The influence of community engagement on stakeholder perspectives in cross-sector integrated care: an integrative review

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Wright, Kelly Metcalf, Whitney Berta This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2148586/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Background Community engagement represents a highly relevant way to integrate care across sectors and address social and structural determinants of health with populations. Yet, advancement of integrated care remains a challenge, particularly across health and social service organizations. Situating social cognition as a key element of integrated care, this paper explores the act community engagement within cross-sector integrated care. Methods An integrative review was conducted to determine what is known about the influence of community engagement on stakeholder perspectives in cross-sector integrated care, and to contribute to a more comprehensive evidence base for building and operationalizing equitable integrated care. In March 2022, four data bases were systematically searched, applying no date limits, for English language articles that described community engagement in relation to integrated care and resulting stakeholder perspectives. Using matrices, numerous variables were extracted and synthesized using thematic analysis derived from the Rainbow Model of Integrated Care and a continuum of community engagement. Results In total, 13 studies were included in this analysis. Two studies included the hospital as a partner, and the rest were a mix of public, private health and social service sectors. Positive stakeholder perspectives (N = 6) were found in studies that were consultative or collaborative, and led with social capital, shared reciprocity, and trust. Moderate and negative perspectives (N = 7) were found in studies that led with a utilitarian stance and lacked collective leadership, governance, longitudinal planning, and joint evaluations. Conclusions This review makes a singular contribution to cross-sector integrated care literature, utilizing perspectives from health and social service organizations to map what is known about the influence of community engagement on cross-sector integrative care. Perspectives from this review support calls for additional integrative care research exploring community-hospital relationships, and how power dynamics influence proximal and distal relationships, capabilities, motivations, and opportunities for collaboration. integrated care cross-sector collaboration community engagement Background Healthcare coordination is an issue of global concern, driven by increased fragmentation across health care systems (Alderwick et al., 2021, Cronin et al., 2021 ; de Montingny et al., 2017). Strategies to improve care coordination and address system fragmentation have been implemented across North America, the United Kingdom, Europe, Australia, and New Zealand (The Commonwealth Fund, 2019 ; Powell et al, 2008 ), yet many patients continue to navigate complex health systems in isolation, determining adequate entry points and pathways to support their health outcomes (Greise et al., 2020). Patients report wanting care that is easy to understand and access, where housing, social services, and health work in close partnership (MOHLTC, 2015). Characterizing this request, is the siloed nature of many North American healthcare systems, that are marked by limited flow of information and resources, reducing efficiency, effectiveness, and quality of health care provision (Dykes et al., 2009 ; Misra et al., 2020). Health systems are responding through goals to improve access to services, create smoother transitions between services and strive for patients to receive the ‘right’ care at the ‘right’ time, reducing the number of times patients must tell their story (Health Quality Ontario, 2020 ). These overarching goals support what is best known in literature as integrated care, a term that denotes health system efforts around the world to improve effectiveness, efficiency, and outcomes (Gordon et al., 2020). Integrated care has demonstrated effectiveness for those with complex heath conditions ranging from diabetes, influenza, and cardiovascular disease (Mays et al., 2016 ). Extending the benefits of integrated care beyond the clinical domain has allowed for the inclusion of population health as a central pillar to integrated care efforts (Kindig & Stoddard, 2003; Shazhad et al., 2019; Uttinbroek et al., 2017). Population health takes into consideration the wide range of factors that influence the health of populations. Herein, a shift in our health care system is seen as we move beyond the traditional biomedical model and pay particular attention to cross-sector collaboration and the influence of public policy to address the social and structural determinants of health and health equity (Shazad et al., 2019). Although integrated care and population health are not novel concepts, realizing their operational synergy remains a challenge (Farmanova et al., 2019 ). Integrated care is difficult to achieve, particularly through the lens of population health where care coordination emphasizes the integration of two service platforms: health and social care (Crocker et al., 2020 ). Health and social services traditionally have long-standing institutional separation, and distinct funding streams and accountability arrangements, making it difficult to seamlessly integrate cross-sector care, even if all have the same end goal to improve health of communities and populations (Crocker et al., 2020 ; Provan et al., 2003 ). Policy makers, however, have not been deterred by these findings and continue to promote cross-sector integrated care as a central pillar in the health system’s role toward addressing the social determinants of health (Alderwick & Gottlieb, 2019 ). As such, community engagement is seen as an effective strategy for harnessing community potential, allowing individuals to regain control of their health and improve population health outcomes (Butterfoss & Kegler, 2002 ). What remains to be uncovered, is what kind of cross-sector collaborations work, with whom, and by what way of community engagement. As cross-sector integrated care arrangements continue to develop between the health and social service sectors, there is a need to move well beyond optimizing organizational and process integration, to that of social cognition which considers what is shared and valued between parties in the commitment to co-ordinating efforts (Evans et al., 2014 ). The ethos of shared values and commitment in care delivery is known as normative integration (Valentijn et al., 2013 ). It has been suggested that normative integration may be the key to addressing ongoing integrative challenges through the development and creation of trust. Trust herein is seen as underpinning quality interactions and relationships necessary for sustained cross-sector integrated care efforts (Roussos and Fawcett, 2000 ). These findings hold promise for population health and community engagement, if significant attention and effort is paid to addressing inequities noted in these partnerships themselves (Johns, 2018). Considering potential lies in advancing cross-sector integrated care through revealing what is shared among care partners, there is a need to better understand the collective beliefs, motivations, and perspectives of those involved in cross-sector integrated care initiatives. A review of the literature was conducted with a goal of summarizing stakeholder perspectives found in community centred cross-sector integrative care research. Conceptual Framework Community Engagement Continuum The process of engaging communities moves on a continuum, as demonstrated by the Clinical and Translational Science Awards Consortium ( 2011 ), from outreach (provision of one-way information), to consultation, involvement (two-way flow of information), collaboration (partnership on all aspects) and shared leadership, inclusive of longer-term partnerships and shared decision making, Appendix A. Among the diverse processes of community engagement, two methodological approaches have emerged. The first being the ‘utilitarian’ perspective, where the community is approached to improve the effectiveness of the intervention and invited for their views, but the intervention has not been designed by the community themselves (Burton et al., 2017 ). The second approach is grounded in the development of social capital. From this perspective, community members are empowered to determine their priorities for health and service redesign (Burton et al., 2017 ). Rainbow Model of Integrated Care The Rainbow Model of Integrated Care (RMIC) is a comprehensive framework used to assess and evaluate integrated care dimensions based on the Triple Aim Framework for primary care (Valentijn et al., 2013 ). The model was validated through a series of Delphi panels and seeks to align integrated care within micro, meso and macro system levels (Valentijn et al., 2015 ). As such, the micro-level refers to levels of clinical integration among professionals in patient care coordination across the health care system. The meso-level refers to both organizational integration and professional integration. The former refers to networks formed between organizations, and the latter as partnerships between health care professionals in integrated care efforts. At the macro-level, system integration refers to linkages between the health care system and external partners. Functional and normative integration span micro, meso and macro system levels. Functional integration includes key supports that are needed in integrative operations, such as financing, management, and information systems. Normative integration, as referred to earlier, is based on the shared vision, values, and mission of efforts through cultural and social attention. Key features of integrated care have been developed into 59 taxonomies by Valentijn at al., (2015) to assist classifying and categorizing the broad spectrum of approaches used in various projects. The RMIC and related taxonomy provides a framework to evaluate integration and outcome measures from the perspectives of both patients and health care providers (Valentijn et al., 2015 ), Appendix B. Aim Integrated care literature over the past two decades has enabled advances in the field through identification of barriers and enablers to system integration. Despite these efforts, considerable difficulty remains in establishing collaboration and cooperation across organizational boundaries (Evans et al., 2014 ). Normative integration is an essential element to Valentijn et al.’s ( 2015 ) RMIC, yet Breton et al., (2019) recognizes differing perspectives of multiple stakeholders may provide the contextual evidence needed to advance integrated care through health care policy and practice across sectors. In addition, a scoping review by Miligan et al. (2021), confirms that community engagement is often used without merit, where a disproportionate number of studies emphasized learning from communities rather than learning with communities. These are extremely important findings given the dearth of literature on stakeholder perspectives in community-centred integrated care and efforts placed toward a global strategy to advance cross-sector collaboration. This review aims to expand the understanding of cross-sector integrated care and normative integration through principles of community engagement and learning with community. In addition, this review aims to provide comprehensive evidence to build and operationalize equitable cross-sector integrated care initiatives grounded in respect and allyship, with the communities served by heath care systems. Objectives developed to meet these aims include i) identification of studies and reviews focusing on cross-sector integrated care utilizing community engagement and participation, ii) critique of quality studies, and iii) identification of well supported themes found within the included research to provide new findings in the expanding field of cross-sector integrated care. Methods An integrative literature review was conducted using Whittemore and Knalf’s framework (2005) as a guide. This integrative review is classified as a mixed studies review, through analysis of both qualitative and quantitative study findings (Grant & Booth, 2009 ). The literature included in this integrative review met clear and specific criteria to support the inclusion and exclusion of articles chosen to represent the data in an unbiased manner (Whittemore & Knalf, 2005). To gather relevant data for the review, key terms were searched on select data bases to yield a cohort of articles for data extraction. Thematic analysis was used through reading and re-reading the articles to identify key themes and findings that emerged from stakeholders regarding their perceptions of cross-sector integrated care efforts (Nowell et al., 2017). Search Strategy Relevant articles were searched using a pre-planned literature search in four data bases: OVID – MEDLINE, OVID – EMBASE, EBSCO-CINHAL and PSYCH-INFO, from 1990-present. The year 1990 was chosen, as the time-period when integrated care was introduced as a concept in medical and social service literature. Data bases were searched using key concepts deemed most relevant to yield data in according with the aim of the review (Whittemore & Knalf, 2005). Key concepts included “community engagement”, “community participation”, “community involvement”, “community mobilization”, “community representation”, “collaborative care”, “integrated care”, “coordinated care”, “collaborative care”, “collaborative care”, “collaborative partnership”, “inter-sectoral care”, “inter-agency care”, “cross-sector collaboration”. Key concepts were combined with Boolean operator AND, and the search words within each concept were combined with OR. Study Selection Criteria This review focuses on the perspectives of all stakeholders involved in cross-sector integrative care initiatives, where the community was actively engaged and included as a partner. Inclusion criteria was devised as: studies that were evaluative in nature, explored an intervention, utilized community and population health interventions, published between January 1990 and Feb 2022, empirical research written in the English language from Canada, USA, Western Europe, UK, Australia and New Zealand. In addition, inclusion criteria included studies that focused on horizontal integration (collaborating organizations, networks, groups in the health system). The exclusion criteria were editorials, opinion pieces, conference abstracts, review papers, non-English papers, dissertations, and those articles with focus on health outcomes only. Search Outcomes Per PRISMA guidelines, eight articles were removed due to duplication (Moher et al., 2009 ) (see Appendix C for PRISMA flow diagram). Titles and abstracts were