163 General discussion Start. Studies in other fields make similar observations that interpersonal dynamics and creating a common frame of reference are essential (13, 22, 30, 34, 53-55). In the context of early life, a recent Danish study into cross-sectoral collaboration for pregnant women in vulnerable situations stressed that knowing each other’s working context is helpful (56), and a study into a Canadian Child Health Network mentioned relationships as ‘system triggers’ that prompt change to professionals’ everyday practice. The systematic review of Such et al. (30) used systems thinking to explore the dynamics between relational and structural governance components in successful collaboration across sectors. Their causal loop diagram showed positive feedback loops between relational aspects, and also high interrelatedness between structural and relational components. Both contribute to the credibility and legitimacy of collaborations. The above implies that continuous efforts should be made to stimulate encounters between professionals from diverse backgrounds, who can then build a collaborative culture and make plans together. While it may be time-consuming and requires acknowledgement of contexts (e.g. historical, political and sociocultural conditions), this seems to be a necessary part of integration. This may be specifically true for collaboration between multiple sectors in contrast to collaboration within one sector, given the larger differences in relational and organizational aspects that require additional investments to foster mutual understanding. Moreover, our findings suggest that positive interpersonal dynamics may facilitate improvements even in the presence of systemic barriers. At the same time, these relational elements are essential to start learning together, which in turn can help to overcome collaborative challenges at different levels (including systemic barriers). 6. Processes of learning are indispensable in cross-sectoral collaboration A final lesson learned from reviewing this thesis’ findings and other scientific and grey literature is that ‘learning’ and its associated elements of reflection and knowledge sharing should be central in the adoption and monitoring of cross-sectoral approaches (18, 30, 53, 57, 58). Developing coalitions Solid Start, or initiating and sustaining cross-sectoral collaboration in a wider perspective, are novel and non-linear processes that unfold in a rapidly evolving field with changing contexts. In these processes, learning is relevant at different levels and scales, between different stakeholders and for different short and long-term purposes (59, 60). Examples in this thesis include learning from (and with) other professionals and experts-by-experience, within and between local coalitions Solid Start, across local and regional levels, and from other integrated care programs and sectors (Chapter 5). We reported that stakeholders use and want to use learning opportunities to improve, share knowledge, prevent duplication of efforts, and overcome collaborative challenges together. Moreover, our Delphi study (Chapter 4) began with stakeholders expressing an interest to learn from other coalitions about monitoring at local level, and their need for local indicators and data to facilitate discussions about local developments in order to learn for future practice and policy. A recent mapping review into LHS of De Bruin and colleagues (18) described three processes of learning. The most often reported learning processes were information 6
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