Rausch, 2014), participants did not mention this as a barrier in this study.

The Collective Impact Model suggests components such as a common agenda and continuous communication are necessary for collaborations to succeed (de Montigny et al., 2019). Steady communication is a building block of trust, which is important for effective collaboration (de Montigny et al., 2019; van Vooren et al., 2023). Interview participants raised related elements when they expressed facilitators to the cross-sector collaboration, such as the multiple modes of engagement used in the partner communications and the open, respectful expression of opinions in partner interactions. The literature emphasizes two additional elements of collaboration – (1) common goals and evaluation criteria and (2) the need to identify the necessary expertise early in the project (Gertel-Rosenberg et al., 2022; van Vooren et al., 2023). Consistent with these findings, study participants emphasized the importance of effective management with goals and timelines as a logistical facilitator of the collaboration because they kept the work on track. Participants also expressed that including different perspectives in the HIA facilitated working across sectors.

The themes derived from the interviews conducted in this study may help advance planning for cross-sector collaboration and research about what works and what does not. The study’s seven themes were derived from the participants’ responses to the interview questions. Systematic, inductive classification of their ideas and impressions into codes and themes provided a structure to capture how the participants viewed this collaboration and cross-sector collaboration more broadly. By using this systematic approach for data collection and analysis, we did not compel a predetermined outcome (Bradley et al., 2007). To promote more consistent and comparable research on cross-sector collaboration around health, it may be useful for future studies to also consider instances of collaboration in terms of their benefits, facilitators, and barriers. It is also important to determine whether the facilitators are logistical, interpersonal, or sectoral and whether the barriers are logistical or systemic. Utilizing these categories could help advance planning for projects that involve cross-sector collaboration around health and research about what works.

In this study, the most common code in the “Health Impact Assessment as a collaborative tool“ theme involved participants expressing hopes that the HIA could inform changes to systems. Specifically, interviewees expressed their desire that the cross-sector collaboration involved in the HIA could lead to the development of a tangible tool for non-health sectors to utilize when considering policies and projects affecting the built environment. This was one of the motivators and goals of the HIA. Future research should explore how participants’ aims to effectuate larger systems change may motivate and facilitate effective cross-sector collaboration around health. Future research should also examine how specific and smaller-scale cross-sector collaborations can lead to larger systems change. The comments made by study participants also suggest that future research should seek to better understand how to sustain collaboration across time, especially as the priorities of partners and circumstances change.

This study should be considered in light of its limitations. This qualitative study involves in-depth, semi-structured interviews of 10 participants from a collaborative, cross-sector HIA in Southern Nevada. It is not intended to be generalizable to other regions or projects. Although the codes and themes were systematically derived from the interview transcripts and comprehensively applied to all comments, other researchers may have generated different codes and themes utilizing a similar process. Social desirability bias, desiring to articulate ideas that would be perceived favourably, may also be of concern. The team conducting this study included six people who were both part of the HIA working group and were also interviewed for this study. Participants therefore may have been hesitant to express their opinions fully. And, participants were interviewed about a project related to their employment. However, to minimize this, the interviewer was external to the cross-sector collaboration (i.e, the HIA), three additional members of the research for this study did not participate in the HIA working group, participants’ responses were kept confidential, and participants were assigned participant numbers to avoid attribution of specific comments to particular participants.

Conclusion

Study participants articulated several facilitators and barriers to cross-sector collaboration around health that may be useful for those planning and executing other cross-sector collaborations around health to consider. Their views suggest that leadership support allows partners to prioritize collaborations and acts as a conduit for additional resources and support. Having early access to support, which may include time, money, specific project resources, and adequate compensation, also facilitates collaboration. Such support may include training for leadership and on-the-ground personnel in areas outside of their areas of expertise. Partners must feel confident in their collaborative mission and be prepared to carry it out. Bringing in a community perspective can also be a challenge for cross-sector collaboration. Addressing this need requires careful allocation of time and other resources to community partners during the project planning phase.

Engaging in cross-sector collaboration also requires seeking out participants and partners with a wide variety of applicable skills across multiple, project-appropriate sectors. This can optimize the likelihood of success. Such an approach could allow these staff to raise public health concerns on the ground level of improvement projects and policies, and it may also increase awareness within those sectors of the many factors affecting community health within the scope of their authority.

Cross-sector collaboration is imperative to improve public health, and carried out with sufficient support and resources, it has the potential to affect communities now and in the future. Despite the challenges, the benefits of cross-sector collaboration can be clear to those thus engaged. Study participants expressed the benefits of cross-sector collaboration through the HIA. They stated that the cross-sector collaboration functioned as a vital way to connect land use and health. Practitioners and researchers may look to the participants’ ideas articulated during this study to assess how such collaborations can be facilitated and how to foresee and mitigate barriers. This study supports the idea that cross-sector collaboration can aid in forming key relationships and partnerships that further a HiAP approach to improve the social determinants of health. Practitioners who seek to engage in HiAP work must also recognize, however, that the changes sparked by cross-sector collaborations may be slow to come, necessitating long-term commitments.

Biographies

Maxim Gakh, JD, MPH, is an Associate Professor based in the University of Nevada, Las Vegas (UNLV) School of Public Health and serves as the Associate Director of the UNLV Health Law Program.

Courtney Coughenour, PhD is Associate Professor of Environmental and Occupational Health at the University of Nevada, Las Vegas.

Bertille Assoumou, MD, PhD currently serves as an Assistant Professor and Grants and Research Director at the Kirk Kerkorian School of Medicine at UNLV, where she leads public health projects and educates future medical and public health professionals.

Emily C. Strickler, MPH is a public health researcher with special interests in the built environment, social determinants of health, and health equity.

Timothy J. Bungum, DrPH is a Professor at the University of Nevada, Las Vegas School of Public Health.

Jennifer R. Pharr, PhD is a Professor at the University of Nevada, Las Vegas, School of Public Health.

Pashtana Usufzy is a Master of Public Health student with a concentration in biostatistics and epidemiology and a Graduate Assistant at the University of Nevada, Las Vegas (UNLV) School of Public Health.

Megan McDonough, MS, RD is a Registered Dietitian and both a PhD student in Epidemiology and Biostatistics and a Graduate Assistant at the UNLV School of Public Health.

Nicole Williams Bungum, MCHS, CHES is the Supervisor for the Office of Chronic Disease Prevention & Health Promotion (OCDPHP) at the Southern Nevada Health District (SNHD).

Mindy Meacham, CHES works as a Health Educator for the Southern Nevada Health District (SNHD) in the Office of Chronic Disease Prevention and Health Promotion.

Funding Statement

Part of the work for this project was supported by grant #NU58DP6578, funded by the Centers for Disease Control and Prevention and awarded to the Southern Nevada Health District. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Center for Disease Control and Prevention or the Department of Health and Human Services. Part of the work for this project was also supported by the University of Nevada, Las Vegas. The publication fees for this article were supported in part by the UNLV University Libraries Open Article Fund.

Disclosure statement

No potential conflict of interest was reported by the author(s).