checked for relevance based on the study inclusion and exclusion criteria. A total of 2410 articles were rejected as they did not meet the objectives laid out in the inclusion criteria. This process yielded 103 articles for full text screening. These articles were read for their relevance, and of these, 90 further studies were rejected as they did not meet the inclusion criteria. Ultimately, 12 qualitative and 1 quantitative study met the criteria for this integrative review. Studies included in this synthesis are summarized in Appendix D. Quality Appraisal The Mixed Method Appraisal Tool 2018 (MMAT) was used to evaluate the research included in this review. Although no specific standard for assessing methodological quality in an integrative review exists (Whittemore and Knalf, 2005), the MMAT is a validated critical appraisal tool that is designed for systematic mixed review studies (Hong et al., 2018). The MMAT leads appraisal with two standard screening questions for all studies under review, then incorporates five tailored screening questions for each study type: qualitative, quantitative randomized control trial, quantitative non-randomized control trial, quantitative descriptive and mixed method. Eleven of the thirteen studies included in this review were deemed high quality. The two studies that were deemed low quality have remained in this analysis, however these findings are taken into consideration during data analysis. Data Abstraction And Synthesis To facilitate analysis, both qualitative and quantitative data were extracted into an evidence table. This table is also known as a matrix, used to organize, support data analysis, and develop themes (Whittemore and Knalf, 2005). Codes were generated for thematic analysis, utilizing the RMIC taxonomy and spectrum of community engagement. After coding each study, the codes were clustered to develop themes through use of a matrix. Matrices were used in three stages to support the fusion of narrative and statistical data (Whittemore and Knalf, 2005). Initially, articles were grouped based on setting, methods, and results. This preliminary data tabulation, allowed for a second matrix to develop and demonstrate similarities and patterns within the data, using the Community Engagement Continuum, the RMIC and 59 key feature integrated care taxonomy to code data within the studies. The third matrix allowed for the emergence of themes to present among the studies, where significance, relevance and novel representation was found related to stakeholder perceptions of cross-sector integrated care. Results are described through alignment with Valentijn’s key feature taxonomy (in italics) below and listed in Table 1 . Table 1 Stakeholder perspectives of cross-sector integrated care in relation to the Rainbow Model of Integrated Care taxonomy Integrated Care Domain Key Feature Positive perspectives Moderate perspectives Negative Perspectives Cicognani et al. Crooks et al. Lee et al. Provan et al. Shan et al. Zhu et al. Middleton et al. Skivington et al. Connaughton-Espino et al. Enard et al. Purcell & Kearns Schultz et al. Van Dijk et al. Clinical Population Health x x x x x x x x x x x x x Client participation x x Patient education x x x Continuity x x Centrality of client needs x x x x x x Information provision to clients x x x Interaction between professional and client x Case management x Individual multidisciplinary care plan x Professional Shared vision between professionals x x x x x x Agreement of interdisciplinary collaboration x x Interpersonal characteristics x x x x x x Interprofessional education x x x Multidisciplinary guidelines/protocols x x Value creation for professional x Interprofessional governance x Organizational Inter-organizational governance x x x x x x x Inter-organizational strategy x Learning organizations x Value creation for organization x x x x Managerial leadership x System Population features x x x x Available resources x x x x x Good governance x x x Stakeholder management x x x x x x x x x x Environmental climate x x Social value creation x Functional Human Resource management x x x x x Regular feedback and performance indicators x x x Resource management x x x x x Information management x Normative Trust x x x x Collective attitude x x Reliable behaviour x x x x Visionary leadership x x Transcending domain perceptions x x x x x Linking cultures x x Quality features of informal collaboration x Results Characteristics of the included studies Of the 13 studies included in this review, seven were based in the USA, three in Europe, two in the UK, and one in Canada. Publication years ranged from 2001–2021 and included 11 qualitative studies, one quantitative study and one mixed method study. The focus of each study explored stakeholder perspectives in cross-sector integrated care and collaboration through population health programs, in community settings. Study topics included: teen pregnancy, domestic violence, breast and prostate cancer, obesity (n = 2), chronic disease prevention, transportation and health, early childhood intervention, social prescribing, and care-dependent seniors. All 13 studies were involved in the integration of health, social care and wider community service and utilized a horizontal integrated care approach. Two studies included the hospital as a partner, the rest included a mix of public/private health and community sectors, and regional/municipal governments. Regarding stakeholder perspectives of cross-sector integrated care initiatives, six studies detailed positive stakeholder perspectives, two studies detailed moderate stakeholder perspectives and five studies detailed negative stakeholder perspectives. Moreover, all studies addressed micro, meso and macro level constructs of integrated care, reflecting the complex needs of the populations targeted within the studies. Integration Processes Clinical integration (micro-level) This dimension represents the heart of integration efforts and is the interface where patients and their families receive care from the health system (Breton et al., 2019). All studies described a clinical integration process to address population health needs. Community health workers (CHW) were utilized in four studies as a key group to mobilize outreach efforts (Enard et al., 2021 ; Schulz et al., 2001 ; Shan et al., 2012 ; Skivington et al., 2018 ). In addition to providing direct clinical integration, CHWs acted as case managers (Skivington et al., 2018 ) and were hired to create linkages among organizations (Enard et al., 2021 ; Skivington et al., 2018 ). Despite three studies undertaking a community based participatory research (CBPR) focus (Crooks et al., 2018 ; Enard et al., 2021 ; Schulz et al., 2001 ), the use of client participation in co-design was used minimally in studies with and without a CBPR focus (Cicognani et al., 2018 ; Purcell & Kearns, 2012 ). Three studies addressed continuity of care as an objective of fluid care delivery. Two of these studies aim to do this through CHW’s (Enard et al., 2021 ; Skivington et al., 2018 ), and through cross-sector collaboration (Connaughton-Espino & Reese, 2021 ). Centrality of client needs was a notable guiding feature in six studies, that sought to integrate and scale client care at micro, meso and macro levels, which was particularly successful when diversified across organizations (Crooks et al., 2018 ; Lee et al., 2021 ; Provan et al., 2003 ; Shan et al., 2012 ; Van Dijk et al., 2016 ; Zhu et al., 2019 ). Professional integration (meso-level) Innate characteristics of professionals were a driving force behind many cross-sector integrated care efforts. In some ways, interpersonal characteristics were seen as a supportive element, an added advantage to a well-functioning partnership and influenced acquired learning in partner organizations (Crooks et al, 2018 ; Shan et al., 2012 ). Herein, a champion or change agent was identified through skilled leaders in intersectoral collaboration (Skivington et al., 2018 ; Van Dijk et al., 2016 ). Yet, the drawback of this emergent leadership was situated in a lack of shared governance or decision making (Zhu et al., 2019 ). As a result, reliance on interpersonal characteristics to build individual relationships when organizational relationships lacked was common finding (Skivington et al., 2018 ). This was demonstrated through dependence on CHW’s to generate community awareness and trust. The skills of CHW’s can be amplified as sole ‘problem solvers and emotional supports’, while the responsibilities of others in the partnership are negated (Purcell & Kearns, 2012 ; Schultz et al., 2001). Shared vision between professionals was often established from the outset in collaborative partnerships (Cicognani et al., 2018 ; Connaughton-Espino & Reese, 2021 ; Crooks et al., 2018 ; Middleton et al., 2013 ; Shan et al., 2012 ; Schulz et al., 2001 ). These early formalities can be captured through agreements of interdisciplinary collaboration or memorandums of understanding (Cicognani et al., 2018 ; Connaughton-Espino & Reese, 2021 ). However, early establishment of shared vision did not necessarily equate with collaborative success in short- or long-term project indicators (Connaughton-Espino & Reese, 2021 ; Middleton et al., 2013 ; Schulz et al., 2013). Of particular importance is who is creating a shared vision from the outset, where excluding key community organizations led to detrimental outcomes (Schulz et al., 2013). Shared vision was found to expand and deepen over time in positive, collaborative working relationships (Cicognani et al., 2018 ; Crooks et al., 2018 ). Furthermore, interprofessional education provided an avenue to facilitate increased awareness of services, inner workings of health systems, and cultural relevance if all parties were present (Enard et al., 2021 ; Purcell & Kearns, 2012 ; Shan et al., 2012 ). When interprofessional education narrowly addressed access to services, rather than cultural community-based teachings, project scope and reach were limited (Enard et al., 2021 , Purcell & Kearns, 2021). Similarly, multidisciplinary guidelines provided a neutral reference for organizations to situate their work, advance understanding in evidenced based practice, strengthen relationships, and increase community capacity (Enard et al., 2021 ; Lee et al., 2020). Organizational integration (meso-level) Nomenclature used to describe cross-sector integrated care initiatives varied widely across studies. The term ‘collaboration or collaborative’ was used most frequently (Crooks et al., 2018 ; Provan et al., 2003 ; Van Dijk et al., 2016 ; Zhu et al., 2019 ), followed by ‘partnership’ (Cicognani et al., 2018 ; Schulz et al., 2001 ; Shan et al., 2012 ), then ‘program’ (Middleton et al., 2013 ; Skivington et al., 2018 ), ‘initiative’ (Connaughton-Espino & Reese, 2021 ) and ‘coalition’ (Purcell & Kearns, 2003). Terms were defined and labelled according to overarching goals of the integrated group or partners themselves. For example, Crooks et al., ( 2018 ) referred to their group as a collaborative, a small agile group of individuals, dedicated and responsive to one another needs. Shan et al., ( 2012 ) equally described accountability measures taken in community partner selection, however partnership inclusivity remained at the forefront. Grounded in anticolonialism and indigenous health principles, Shan et al., ( 2012 ) chose to refrain from using the term ‘collaborative’. Even among partners within the same study various terms were used dependent on perceived goals and desires. One hospital partner referred to their interaction with community services as a collaborative, when further analysis by Zhu et al. ( 2019 ) revealed the level of engagement was in fact cross-sector interaction, a unidirectional level of outreach. In addition, poor interorganizational governance between the health and community sectors was causal for group reorientation and labelling. Purcell & Kearns ( 2012 ) demonstrated how the community sector can break ties with an organizational working group and refer to themselves as a ‘coalition’ in effort to build their own capacity. Attention, dedication, and alignment of interorganizational governance played a significant role in the positive perspectives of stakeholders in community centered integrated care. The opportunity for all partners to meet regularly, co-design programs and share decision making allowed for greater understanding of capabilities within the group (Cocgnani et al., 2018; Crooks et al., 2018 ; Middleton et al., 2013 ; Shan et al., 2012 ). Moreover, attention placed on the general SDOH within a community, rather than a narrow programmatic focus allowed stakeholders to unite through a common vision, act with honesty and value local, bottom-up experiences of health promotion (Cocgnani et al., 2018; Crooks et al., 2018 ; Shan et al., 2012 ). Progress reports and annual work plans provided added support and direction within partnerships to create learning organizations to advance collective research and program development (Crooks et al., 2018 ; Lee et al., 2021 ). Conversely, the exclusion of key working group partners from the outset fractured trust and momentum in advancing project goals (Purcell & Kearns, 2012 ; Shultz et al., 2001). Negative perspectives of stakeholders were found in studies suggested to be based in CBPR and consensus building but lacked attention to these efforts throughout (Connaughton-Espino & Reese, 2021 ; Schulz et al, 2001 ). Negative perspectives among stakeholders were also found in studies whose outcome presented as value creation for organization . Herein, a beneficial outcome for the organization is sought after verses overarching population health features. This demonstrated paralysation of community social capital and health equity, as well as disabling trust, at the hand of academic, health and municipal partners (Enard et al., 2021 ; Purcell & Kearns, 2012 ; Schulz et al., 2001 ). System Integration (macro-level) Equal to the importance of robust interorganizational governance in community centred integrated care, is diverse stakeholder management . Programs, partnerships, and collaborations that upheld commitment from diverse stakeholders were resoundingly positive through stakeholder perspectives. These initiatives included engagement from municipalities (Cocgnani et al., 2018; Crooks et al., 2018 ; Shan et al., 2012 ), and public and private organizations (Lee et al, 2021 ; Provan et al., 2003 ; Zhu et al., 2019 ). Importantly, each study referenced above referred to community organization representatives as key stakeholders. The involvement of distant funding partners and government legislators did not necessarily equate to program longevity or positive experiences among project partners. This was particularly true when direct funding partners and those in decision making authority were not involved in proximal stakeholder management (Connaughton-Espino, 2021 ; Enard et al., 2021 ; Shultz et al., 2001; van Dijk et al, 2016 ). Funding that was diversified and secured created opportunity for program partners to plan longitudinally, develop trust and cultivate relationships with each other and their communities (Cocgnani et al., 2018; Crooks et al., 2018 ; Lee et al, 2021 ; Provan et al., 2003 ; Zhu et al., 2019 ). Programmatic Alignment And Leadership Style The context in which programs are created directly sets them up for success or failure. Those designed to respond to gaps in care were often seen as bridging rather than building sustainable solutions. This is detailed through reliance on CHW’s in the context of deepening austerity measures (Skivington et al., 2018 ), and competitive tender practices to appoint new partners in care, which limits foundational integrated care development (van Dijk et al., 2016 ). Programs that were created through existing structures and systems, governed by institutional polices, had a greater reach and opportunity to evolve through stakeholder acceptance and comfort (Crooks et al., 2018 , Lee et al., 2021 ; Shan et al., 2012 ). Although diverse stakeholder representation was deemed beneficial at the proximal level in community centred integrated care, Middleton et al., ( 2013 ) calls for a single leader to champion efforts. In this example, public health and local authorities worked ‘side by side’, while the community voice was absent in leadership representation. Conversely, Crooks et al., ( 2018 ) called for distributed leadership, that is emergent and context dependent. Reliance on trust and foundational relationships was seen as pivotal to enacting this leadership style, which requires shared project completion by partners in varying roles, also known as socially distributed cognition (Crooks et al., 2018 ). Functional Integration (macro-level) Indices of functional integration were found in 9/13 studies. A variety of human resource management structures were found, where community partners or representatives were included in joint planning and hiring processes (Cocgnani et al., 2018; Crooks et al., 2018 ; Lee et al., 2021 , Shan et al., 2012 ; van Dijk et al., 2016 ). Those that employed community organizations as a third party to complete outreach and engagement work had less favourable outcomes, and uniquely all stakeholders in these arrangements spoke to this power imbalance as projects progressed (Connaughton-Espino & Reese, 2021 ; Enard et al., 2021 ; Purcell & Kearns, 2012 ; Shultz et al., 2001). Although few projects demonstrated regular feedback and performance indicators (Crooks et al., 2018 ; Lee et al., 2021 ), recognition of their importance to conduct quality improvement and celebrate success was noted (Middleton et al., 2013 ; Zhu et al., 2019 ). Projects that had regular feedback mechanisms reported positive perspectives from stakeholders (Crooks et al., 2018 ; Lee et al., 2021 ), whereas the development of joint evaluative frameworks, with community partners, to address soft versus hard performance indicators was seen as a necessary endeavor to create neutral ground among cross-sector partnerships (Middleton et al., 2013 ; Zhu et al., 2019 ). Despite the complex and tailored approaches that integrated care requires, several studies called for a framework to guide professionals toward developing mutually agreed upon goals to sustain relationships in urban and rural cross-sector partnerships (Enard et al., 2021 ; van Dijk et al., 2016 ; Zhu et al., 2019 ). Normative Integration (macro-level) Among the studies, there was a direct relationship between the level of community engagement and the resulting perceptions of stakeholders. Specifically, the further along the continuum of community engagement, the more positive were stakeholders’ perceptions of their integrated care experiences (Table 2 ). Although normative integration was referred to explicitly in only one study (van Dijk et al., 2016 ), an abundance of shared stakeholder attributes, values and desires presented across the studies. The concept of trust was found in 9/13 studies and was seen as a multilayered construct. Cicognani et al. ( 2018 ) found that trust was associated with health partnership performance, and tied to efficacy, commitment, and a sense of belonging within community. Similarly, deepening and building relationships lead to trust, and was present in all levels and systems of care integration (Crooks et al., 2018 ; Lee et al., 2021 ; Provan et al., 2003 ). Among all studies, trust was coveted but it was unachievable in some settings due to power inequities, lack of time or investment within partnerships (Connaughton-Espino & Reese, 2021 ; Enard et al., 2021 ; Schultz et al., 2001; Skvington et al., 2018). Once trust was fractured, it was difficult to repair (Connaughton-Espino & Reese, 2021 ; Enard et al., 2021 ; Purcell & Kearns, 2012 ; Schultz et al., 2001; van Dijk et al., 2016 ). This is a sentinel finding given the importance of creating a collective attitude and shared vision at the beginning of a partnership to support momentum, longevity, and integration into existing partnerships (Crooks et al., 2018 ; Shan et al., 2012 ). Several studies reviewed the importance of being flexible, reinventing roles as needed and transcending domain perceptions (Crooks et al., 2018 ; Lee et al., 2021 , Provan et al., 2003 ; Purcell & Kearns, 2012 ; van Dijk et al., 2016 ). Plausibility to transcend one’s professional domain perceptions comes with good governance, partnership security and visionary leadership , however few studies identified such a leader (Crooks et al., 2018 ; Lee et al., 2021 ). Lastly, integrated care projects within studies were conducted between two – eight years, two years being the average length of time. There does not appear to be a correlation between project duration, level of community engagement and stakeholder perception. All studies were enacted without a sense of urgency identified. Table 2 Stakeholder perspectives of cross-sector integrated care in relation to community engagement level Level of Community Engagement Positive perspectives Moderate perspectives Negative Perspectives Cicognani et al. Crooks et al. Lee et al. Provan et al. Shan et al. Zhu et al. Middleton et al. Skivington et al. Connaughton-Espino et al. Enard et al. Purcell & Kearns Schultz et al. Van Dijk et al. Outreach x x x x Consultation x x x x x Involvement x x x Collaboration x x Shared leadership x Discussion The purpose of this integrative review was to identify what is known about the influence of community engagement on stakeholder perspectives involved in cross-sector integrated care initiatives. Thirteen studies were identified that explored this concept from North America, Europe, and the United Kingdom. Through this methodology and data analysis, new information has been uncovered which provides new insight and relevance for providers in health and social services, at the clinical, organizational and system level. Positive stakeholder perspectives were found in six studies, moderate or mixed stakeholder perspectives were found in two studies and negative stakeholder perspectives were found in five studies. All studies supported the client through a population health focus, yet only half the studies attempted to scale client care and address ongoing needs through micro, meso and macro system levels (Crooks et al., 2018 ; Lee et al., 2021 ; Provan et al., 2003 ; Shan et al., 2012 ; Van Dijk et al., 2016 ; Zhu et al., 2019 ). According to several studies, the focus on clinical versus population health programming was detrimental through increased reliance on third party workers (CHW’s) to bridge notable gaps in care and serve as problem solvers with their unique interpersonal skill sets (Enard et al., 2020; Schulz et al., 2001 ; Skivington et al., 2018 ). This suggests that there may be merit in exploring nonclinical opportunities in integrated care, the structural and social determinants of health specific to communities and advancing social capital through health equity approaches. Formalities established at the beginning of collaborative care partnerships are integral to create conditions of trust, conflict and efficacy that become resources or liabilities during continued efforts (Ansell & Gash, 2008 ). Several studies spoke to creating a shared vision from the outset of their collaboration, however when this was not followed through, it led to negative stakeholder experiences (Connaughton-Espino, 2021 ; Middleton et al., 2013 ; Shultz et al., 2001). This leads to question, who is at the table in these early conversations, and who is brought in as programs unfold? The importance of governance is as it relates to the perspectives of stakeholders within community-centred integrated care cannot be understated. Studies that established a level of commitment from the outset demonstrated resoundingly positive perspectives through community centred co-design (Cicogangi et al., 2018; Crooks et al., 2018 ; Lee et al., 2021 ; Shan et al., 2012 ). Studies that involved less than five stakeholders were able to utilize and rely on a distributive leadership style (Crooks et al., 2018 ), however studies reflecting the multisectoral nature of integrated care, requested the emergence of one leader, to act as a facilitator (Middleton et al., 2013 ; Zhu et al., 2021). This was seen as particularly important in new intersectoral partnerships, where relationships and trust have yet to be established (Connaughton-Espino & Reese, 2021 ; Enard et al., 2021 ; Schultz et al., 2001; Skvington et al., 2018). The opportunity for program partners to forge relationships, plan longitudinally and develop trust was also evident in studies that included committed and diverse stakeholder representation, municipal or region representation and funding security (Cicognani et al., 2018 ; Crooks et al., 2018 ; Lee et al., 2021 ; Shan et al., 2012 ). Considering the integral role that hospitals play in rural and urban health outcomes, the fact they were included in only two studies is a cause for greater reflection. This can be demonstrated by a sentiment offered by a community partner quoted in one study, ‘the hospital gets recognition, the community gets served’ (Enard et al., 2021 ). Herein lies the foundation of community-centred integrated care. The very inequities that integrated care is attempting to solve can be easily recreated in project work when inadequate attention is paid to power imbalances within partnerships and structures themselves (Connaughton-Espino & Reese, 2021 ; Enard et al., 2021 ; Middleton et al., 2013 ; Purcell & Kearns, 2012 ; Schultz et al., 2001; Skvington et al., 2018). Lastly, there is need to develop joint evaluative frameworks to assist with evaluation, share educational resources and training programs to support the institutionalization within cross-sector integrated care (Lee et al., 2021 ; Middleton et al., 2013 ; Zhu et al., 2021). Implications For Research And Theory Over the past three decades, integrated care has taken strides toward community health and social services models, improving quality of care using patient centred measures, and addressing underlying cultural attitudes and norms within specific populations (Evans et al., 2013 ). Yet, the reality of establishing collaborative interagency relationships with communities as partners is a challenging, long term and complex process (van Eyk & Baum, 2002 ). Stakeholders typically define integrated care around patient needs (Crocker et al., 2020 ) and research tends to highlight perspectives of single stakeholder groups in analysis rather than joint evaluations. This review contributes to these findings and highlights the lack of hospital perspectives as a key partner in collaborative care. Resultingly, there is a need to explore the concept of power inequity across hospital and community integrated care initiatives in greater detail, and how power influences proximal and distal relationships, capabilities, motivations, and opportunities for collaboration. Findings from this integrative review support tenets of social cognitive theory (SCT), which considers the unique way individuals acquire and maintain behaviour within social environments (Bandura, 2005 ). The notion of trust amongst stakeholders as a recurring theme in this review highlights the merit of SCT’s concept of self-efficacy. Trust is integral to building efficacy and has the potential to generate social capital within communities grounded in these constructs (Foley & Edwards, 1996 ). Findings from this review also contribute to the theory of mental models, as psychological representations consisting of knowledge and beliefs which enable action and interpretation in a specific domain (Mohammed et al., 2010 ). Less is known within this theory about how important beliefs/perspectives converge and diverge across stakeholder groups and influence inter-organizational relations. Therefore, shared stakeholder perspectives explored within this review, contribute to the literature supporting normative integration as pivotal in co-creating models of care. Implications For Policy And Practice Health systems globally are reorienting services to achieve quadruple aim outcomes (Bachynsky, 2020 ). Perspectives from stakeholders in this review support calls to promote collaborative governance models that are situated in trust, collaborative commitment, and a facilitative leadership style. The influence that policy makers have on this work is immense. In this regard, policy makers are encouraged to honour enduring collaborative governance structures among health and social service organizations, which is truly essential in the establishment of trust, equity, and sustainable integrated care practice (Gordon et al., 2020). Considering that the benefits and necessity of collaborative care are increasingly recognized across health systems, a significant opportunity presents for hospitals, community health and social service organizations to devise collective strategies for partnership. Creation of joint evaluative frameworks and collaborative training programs, with community partners, to support knowledge transfer and establish leadership within community-centred integrated care are needed (Barraclough et al., 2021). Organizations and institutions involved in integrated care would benefit in viewing themselves as a complex and adaptive system, with agility and readiness to respond to local circumstance, through reliance on emergent ways of thinking and sense making (Edgren & Barnard, 2012 ). Moreover, when organizations recognize their role as a collective learning partner, effective cross-sector partnerships emerge (Montigny et al., 2016). Despite well intentions of CBPR to develop equitable partnership between academic researchers and community members, review findings demonstrate this is not always the case. The foundation of community-centred integrated care lies in recognizing where unearned advantage and disadvantage are placed within social structures. Those involved in cross-sector care need to recognize their positions of privilege and work in solidarity to collectively act against systems of inequity (Nixon, 2019 ). Organizations and instructions embarking on cross-sector integrated care would benefit in exploring principles of critical allyship with community partners and acknowledge the possibility of institutionalized tension before the collaboration process begins (Gordon et al., 2020). Limitations And Strengths One of the strengths of this study is the unique combination of the RMIC conceptual framework, taxonomy and Community Engagement Continuum used for coding and analysis. The widespread use and recognition of the RMIC as validated framework adds value to the expanding body of research on normative integration included in this study and current literature. Limitations of this study include that data extraction was completed by one researcher, however the coding review process through matrices was systematic and repeated three times in sequence. In addition, only English language studies were reviewed. Another limitation of this study is that all 13 studies analyzed were predominately written from an academic perspective. The academic author of one study also identified as a community member, however given the lack of community or professional authorship, hard conclusions regarding stakeholder’s perspectives of community-centered integrated care is challenging to deduce. This could be a topic for additional research. Conclusion This review identified the collective influence community engagement has on stakeholder perspectives involved in cross-sector integrated care. Positive stakeholder perspectives were noted to a greater degree when the community is engaged in a collaborative sense or when shared leadership ensues. Diverse stakeholder management, government and political support, secure funding structures, collective governance and facilitative leadership were seen to foster the trust and build relationships necessary for positive stakeholder experiences in cross-sector integrated care. Community-centred integrated care requires a multifaceted approach, situated in critical allyship, to advance population health outcomes through research, education, policy, and practice. This review demonstrates the need to further evaluate the roles that hospitals play in micro, meso and macro level community-centred integrated care, and their impacts and perspectives as integrated care partners. The application of the Rainbow Model of Integrated Care within this paper, provides a foundation to explore the experience of community-centred integrated care among diverse stakeholders, in novel and established programs. Such findings will continue to advance our understanding of core tenants needed to enact equitable community-centred integrated care to promote community health and well-being. Declarations Acknowledgements We thank Mikaela Mitchell (University of Toronto Libraries) for her expert assistance in supporting the search strategy as well as Sioban Nelson (University of Toronto) and Jennifer Price (Women’s College Hospital) for their contributions in guiding the conceptualization and review of this manuscript. We also thank the peer reviewers for their constructive comments on the original manuscript. Authors' contributions V.W. contributed to data collection, analysis, and interpretation and drafting the manuscript. V.W., K.M., and W.B. contributed to data interpretation and editing the article. All authors approved the final version of the submitted manuscript. Funding None to declare Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Ethics approval and consent to participate Not applicable Consent for publication Not applicable Competing interests The authors declare that they have no competing interests References Alderwick, H., & Gottlieb, L.M. (2019). Meanings and misunderstandings: a social determinants lexicon for health care systems. Millbank Quarterly, 97 (2), 407-419. DOI: 10.1111/1468-0009.12390 Alderwice, H., Hutchings, A., Briggs, A., & Mays, N. (2021). The impacts of collaboration between local health care and non-health care organizations and factors shaping how they work: a systematic review of reviews. BMC Public Health, 21 , 753-769. DOI: 10.1186/s12889-021-10630-1 Ansell C, Gash A. (2008). Collaborative Governance in Theory and Practice. Journal of Public Administration Research and Theory , 18 (4): 543–571. doi.org/10.1093/jopart/mum032 Bachynsky, N. (2020). Implications for policy: the triple aim, quadruple aim and interprofessional collaboration. Nursing Forum, 55 , 54-64. DOI: 10.1111/nuf.12382 Barraclough F, Smith-Merry J, Stein V, Pit S. Workforce Development in Integrated Care: A Scoping Review. International Journal of Integrated Care, 21 (4): 23-37. doi.org/10.5334/ijic.6004 Bandura, A. (2005). The evolution of social cognitive theory. In K.G. Smith & M.A. Hitts (Eds). Great Minds in Management . (pp 9-35). Oxford: Oxford University Press. Retrieved from http://www.uky.edu/~eushe2/BanduraPubs/Bandura2005.pdf Breton, M, et al. Multiple Perspectives Analysis of the Implementation of an Integrated Care Model for Older Adults in Quebec. International Journal of Integrated Care, 19 (4), 6-19. doi.org/10.5334/ijic.4634 Burton, G., Thomas, J., O’Mara-Eves, A., Jamal, F., Oliver, S., & Kavanagh, J. (2017). Narratives of community engagement: a systematic review-derived conceptual framework for public health interventions. BMC Public Health, 17 , 944-959. DOI: 10.1186/s12889-017-4958-4 Butterfoss, F.D, & Kegler, M.C. (2002). Toward a comprehensive understanding of community coalitions: moving from practice to theory. In: DiClemente R, Crosby R, Kegler MC, eds. Emerging theories in health promotion practice and research, 2 nd ed . (pp. 157-193). San Francisco, CA: Jossey-Bass. https://soh.iums.ac.ir/uploads/emerging_theories.pdf Cicognani, E., Albansi, C., Valletta, L., & Pratti, G. (2018). Quality collaboration within health promotion partnerships: impact on sense of community, empowerment and perceived projects’ outcomes. Journal of Community Psychology, 48 , 323-336. DOI: 10.1002/jcop.22254 Clinical and Translational Science Awards Consortium. (2011). Principles of community engagement . (2 nd Ed.). NIH Publication No. 11-7782. Bethesda, MD: National Institutes of Health. Retrieved from https://www.atsdr.cdc.gov/communityengagement/index.html Connaughton-Espino, T., & Reese, B.M. (2021). North Carolina youth connected: lessons learned in engaging community leaders in preventing teen pregnancy. Progress in Community Health Partnerships: Research, Education, and Action, 15 (4), 517-524. doi.org/10.1353/cpr.2021.0064 Crocker, H., Kelly, L., Harlock, J., Fitzpatrick, R., & Peters, M. (2020). Measuring the benefits of the integration of health and social care: qualitative interviews with professional stakeholders and patient representatives . BMC Health Services Research, 20 , 515-524. doi.org/10.1186/s12913-020-05374-4 Cronin, C., Franz, B., & Garlington, S. (2021). Population health partnerships and social capital: facilitating hospital-community partnerships. SMM-Population Health, 13, 1-7. doi.org/10.1016/j.ssmph.2021.100739 Crooks, C.V., Exner-Cortens, D., Siebold, W., Moore, K., Grassgreen, L, Owen, P., Rausch, A., & Rosier, M. (2018). The role of relationships in collaborative partnership success: lessons from the Alaska Fourth R project. Evaluation and Program Planning, 67 , 97-104. doi.org/10.1016/j.evalprogram.2017.12.007 de Montigny, J.G., Desjardin, S., Bouchard, L. (2017). The fundamentals for cross-sector collaboration for social change to promote population health. Global Health Promotion, 26 (2), 41-50. DOI: 10.11/77/1757975917714036 Dykes, P.C., Carroll, D.L., Hurley, A.C., Benoit, A., & Middleton, B. (2009). Why do patients in acute care hospitals fall? Can falls be prevented? Journal of Nursing Administration, 39 (6), 299-304. doi:10.1097/NNA.0b013e3181a7788a. Edgren, L., & Barnard, K. (2012). Complex adaptive systems for management of integrated care. Leadership in Health Services, 25 (1), 39-51. DOI: 10.1108/17511871211198061 Enard, K.R., Nicks, S.E., Campbell, B.A., & McClure, S.M. (2021). In pursuit of equity: partnering to improve breast and prostate cancer outcomes among African Americans. Cancer Causes & Control, 32 , 473-482. doi.org/10/1007/s10552-021-01412-6 Evans, J.M., Baker G.R., Bertha, W., & Barnsely, J. (2013). The evolution of integrated care strategies. Advances in Health Care Management, 15 , 125-161. doi:10.1108/S1474-8231(2013)0000015011 Evans, J.M., Baker G.R., Bertha, W., & Barnsely, J. (2014). A cognitive perspective on health systems integration: results of a Canadian delphi study. BMC Health Service Research, 14 , 222-235. http://www.biomedcentral.com/1472-6963/14/222 Farmanova, E., Baker, G.R., Cohen, D. (2019). Combining integration of care and a population health approach: a scoping review of redesign strategies and interventions, and their Impact. International Journal of Integrated Care, 19 (2), 5-30. doi.org/10.5334/ijic.4197 Foley, M.W., & Edwards, B. (1996). The Paradox of Civil Society. Journal of Democracy 7 (3), 38-52. doi:10.1353/jod.1996.0048. Gordon, D., McKay, S., Marchildon, G., Bhatia, R.S., & Shaw, J. Collaborative governance for integrated care: insights from a policy stakeholder dialogue. International Journal of Integrated Care, 20 (1), 3-14. doi.org/10.5334/ijic.4684 Grant, M, G., & Booth, A. (2009). A typology of reviews: an analysis of 14 review types and associates methodologies. Health information and libraries journal, 26 , 91-108. DOI: 10.1111/j.14711842.2009.00848.x Griese, L., Berens, E. M., Nowak, P., Pelikan, J. M., & Schaeffer, D. (2020). Challenges in navigating the health care system: development of an instrument measuring navigation health literacy. International journal of environmental research and public health , 17 (16), 5731-5748. doi.org/10.3390/ijerph17165731 Health Quality Ontario. (2020). Transitions between home and hospital. https://www.hqontario.ca/Portals/0/documents/evidence/quality-standards/qs-transitions-between-hospital-and-home-quality-standard-en.pdf Hong, Q.N., Pluye, P., Fàbregues, S., Bartlett, G., Boardman, F., Cargo, M., Dagenais., P., Gagnon M.P., Griffiths, F., Nicolau, B., O’Cathain, A., Rousseau, M.C., & Vedel, I. (2008). Mixed Methods Appraisal Tool (MMAT). http://mixedmethodsappraisaltoolpublic.pbworks.com/w/file/fetch/127916259/MMAT_2018_criteria-manual_2018-08-01_ENG.pdf Johns, S. (2010). Early childhood service development and intersectoral collaboration in rural Australia. Australian Journal of Primary Health Care, 16 , 40-46. DOI: 10.1071/PY09050 Lee, R.E., Parker, N.H., Hallet, A.M., Kao, D., Modelska, M.J., Rifai, H., Soltero, E.G., & O’Connor, D.P. (2021). Stakeholder perspectives and sustainability of an integrated care model for the prevention and management of obesity: the childhood obesity research demonstration project. Theory of Behavioural Medicine, 11 , 393-407. doi: 10.1093/tbm/ibaa058 Mays, G.P., Mamaril, C.B., & Timsina, L.R. (2016). Preventable death rates fell where communities expanded population health activities through multisector networks. Health Affairs, 35 , 2005–2013. DOI: 10.1377/hlthaff.2016.0848 Middleton, G, Henderson, H, & Evans, D. (2013). Implementing a community-based obesity prevention programme: experiences of stakeholders in the north east of England. Health Promotion International, 29 (2), 201-211. doi: 10.1093/heapro/das072 Milligan, C., & Berta, W. (2021). Reimagining community relationships for organizational learning: a scoping review with implication for a learning health system. BMC Health Services Research, 21 , 603-613. doi.org/10.1186/s12913-021-06640-9 Mirsa, V., Sedig, K., Dixon, D., & Sibbald, S. (2020). Commentary. Canadian Family Physician, 66 , 399-403. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7292521/pdf/0660399.pdf Mohammed, S., Ferzandi, L., & Hamilton, K. (2010). Metaphor no more: a 15-year review of the team mental model construct. Journal of Air Waste Management Association, 36 (4), 876–910. doi.org/10.1177/0149206309356804 Moher, D., Liberati, A., Telzlaff, J., Altman, D. G., & the PRISMA Group (2009). Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. Annals of Internal Medicine, 151 (4), 264– 269. doi.org/10.7326/0003-4819-151-4-200908180-00135 MOHLTC (Ministry of Health and Long Term Care). (2015). Bringing Care Home. https://health.gov.on.ca/en/public/programs/lhin/docs/hcc_report.pdf Montigny, J.G., Desjardins, S., & Bouchard, L. (2017). The fundamentals of cross-sector collaboration for social change to promote population health. Global Health Promotion, 26 (2), 41-50. DOI: 10.1177/1757975917714036 Nixon, S. (2019). The coin model of privilege and critical allyship: implications for health. BMC Public Health, 19 , 1637-1650. doi.org/10.1186/s12889-019-7884-9 Nowel, L.S., Norris, J, M., Deborah E.W., & Moules, N.J. (2017). Thematic analysis: striving to meet the trustworthiness criteria. International Journal of Qualitative Methods, 16 , 1-13. Doi: 10.1177/1609406917733847 Pfaff, K., Baxter, P., Jack, S., & Ploeg, J. (2014). An integrative review of the factors influencing new graduate nurse engagement in inter-professional collaboration. Journal of Advanced Nursing, 70 , 4–20. doi.org/10.1111/jan.12195 Powell, D.G., Williams, A.M., Larsen K., Perkins, D., Roland, M., & Harris, M.F. (2008). Coordinating primary health care: an analysis of the outcomes of a systematic review. Medical Journal of Australia, 188 (8), 65-8. doi: 10.5694/j.1326-5377.2008.tb01748.x Provan, K.G., Nakama, L., Veazie, M.A., Teufel-Shone, N.I., & Huddleston, C. (2003). Building community capacity around chronic disease service through collaborative interorganizational network. Health Education and Behavior, 30( 6), 646-662. DOI: 10.1177/10901981032255366 Purcell, L., & Kearns, N. (2012). Impacts of an HIA on inter-agency and inter-sectoral partnerships and community participation: lessons from a local level HIA in the Republic of Ireland. Health Promotion International, 28( 4), 522-532. doi: 10.1093/heapro/das032 Roussos, S.T., & Fawcett, S.B. (2000). A review of collaborative partnerships as a strategy for improving community health. Annual Review Public Health, 21 , 369-402. doi: 10.1146/annurev.publhealth.21.1.369. Schulz, A.J., Israel, B.A., Parker, E.A., Lockett, M., Hill, Y., & Rochelle, W. (2001). The east side village health worker partnership: integrating research with action to reduce health disparities. Public Health Reports, 116 , 548-557. DOI: 10.1093/phr/116.6.548 Shahzad, M., Upshur, R., Donnelly, P. Bharmal, A., Wei, X., Feng, P., & Brown, A.D . (2019). A population-based approach to integrated healthcare delivery: a scoping review of clinical care and public health collaboration. BMC Public Health , 19 , 708-723. doi.org/10.1186/s12889-019-7002-z Shan, H., Muhajarine, N., Lopston, K., & Jeffery, B. (2012). Building social capital as a pathway to success: community development practices of an early childhood intervention program in Canada. Health Promotion International, 2 , 244-255. DOI: 10.1093/heapro/das063 Skivington, K., Smith, M., Rui Chng, N., Mackenzie, M., Wyke, S., & Mercer, S.W. (2018). Delivering a primary-care based social prescribing initiative: a qualitative study of the benefits and challenges. British Journal of General Practice, 68 (672), 487-494. DOI: 10.3399/bjgp18X696617 The Commonwealth Fund. (2019). International health care system profiles: what is being done to promote delivery system integration and care coordination? https://international.common wealthfund.org/features/integration Uittenbroek, R.J., Kremer, H.P., Spoorenberg, S.L., Reijneveld, S.A., & Wynia, K. (2017). Integrated care for older adults improves perceived quality of care: results of a randomized controlled trial of embrace. Journal of General Internal Medicine , 32 (5), 516–23. DOI: 10.1007/s11606-016-3742-y UN (United Nations).(2015). Partnerships for sustainable development goals: a legacy review towards realizing the 2030 Agenda . https://sustainabledevelopment.un.org/content/documents/2257Partnerships%20for%2 0SDGs%20-%20a%20review%20web.pdf Valentijn, P.P., Schepman, S.M., Opheij, W., & Bruijnzeels, M.A. (2013). Understanding integrated care: a comprehensive conceptual framework based on the integrative functions of primary care. International Journal of Integrated Care, 13 , 1-12. doi: 10.5334/ijic.886 Valentijn, P.P., Vrijhoef, H.J.M., Ruwaard, D, Boesveld, Arends, R, Y., & Bruijnzeels, M.A. (2015). Towards an international taxonomy of integrated primary care: a delphi consensus approach. BMC Family Practice, 16 , 64-79. DOI: 10.1186/s12875-015-0278-x van Dijk, H.M., Cramm, J.M., & Nieboer, A.P. (2016). How to build an integrated neighbourhood approach to support community-dwelling older people. International Journal of Integrated Care, 16 (2), 4-19. doi.org/10.5334/ijic.1596 van Eyk, H., & Baum, F. (2002). Learning about interagency collaboration: trialling collaborative projects between hospital and community health services. Health and Social care in the Community, 10 (4), 262-269. DOI: 10.1046/j.1365-2534.2002.00369.x Vangen, S., Hayes, J.P., & Cornforth, C. (2015). Governing cross-sector, inter-organizational collaborations. Public Management Review, 17 , 1237–1260. doi.org/10.1080/14719037.2014.903658 Whittemore, R., & Knafl, K. (2005). The integrative review: updated methodology. Journal of Advanced Nursing, 52 (5), 546–553. doi.org/10.1111/j.1365-2648.2005.03621.x WHO (World Health Organization).(2012). Health promotion: the first international conference on health promotion, 1986 . Retrieved April 10, 2022, from https://www.who.int/teams/health-promotion/enhanced-wellbeing/first-global-conference Zhu, X., Weigel, P., Baloh, J., Nataliansyah M., Gunn, N., & Mueller, K. (2019). Mobilising cross-sector collaborations to improve population health in US rural communities: a qualitative study. BMJ Open, 9 , 1-8. doi: 10.1136/bmjopen-2019-030983 Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2148586","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":163938668,"identity":"c28bad46-40b4-4c09-b6b5-870b3ce2f8ee","order_by":0,"name":"Vanessa L. Wright","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBElEQVRIiWNgGAWjYBACgwNwBmMDMwODDclaEtIYeMDcBKK0MDAAtRwmrEWy/ezBhz/+2DEY3D7c/Lrwx/nE/ey9Dx8X/rBh4G8/gF1LT16yMW9bMoPZucQ26xkJtxN7eI4bG88AulDiDHarJBtyzKRBvjA7w9hmzAPSIpHGJs0DdKEBDtfx878x//njTz1MyzkkLfwPsGuRyDFj4GE7zGB/hrH5MU/CASQtEthtYZN4YyzN23acxxJoCzNPWrJxz5ljzMY8aWk8Ejew28LGn2P48cefajmDM+yPP/PY2Mm2t7cxPuaxsZHj78duCwzwgG1EFyEImD8Qo2oUjIJRMApGHgAAvklZv7Uc1HsAAAAASUVORK5CYII=","orcid":"","institution":"University of Toronto","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Vanessa","middleName":"L.","lastName":"Wright","suffix":""},{"id":163938669,"identity":"e25bcba9-653e-4bdd-bfe8-928a63317e47","order_by":1,"name":"Kelly Metcalf","email":"","orcid":"","institution":"University of Toronto","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Kelly","middleName":"","lastName":"Metcalf","suffix":""},{"id":163938670,"identity":"a38892e1-2a77-4b9c-bbbd-9764822f53ea","order_by":2,"name":"Whitney Berta","email":"","orcid":"","institution":"University of Toronto","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Whitney","middleName":"","lastName":"Berta","suffix":""}],"badges":[],"createdAt":"2022-10-09 19:29:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2148586/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2148586/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":31093169,"identity":"370a0116-a080-4ec9-aa07-5bb622a42332","added_by":"auto","created_at":"2023-01-04 14:55:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":499361,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2148586/v1/f3130ec3-a7d9-4018-8dde-ed42ce3d1cfc.pdf"},{"id":31093166,"identity":"789b5204-2cd6-42a3-9a60-1e63d549243a","added_by":"auto","created_at":"2023-01-04 14:54:56","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":1034206,"visible":true,"origin":"","legend":"","description":"","filename":"BMC.IntegrativeReview.Supplementary.Dec.29.2022.VWright.docx","url":"https://assets-eu.researchsquare.com/files/rs-2148586/v1/b9c23b163d7834288ad87dd4.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"The influence of community engagement on stakeholder perspectives in cross-sector integrated care: an integrative review","fulltext":[{"header":"Background","content":"\u003cp\u003eHealthcare coordination is an issue of global concern, driven by increased fragmentation across health care systems (Alderwick et al., 2021, Cronin et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e; de Montingny et al., 2017). Strategies to improve care coordination and address system fragmentation have been implemented across North America, the United Kingdom, Europe, Australia, and New Zealand (The Commonwealth Fund, \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e; Powell et al, \u003cspan class=\"CitationRef\"\u003e2008\u003c/span\u003e), yet many patients continue to navigate complex health systems in isolation, determining adequate entry points and pathways to support their health outcomes (Greise et al., 2020).\u003c/p\u003e\n\u003cp\u003ePatients report wanting care that is easy to understand and access, where housing, social services, and health work in close partnership (MOHLTC, 2015). Characterizing this request, is the siloed nature of many North American healthcare systems, that are marked by limited flow of information and resources, reducing efficiency, effectiveness, and quality of health care provision (Dykes et al., \u003cspan class=\"CitationRef\"\u003e2009\u003c/span\u003e; Misra et al., 2020). Health systems are responding through goals to improve access to services, create smoother transitions between services and strive for patients to receive the \u0026lsquo;right\u0026rsquo; care at the \u0026lsquo;right\u0026rsquo; time, reducing the number of times patients must tell their story (Health Quality Ontario, \u003cspan class=\"CitationRef\"\u003e2020\u003c/span\u003e). These overarching goals support what is best known in literature as integrated care, a term that denotes health system efforts around the world to improve effectiveness, efficiency, and outcomes (Gordon et al., 2020).\u003c/p\u003e\n\u003cp\u003eIntegrated care has demonstrated effectiveness for those with complex heath conditions ranging from diabetes, influenza, and cardiovascular disease (Mays et al., \u003cspan class=\"CitationRef\"\u003e2016\u003c/span\u003e). Extending the benefits of integrated care beyond the clinical domain has allowed for the inclusion of population health as a central pillar to integrated care efforts (Kindig \u0026amp; Stoddard, 2003; Shazhad et al., 2019; Uttinbroek et al., 2017). Population health takes into consideration the wide range of factors that influence the health of populations. Herein, a shift in our health care system is seen as we move beyond the traditional biomedical model and pay particular attention to cross-sector collaboration and the influence of public policy to address the social and structural determinants of health and health equity (Shazad et al., 2019).\u003c/p\u003e\n\u003cp\u003eAlthough integrated care and population health are not novel concepts, realizing their operational synergy remains a challenge (Farmanova et al., \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e). Integrated care is difficult to achieve, particularly through the lens of population health where care coordination emphasizes the integration of two service platforms: health and social care (Crocker et al., \u003cspan class=\"CitationRef\"\u003e2020\u003c/span\u003e). Health and social services traditionally have long-standing institutional separation, and distinct funding streams and accountability arrangements, making it difficult to seamlessly integrate cross-sector care, even if all have the same end goal to improve health of communities and populations (Crocker et al., \u003cspan class=\"CitationRef\"\u003e2020\u003c/span\u003e; Provan et al., \u003cspan class=\"CitationRef\"\u003e2003\u003c/span\u003e). Policy makers, however, have not been deterred by these findings and continue to promote cross-sector integrated care as a central pillar in the health system\u0026rsquo;s role toward addressing the social determinants of health (Alderwick \u0026amp; Gottlieb, \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e). As such, community engagement is seen as an effective strategy for harnessing community potential, allowing individuals to regain control of their health and improve population health outcomes (Butterfoss \u0026amp; Kegler, \u003cspan class=\"CitationRef\"\u003e2002\u003c/span\u003e). What remains to be uncovered, is what kind of cross-sector collaborations work, with whom, and by what way of community engagement.\u003c/p\u003e\n\u003cp\u003eAs cross-sector integrated care arrangements continue to develop between the health and social service sectors, there is a need to move well beyond optimizing organizational and process integration, to that of social cognition which considers what is shared and valued between parties in the commitment to co-ordinating efforts (Evans et al., \u003cspan class=\"CitationRef\"\u003e2014\u003c/span\u003e). The ethos of shared values and commitment in care delivery is known as \u003cem\u003enormative integration\u003c/em\u003e (Valentijn et al., \u003cspan class=\"CitationRef\"\u003e2013\u003c/span\u003e). It has been suggested that normative integration may be the key to addressing ongoing integrative challenges through the development and creation of trust. Trust herein is seen as underpinning quality interactions and relationships necessary for sustained cross-sector integrated care efforts (Roussos and Fawcett, \u003cspan class=\"CitationRef\"\u003e2000\u003c/span\u003e). These findings hold promise for population health and community engagement, if significant attention and effort is paid to addressing inequities noted in these partnerships themselves (Johns, 2018). Considering potential lies in advancing cross-sector integrated care through revealing what is shared among care partners, there is a need to better understand the collective beliefs, motivations, and perspectives of those involved in cross-sector integrated care initiatives. A review of the literature was conducted with a goal of summarizing stakeholder perspectives found in community centred cross-sector integrative care research.\u003c/p\u003e\n\u003ch2\u003eConceptual Framework\u003c/h2\u003e\n\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n\u003ch2\u003eCommunity Engagement Continuum\u003c/h2\u003e\n\u003cp\u003eThe process of engaging communities moves on a continuum, as demonstrated by the Clinical and Translational Science Awards Consortium (\u003cspan class=\"CitationRef\"\u003e2011\u003c/span\u003e), from outreach (provision of one-way information), to consultation, involvement (two-way flow of information), collaboration (partnership on all aspects) and shared leadership, inclusive of longer-term partnerships and shared decision making, Appendix A. Among the diverse processes of community engagement, two methodological approaches have emerged. The first being the \u0026lsquo;utilitarian\u0026rsquo; perspective, where the community is approached to improve the effectiveness of the intervention and invited for their views, but the intervention has not been designed by the community themselves (Burton et al., \u003cspan class=\"CitationRef\"\u003e2017\u003c/span\u003e). The second approach is grounded in the development of social capital. From this perspective, community members are empowered to determine their priorities for health and service redesign (Burton et al., \u003cspan class=\"CitationRef\"\u003e2017\u003c/span\u003e).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n\u003ch2\u003eRainbow Model of Integrated Care\u003c/h2\u003e\n\u003cp\u003eThe Rainbow Model of Integrated Care (RMIC) is a comprehensive framework used to assess and evaluate integrated care dimensions based on the Triple Aim Framework for primary care (Valentijn et al., \u003cspan class=\"CitationRef\"\u003e2013\u003c/span\u003e). The model was validated through a series of Delphi panels and seeks to align integrated care within micro, meso and macro system levels (Valentijn et al., \u003cspan class=\"CitationRef\"\u003e2015\u003c/span\u003e). As such, the micro-level refers to levels of clinical integration among professionals in patient care coordination across the health care system. The meso-level refers to both organizational integration and professional integration. The former refers to networks formed between organizations, and the latter as partnerships between health care professionals in integrated care efforts. At the macro-level, system integration refers to linkages between the health care system and external partners. Functional and normative integration span micro, meso and macro system levels. Functional integration includes key supports that are needed in integrative operations, such as financing, management, and information systems. Normative integration, as referred to earlier, is based on the shared vision, values, and mission of efforts through cultural and social attention. Key features of integrated care have been developed into 59 taxonomies by Valentijn at al., (2015) to assist classifying and categorizing the broad spectrum of approaches used in various projects. The RMIC and related taxonomy provides a framework to evaluate integration and outcome measures from the perspectives of both patients and health care providers (Valentijn et al., \u003cspan class=\"CitationRef\"\u003e2015\u003c/span\u003e), Appendix B.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch2\u003eAim\u003c/h2\u003e\n\u003cp\u003eIntegrated care literature over the past two decades has enabled advances in the field through identification of barriers and enablers to system integration. Despite these efforts, considerable difficulty remains in establishing collaboration and cooperation across organizational boundaries (Evans et al., \u003cspan class=\"CitationRef\"\u003e2014\u003c/span\u003e). Normative integration is an essential element to Valentijn et al.\u0026rsquo;s (\u003cspan class=\"CitationRef\"\u003e2015\u003c/span\u003e) RMIC, yet Breton et al., (2019) recognizes differing perspectives of multiple stakeholders may provide the contextual evidence needed to advance integrated care through health care policy and practice across sectors. In addition, a scoping review by Miligan et al. (2021), confirms that community engagement is often used without merit, where a disproportionate number of studies emphasized learning \u003cem\u003efrom\u003c/em\u003e communities rather than learning \u003cem\u003ewith\u003c/em\u003e communities. These are extremely important findings given the dearth of literature on stakeholder perspectives in community-centred integrated care and efforts placed toward a global strategy to advance cross-sector collaboration. This review aims to expand the understanding of cross-sector integrated care and normative integration through principles of community engagement and learning with community. In addition, this review aims to provide comprehensive evidence to build and operationalize equitable cross-sector integrated care initiatives grounded in respect and allyship, with the communities served by heath care systems. Objectives developed to meet these aims include i) identification of studies and reviews focusing on cross-sector integrated care utilizing community engagement and participation, ii) critique of quality studies, and iii) identification of well supported themes found within the included research to provide new findings in the expanding field of cross-sector integrated care.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eAn integrative literature review was conducted using Whittemore and Knalf\u0026rsquo;s framework (2005) as a guide. This integrative review is classified as a mixed studies review, through analysis of both qualitative and quantitative study findings (Grant \u0026amp; Booth, \u003cspan class=\"CitationRef\"\u003e2009\u003c/span\u003e). The literature included in this integrative review met clear and specific criteria to support the inclusion and exclusion of articles chosen to represent the data in an unbiased manner (Whittemore \u0026amp; Knalf, 2005). To gather relevant data for the review, key terms were searched on select data bases to yield a cohort of articles for data extraction. Thematic analysis was used through reading and re-reading the articles to identify key themes and findings that emerged from stakeholders regarding their perceptions of cross-sector integrated care efforts (Nowell et al., 2017).\u003c/p\u003e\n\u003ch3\u003eSearch Strategy\u003c/h3\u003e\n\u003cp\u003eRelevant articles were searched using a pre-planned literature search in four data bases: OVID \u0026ndash; MEDLINE, OVID \u0026ndash; EMBASE, EBSCO-CINHAL and PSYCH-INFO, from 1990-present. The year 1990 was chosen, as the time-period when integrated care was introduced as a concept in medical and social service literature. Data bases were searched using key concepts deemed most relevant to yield data in according with the aim of the review (Whittemore \u0026amp; Knalf, 2005). Key concepts included \u0026ldquo;community engagement\u0026rdquo;, \u0026ldquo;community participation\u0026rdquo;, \u0026ldquo;community involvement\u0026rdquo;, \u0026ldquo;community mobilization\u0026rdquo;, \u0026ldquo;community representation\u0026rdquo;, \u0026ldquo;collaborative care\u0026rdquo;, \u0026ldquo;integrated care\u0026rdquo;, \u0026ldquo;coordinated care\u0026rdquo;, \u0026ldquo;collaborative care\u0026rdquo;, \u0026ldquo;collaborative care\u0026rdquo;, \u0026ldquo;collaborative partnership\u0026rdquo;, \u0026ldquo;inter-sectoral care\u0026rdquo;, \u0026ldquo;inter-agency care\u0026rdquo;, \u0026ldquo;cross-sector collaboration\u0026rdquo;. Key concepts were combined with Boolean operator AND, and the search words within each concept were combined with OR.\u003c/p\u003e\n\u003ch3\u003eStudy Selection Criteria\u003c/h3\u003e\n\u003cp\u003eThis review focuses on the perspectives of all stakeholders involved in cross-sector integrative care initiatives, where the community was actively engaged and included as a partner. Inclusion criteria was devised as: studies that were evaluative in nature, explored an intervention, utilized community and population health interventions, published between January 1990 and Feb 2022, empirical research written in the English language from Canada, USA, Western Europe, UK, Australia and New Zealand. In addition, inclusion criteria included studies that focused on horizontal integration (collaborating organizations, networks, groups in the health system). The exclusion criteria were editorials, opinion pieces, conference abstracts, review papers, non-English papers, dissertations, and those articles with focus on health outcomes only.\u003c/p\u003e\n\u003ch3\u003eSearch Outcomes\u003c/h3\u003e\n\u003cp\u003ePer PRISMA guidelines, eight articles were removed due to duplication (Moher et al., \u003cspan class=\"CitationRef\"\u003e2009\u003c/span\u003e) (see Appendix C for PRISMA flow diagram). Titles and abstracts were checked for relevance based on the study inclusion and exclusion criteria. A total of 2410 articles were rejected as they did not meet the objectives laid out in the inclusion criteria. This process yielded 103 articles for full text screening. These articles were read for their relevance, and of these, 90 further studies were rejected as they did not meet the inclusion criteria. Ultimately, 12 qualitative and 1 quantitative study met the criteria for this integrative review. Studies included in this synthesis are summarized in Appendix D.\u003c/p\u003e\n\u003ch3\u003eQuality Appraisal\u003c/h3\u003e\n\u003cp\u003eThe Mixed Method Appraisal Tool 2018 (MMAT) was used to evaluate the research included in this review. Although no specific standard for assessing methodological quality in an integrative review exists (Whittemore and Knalf, 2005), the MMAT is a validated critical appraisal tool that is designed for systematic mixed review studies (Hong et al., 2018). The MMAT leads appraisal with two standard screening questions for all studies under review, then incorporates five tailored screening questions for each study type: qualitative, quantitative randomized control trial, quantitative non-randomized control trial, quantitative descriptive and mixed method. Eleven of the thirteen studies included in this review were deemed high quality. The two studies that were deemed low quality have remained in this analysis, however these findings are taken into consideration during data analysis.\u003c/p\u003e\n\u003ch3\u003eData Abstraction And Synthesis\u003c/h3\u003e\n\u003cp\u003eTo facilitate analysis, both qualitative and quantitative data were extracted into an evidence table. This table is also known as a matrix, used to organize, support data analysis, and develop themes (Whittemore and Knalf, 2005). Codes were generated for thematic analysis, utilizing the RMIC taxonomy and spectrum of community engagement. After coding each study, the codes were clustered to develop themes through use of a matrix. Matrices were used in three stages to support the fusion of narrative and statistical data (Whittemore and Knalf, 2005). Initially, articles were grouped based on setting, methods, and results. This preliminary data tabulation, allowed for a second matrix to develop and demonstrate similarities and patterns within the data, using the Community Engagement Continuum, the RMIC and 59 key feature integrated care taxonomy to code data within the studies. The third matrix allowed for the emergence of themes to present among the studies, where significance, relevance and novel representation was found related to stakeholder perceptions of cross-sector integrated care. Results are described through alignment with Valentijn\u0026rsquo;s key feature taxonomy (in italics) below and listed in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eStakeholder perspectives of cross-sector integrated care in relation to the Rainbow Model of Integrated Care taxonomy\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eIntegrated Care Domain\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eKey Feature\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"6\" align=\"left\"\u003e\n\u003cp\u003ePositive perspectives\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eModerate perspectives\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"5\" align=\"left\"\u003e\n\u003cp\u003eNegative Perspectives\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCicognani et al.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCrooks et al.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLee et al.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eProvan et al.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eShan et al.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eZhu et al.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMiddleton et al.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSkivington et al.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eConnaughton-Espino et al.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEnard et al.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePurcell \u0026amp; Kearns\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSchultz et al.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eVan Dijk et al.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"9\" align=\"left\"\u003e\n\u003cp\u003eClinical\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePopulation Health\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eClient participation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePatient education\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eContinuity\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCentrality of client needs\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eInformation provision to clients\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eInteraction between professional and client\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCase management\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eIndividual multidisciplinary care plan\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"7\" align=\"left\"\u003e\n\u003cp\u003eProfessional\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eShared vision between professionals\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAgreement of interdisciplinary collaboration\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eInterpersonal characteristics\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eInterprofessional education\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMultidisciplinary guidelines/protocols\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eValue creation for professional\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eInterprofessional governance\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"5\" align=\"left\"\u003e\n\u003cp\u003eOrganizational\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eInter-organizational governance\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eInter-organizational strategy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLearning organizations\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eValue creation for organization\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eManagerial leadership\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"6\" align=\"left\"\u003e\n\u003cp\u003eSystem\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePopulation features\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAvailable resources\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGood governance\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eStakeholder management\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEnvironmental climate\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSocial value creation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"4\" align=\"left\"\u003e\n\u003cp\u003eFunctional\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHuman Resource management\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRegular feedback and performance indicators\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eResource management\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eInformation management\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"7\" align=\"left\"\u003e\n\u003cp\u003eNormative\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTrust\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCollective attitude\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eReliable behaviour\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eVisionary leadership\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTranscending domain perceptions\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLinking cultures\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eQuality features of informal collaboration\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n\u003ch2\u003eCharacteristics of the included studies\u003c/h2\u003e\n\u003cp\u003eOf the 13 studies included in this review, seven were based in the USA, three in Europe, two in the UK, and one in Canada. Publication years ranged from 2001\u0026ndash;2021 and included 11 qualitative studies, one quantitative study and one mixed method study. The focus of each study explored stakeholder perspectives in cross-sector integrated care and collaboration through population health programs, in community settings. Study topics included: teen pregnancy, domestic violence, breast and prostate cancer, obesity (n\u0026thinsp;=\u0026thinsp;2), chronic disease prevention, transportation and health, early childhood intervention, social prescribing, and care-dependent seniors. All 13 studies were involved in the integration of health, social care and wider community service and utilized a horizontal integrated care approach. Two studies included the hospital as a partner, the rest included a mix of public/private health and community sectors, and regional/municipal governments. Regarding stakeholder perspectives of cross-sector integrated care initiatives, six studies detailed positive stakeholder perspectives, two studies detailed moderate stakeholder perspectives and five studies detailed negative stakeholder perspectives. Moreover, all studies addressed micro, meso and macro level constructs of integrated care, reflecting the complex needs of the populations targeted within the studies.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch2\u003eIntegration Processes\u003c/h2\u003e\n\u003ch2\u003eClinical integration (micro-level)\u003c/h2\u003e\n\u003cp\u003eThis dimension represents the heart of integration efforts and is the interface where patients and their families receive care from the health system (Breton et al., 2019). All studies described a clinical integration process to address population health needs. Community health workers (CHW) were utilized in four studies as a key group to mobilize outreach efforts (Enard et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e; Schulz et al., \u003cspan class=\"CitationRef\"\u003e2001\u003c/span\u003e; Shan et al., \u003cspan class=\"CitationRef\"\u003e2012\u003c/span\u003e; Skivington et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e). In addition to providing direct clinical integration, CHWs acted as case managers (Skivington et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e) and were hired to create linkages among organizations (Enard et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e; Skivington et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e). Despite three studies undertaking a community based participatory research (CBPR) focus (Crooks et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e; Enard et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e; Schulz et al., \u003cspan class=\"CitationRef\"\u003e2001\u003c/span\u003e), the use of \u003cem\u003eclient participation\u003c/em\u003e in co-design was used minimally in studies with and without a CBPR focus (Cicognani et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e; Purcell \u0026amp; Kearns, \u003cspan class=\"CitationRef\"\u003e2012\u003c/span\u003e). Three studies addressed \u003cem\u003econtinuity\u003c/em\u003e of care as an objective of fluid care delivery. Two of these studies aim to do this through CHW\u0026rsquo;s (Enard et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e; Skivington et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e), and through cross-sector collaboration (Connaughton-Espino \u0026amp; Reese, \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e). \u003cem\u003eCentrality of client needs\u003c/em\u003e was a notable guiding feature in six studies, that sought to integrate and scale client care at micro, meso and macro levels, which was particularly successful when diversified across organizations (Crooks et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e; Lee et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e; Provan et al., \u003cspan class=\"CitationRef\"\u003e2003\u003c/span\u003e; Shan et al., \u003cspan class=\"CitationRef\"\u003e2012\u003c/span\u003e; Van Dijk et al., \u003cspan class=\"CitationRef\"\u003e2016\u003c/span\u003e; Zhu et al., \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\n\u003ch2\u003eProfessional integration (meso-level)\u003c/h2\u003e\n\u003cp\u003eInnate characteristics of professionals were a driving force behind many cross-sector integrated care efforts. In some ways, \u003cem\u003einterpersonal characteristics\u003c/em\u003e were seen as a supportive element, an added advantage to a well-functioning partnership and influenced acquired learning in partner organizations (Crooks et al, \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e; Shan et al., \u003cspan class=\"CitationRef\"\u003e2012\u003c/span\u003e). Herein, a champion or change agent was identified through skilled leaders in intersectoral collaboration (Skivington et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e; Van Dijk et al., \u003cspan class=\"CitationRef\"\u003e2016\u003c/span\u003e). Yet, the drawback of this emergent leadership was situated in a lack of shared governance or decision making (Zhu et al., \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e). As a result, reliance on interpersonal characteristics to build individual relationships when organizational relationships lacked was common finding (Skivington et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e). This was demonstrated through dependence on CHW\u0026rsquo;s to generate community awareness and trust. The skills of CHW\u0026rsquo;s can be amplified as sole \u0026lsquo;problem solvers and emotional supports\u0026rsquo;, while the responsibilities of others in the partnership are negated (Purcell \u0026amp; Kearns, \u003cspan class=\"CitationRef\"\u003e2012\u003c/span\u003e; Schultz et al., 2001).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eShared vision between professionals\u003c/em\u003e was often established from the outset in collaborative partnerships (Cicognani et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e; Connaughton-Espino \u0026amp; Reese, \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e; Crooks et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e; Middleton et al., \u003cspan class=\"CitationRef\"\u003e2013\u003c/span\u003e; Shan et al., \u003cspan class=\"CitationRef\"\u003e2012\u003c/span\u003e; Schulz et al., \u003cspan class=\"CitationRef\"\u003e2001\u003c/span\u003e). These early formalities can be captured through \u003cem\u003eagreements of interdisciplinary collaboration\u003c/em\u003e or memorandums of understanding (Cicognani et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e; Connaughton-Espino \u0026amp; Reese, \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e). However, early establishment of shared vision did not necessarily equate with collaborative success in short- or long-term project indicators (Connaughton-Espino \u0026amp; Reese, \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e; Middleton et al., \u003cspan class=\"CitationRef\"\u003e2013\u003c/span\u003e; Schulz et al., 2013). Of particular importance is who is creating a shared vision from the outset, where excluding key community organizations led to detrimental outcomes (Schulz et al., 2013). Shared vision was found to expand and deepen over time in positive, collaborative working relationships (Cicognani et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e; Crooks et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e). Furthermore, \u003cem\u003einterprofessional education\u003c/em\u003e provided an avenue to facilitate increased awareness of services, inner workings of health systems, and cultural relevance if all parties were present (Enard et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e; Purcell \u0026amp; Kearns, \u003cspan class=\"CitationRef\"\u003e2012\u003c/span\u003e; Shan et al., \u003cspan class=\"CitationRef\"\u003e2012\u003c/span\u003e). When interprofessional education narrowly addressed access to services, rather than cultural community-based teachings, project scope and reach were limited (Enard et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e, Purcell \u0026amp; Kearns, 2021). Similarly, \u003cem\u003emultidisciplinary guidelines\u003c/em\u003e provided a neutral reference for organizations to situate their work, advance understanding in evidenced based practice, strengthen relationships, and increase community capacity (Enard et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e; Lee et al., 2020).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\n\u003ch2\u003eOrganizational integration (meso-level)\u003c/h2\u003e\n\u003cp\u003eNomenclature used to describe cross-sector integrated care initiatives varied widely across studies. The term \u0026lsquo;collaboration or collaborative\u0026rsquo; was used most frequently (Crooks et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e; Provan et al., \u003cspan class=\"CitationRef\"\u003e2003\u003c/span\u003e; Van Dijk et al., \u003cspan class=\"CitationRef\"\u003e2016\u003c/span\u003e; Zhu et al., \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e), followed by \u0026lsquo;partnership\u0026rsquo; (Cicognani et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e; Schulz et al., \u003cspan class=\"CitationRef\"\u003e2001\u003c/span\u003e; Shan et al., \u003cspan class=\"CitationRef\"\u003e2012\u003c/span\u003e), then \u0026lsquo;program\u0026rsquo; (Middleton et al., \u003cspan class=\"CitationRef\"\u003e2013\u003c/span\u003e; Skivington et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e), \u0026lsquo;initiative\u0026rsquo; (Connaughton-Espino \u0026amp; Reese, \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e) and \u0026lsquo;coalition\u0026rsquo; (Purcell \u0026amp; Kearns, 2003). Terms were defined and labelled according to overarching goals of the integrated group or partners themselves. For example, Crooks et al., (\u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e) referred to their group as a collaborative, a small agile group of individuals, dedicated and responsive to one another needs. Shan et al., (\u003cspan class=\"CitationRef\"\u003e2012\u003c/span\u003e) equally described accountability measures taken in community partner selection, however partnership inclusivity remained at the forefront. Grounded in anticolonialism and indigenous health principles, Shan et al., (\u003cspan class=\"CitationRef\"\u003e2012\u003c/span\u003e) chose to refrain from using the term \u0026lsquo;collaborative\u0026rsquo;. Even among partners within the same study various terms were used dependent on perceived goals and desires. One hospital partner referred to their interaction with community services as a collaborative, when further analysis by Zhu et al. (\u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e) revealed the level of engagement was in fact cross-sector interaction, a unidirectional level of outreach. In addition, poor interorganizational governance between the health and community sectors was causal for group reorientation and labelling. Purcell \u0026amp; Kearns (\u003cspan class=\"CitationRef\"\u003e2012\u003c/span\u003e) demonstrated how the community sector can break ties with an organizational working group and refer to themselves as a \u0026lsquo;coalition\u0026rsquo; in effort to build their own capacity.\u003c/p\u003e\n\u003cp\u003eAttention, dedication, and alignment of \u003cem\u003einterorganizational governance\u003c/em\u003e played a significant role in the positive perspectives of stakeholders in community centered integrated care. The opportunity for all partners to meet regularly, co-design programs and share decision making allowed for greater understanding of capabilities within the group (Cocgnani et al., 2018; Crooks et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e; Middleton et al., \u003cspan class=\"CitationRef\"\u003e2013\u003c/span\u003e; Shan et al., \u003cspan class=\"CitationRef\"\u003e2012\u003c/span\u003e). Moreover, attention placed on the general SDOH within a community, rather than a narrow programmatic focus allowed stakeholders to unite through a common vision, act with honesty and value local, bottom-up experiences of health promotion (Cocgnani et al., 2018; Crooks et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e; Shan et al., \u003cspan class=\"CitationRef\"\u003e2012\u003c/span\u003e). Progress reports and annual work plans provided added support and direction within partnerships to create \u003cem\u003elearning organizations\u003c/em\u003e to advance collective research and program development (Crooks et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e; Lee et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e). Conversely, the exclusion of key working group partners from the outset fractured trust and momentum in advancing project goals (Purcell \u0026amp; Kearns, \u003cspan class=\"CitationRef\"\u003e2012\u003c/span\u003e; Shultz et al., 2001). Negative perspectives of stakeholders were found in studies suggested to be based in CBPR and consensus building but lacked attention to these efforts throughout (Connaughton-Espino \u0026amp; Reese, \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e; Schulz et al, \u003cspan class=\"CitationRef\"\u003e2001\u003c/span\u003e). Negative perspectives among stakeholders were also found in studies whose outcome presented as \u003cem\u003evalue creation for organization\u003c/em\u003e. Herein, a beneficial outcome for the organization is sought after verses overarching population health features. This demonstrated paralysation of community social capital and health equity, as well as disabling trust, at the hand of academic, health and municipal partners (Enard et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e; Purcell \u0026amp; Kearns, \u003cspan class=\"CitationRef\"\u003e2012\u003c/span\u003e; Schulz et al., \u003cspan class=\"CitationRef\"\u003e2001\u003c/span\u003e).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\n\u003ch2\u003eSystem Integration (macro-level)\u003c/h2\u003e\n\u003cp\u003eEqual to the importance of robust interorganizational governance in community centred integrated care, is diverse \u003cem\u003estakeholder management\u003c/em\u003e. Programs, partnerships, and collaborations that upheld commitment from diverse stakeholders were resoundingly positive through stakeholder perspectives. These initiatives included engagement from municipalities (Cocgnani et al., 2018; Crooks et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e; Shan et al., \u003cspan class=\"CitationRef\"\u003e2012\u003c/span\u003e), and public and private organizations (Lee et al, \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e; Provan et al., \u003cspan class=\"CitationRef\"\u003e2003\u003c/span\u003e; Zhu et al., \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e). Importantly, each study referenced above referred to community organization representatives as key stakeholders. The involvement of distant funding partners and government legislators did not necessarily equate to program longevity or positive experiences among project partners. This was particularly true when direct funding partners and those in decision making authority were not involved in proximal stakeholder management (Connaughton-Espino, \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e; Enard et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e; Shultz et al., 2001; van Dijk et al, \u003cspan class=\"CitationRef\"\u003e2016\u003c/span\u003e). Funding that was diversified and secured created opportunity for program partners to plan longitudinally, develop trust and cultivate relationships with each other and their communities (Cocgnani et al., 2018; Crooks et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e; Lee et al, \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e; Provan et al., \u003cspan class=\"CitationRef\"\u003e2003\u003c/span\u003e; Zhu et al., \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e\n\u003c/div\u003e\n\u003ch2\u003eProgrammatic Alignment And Leadership Style\u003c/h2\u003e\n\u003cp\u003eThe context in which programs are created directly sets them up for success or failure. Those designed to respond to gaps in care were often seen as bridging rather than building sustainable solutions. This is detailed through reliance on CHW\u0026rsquo;s in the context of deepening austerity measures (Skivington et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e), and competitive tender practices to appoint new partners in care, which limits foundational integrated care development (van Dijk et al., \u003cspan class=\"CitationRef\"\u003e2016\u003c/span\u003e). Programs that were created through existing structures and systems, governed by institutional polices, had a greater reach and opportunity to evolve through stakeholder acceptance and comfort (Crooks et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e, Lee et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e; Shan et al., \u003cspan class=\"CitationRef\"\u003e2012\u003c/span\u003e). Although diverse stakeholder representation was deemed beneficial at the proximal level in community centred integrated care, Middleton et al., (\u003cspan class=\"CitationRef\"\u003e2013\u003c/span\u003e) calls for a single leader to champion efforts. In this example, public health and local authorities worked \u0026lsquo;side by side\u0026rsquo;, while the community voice was absent in leadership representation. Conversely, Crooks et al., (\u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e) called for distributed leadership, that is emergent and context dependent. Reliance on trust and foundational relationships was seen as pivotal to enacting this leadership style, which requires shared project completion by partners in varying roles, also known as socially distributed cognition (Crooks et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\n\u003ch2\u003eFunctional Integration (macro-level)\u003c/h2\u003e\n\u003cp\u003eIndices of functional integration were found in 9/13 studies. A variety of \u003cem\u003ehuman resource management\u003c/em\u003e structures were found, where community partners or representatives were included in joint planning and hiring processes (Cocgnani et al., 2018; Crooks et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e; Lee et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e, Shan et al., \u003cspan class=\"CitationRef\"\u003e2012\u003c/span\u003e; van Dijk et al., \u003cspan class=\"CitationRef\"\u003e2016\u003c/span\u003e). Those that employed community organizations as a third party to complete outreach and engagement work had less favourable outcomes, and uniquely all stakeholders in these arrangements spoke to this power imbalance as projects progressed (Connaughton-Espino \u0026amp; Reese, \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e; Enard et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e; Purcell \u0026amp; Kearns, \u003cspan class=\"CitationRef\"\u003e2012\u003c/span\u003e; Shultz et al., 2001). Although few projects demonstrated \u003cem\u003eregular feedback and performance indicators\u003c/em\u003e (Crooks et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e; Lee et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e), recognition of their importance to conduct quality improvement and celebrate success was noted (Middleton et al., \u003cspan class=\"CitationRef\"\u003e2013\u003c/span\u003e; Zhu et al., \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e). Projects that had regular feedback mechanisms reported positive perspectives from stakeholders (Crooks et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e; Lee et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e), whereas the development of joint evaluative frameworks, with community partners, to address soft versus hard performance indicators was seen as a necessary endeavor to create neutral ground among cross-sector partnerships (Middleton et al., \u003cspan class=\"CitationRef\"\u003e2013\u003c/span\u003e; Zhu et al., \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e). Despite the complex and tailored approaches that integrated care requires, several studies called for a framework to guide professionals toward developing mutually agreed upon goals to sustain relationships in urban and rural cross-sector partnerships (Enard et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e; van Dijk et al., \u003cspan class=\"CitationRef\"\u003e2016\u003c/span\u003e; Zhu et al., \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\n\u003ch2\u003eNormative Integration (macro-level)\u003c/h2\u003e\n\u003cp\u003eAmong the studies, there was a direct relationship between the level of community engagement and the resulting perceptions of stakeholders. Specifically, the further along the continuum of community engagement, the more positive were stakeholders\u0026rsquo; perceptions of their integrated care experiences (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). Although normative integration was referred to explicitly in only one study (van Dijk et al., \u003cspan class=\"CitationRef\"\u003e2016\u003c/span\u003e), an abundance of shared stakeholder attributes, values and desires presented across the studies. The concept of \u003cem\u003etrust\u003c/em\u003e was found in 9/13 studies and was seen as a multilayered construct. Cicognani et al. (\u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e) found that trust was associated with health partnership performance, and tied to efficacy, commitment, and a sense of belonging within community. Similarly, deepening and building relationships lead to trust, and was present in all levels and systems of care integration (Crooks et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e; Lee et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e; Provan et al., \u003cspan class=\"CitationRef\"\u003e2003\u003c/span\u003e). Among all studies, trust was coveted but it was unachievable in some settings due to power inequities, lack of time or investment within partnerships (Connaughton-Espino \u0026amp; Reese, \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e; Enard et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e; Schultz et al., 2001; Skvington et al., 2018). Once trust was fractured, it was difficult to repair (Connaughton-Espino \u0026amp; Reese, \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e; Enard et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e; Purcell \u0026amp; Kearns, \u003cspan class=\"CitationRef\"\u003e2012\u003c/span\u003e; Schultz et al., 2001; van Dijk et al., \u003cspan class=\"CitationRef\"\u003e2016\u003c/span\u003e). This is a sentinel finding given the importance of creating a \u003cem\u003ecollective attitude\u003c/em\u003e and \u003cem\u003eshared vision\u003c/em\u003e at the beginning of a partnership to support momentum, longevity, and integration into existing partnerships (Crooks et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e; Shan et al., \u003cspan class=\"CitationRef\"\u003e2012\u003c/span\u003e). Several studies reviewed the importance of being flexible, reinventing roles as needed and \u003cem\u003etranscending domain perceptions\u003c/em\u003e (Crooks et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e; Lee et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e, Provan et al., \u003cspan class=\"CitationRef\"\u003e2003\u003c/span\u003e; Purcell \u0026amp; Kearns, \u003cspan class=\"CitationRef\"\u003e2012\u003c/span\u003e; van Dijk et al., \u003cspan class=\"CitationRef\"\u003e2016\u003c/span\u003e). Plausibility to transcend one\u0026rsquo;s professional domain perceptions comes with good governance, partnership security and \u003cem\u003evisionary leadership\u003c/em\u003e, however few studies identified such a leader (Crooks et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e; Lee et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e). Lastly, integrated care projects within studies were conducted between two \u0026ndash; eight years, two years being the average length of time. There does not appear to be a correlation between project duration, level of community engagement and stakeholder perception. All studies were enacted without a \u003cem\u003esense of urgency\u003c/em\u003e identified.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eStakeholder perspectives of cross-sector integrated care in relation to community engagement level\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eLevel of Community Engagement\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"6\" align=\"left\"\u003e\n\u003cp\u003ePositive perspectives\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eModerate perspectives\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"5\" align=\"left\"\u003e\n\u003cp\u003eNegative Perspectives\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCicognani et al.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCrooks et al.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLee et al.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eProvan et al.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eShan et al.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eZhu et al.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMiddleton et al.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSkivington et al.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eConnaughton-Espino et al.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEnard et al.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePurcell \u0026amp; Kearns\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSchultz et al.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eVan Dijk et al.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOutreach\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eConsultation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eInvolvement\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCollaboration\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eShared leadership\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe purpose of this integrative review was to identify what is known about the influence of community engagement on stakeholder perspectives involved in cross-sector integrated care initiatives. Thirteen studies were identified that explored this concept from North America, Europe, and the United Kingdom. Through this methodology and data analysis, new information has been uncovered which provides new insight and relevance for providers in health and social services, at the clinical, organizational and system level. Positive stakeholder perspectives were found in six studies, moderate or mixed stakeholder perspectives were found in two studies and negative stakeholder perspectives were found in five studies. All studies supported the client through a population health focus, yet only half the studies attempted to scale client care and address ongoing needs through micro, meso and macro system levels (Crooks et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Lee et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Provan et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2003\u003c/span\u003e; Shan et al., \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Van Dijk et al., \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Zhu et al., \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). According to several studies, the focus on clinical versus population health programming was detrimental through increased reliance on third party workers (CHW\u0026rsquo;s) to bridge notable gaps in care and serve as problem solvers with their unique interpersonal skill sets (Enard et al., 2020; Schulz et al., \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2001\u003c/span\u003e; Skivington et al., \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). This suggests that there may be merit in exploring nonclinical opportunities in integrated care, the structural and social determinants of health specific to communities and advancing social capital through health equity approaches.\u003c/p\u003e \u003cp\u003eFormalities established at the beginning of collaborative care partnerships are integral to create conditions of trust, conflict and efficacy that become resources or liabilities during continued efforts (Ansell \u0026amp; Gash, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2008\u003c/span\u003e). Several studies spoke to creating a shared vision from the outset of their collaboration, however when this was not followed through, it led to negative stakeholder experiences (Connaughton-Espino, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Middleton et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Shultz et al., 2001). This leads to question, who is at the table in these early conversations, and who is brought in as programs unfold? The importance of governance is as it relates to the perspectives of stakeholders within community-centred integrated care cannot be understated. Studies that established a level of commitment from the outset demonstrated resoundingly positive perspectives through community centred co-design (Cicogangi et al., 2018; Crooks et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Lee et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Shan et al., \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). Studies that involved less than five stakeholders were able to utilize and rely on a distributive leadership style (Crooks et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2018\u003c/span\u003e), however studies reflecting the multisectoral nature of integrated care, requested the emergence of one leader, to act as a facilitator (Middleton et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Zhu et al., 2021). This was seen as particularly important in new intersectoral partnerships, where relationships and trust have yet to be established (Connaughton-Espino \u0026amp; Reese, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Enard et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Schultz et al., 2001; Skvington et al., 2018).\u003c/p\u003e \u003cp\u003eThe opportunity for program partners to forge relationships, plan longitudinally and develop trust was also evident in studies that included committed and diverse stakeholder representation, municipal or region representation and funding security (Cicognani et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Crooks et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Lee et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Shan et al., \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). Considering the integral role that hospitals play in rural and urban health outcomes, the fact they were included in only two studies is a cause for greater reflection. This can be demonstrated by a sentiment offered by a community partner quoted in one study, \u0026lsquo;the hospital gets recognition, the community gets served\u0026rsquo; (Enard et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Herein lies the foundation of community-centred integrated care. The very inequities that integrated care is attempting to solve can be easily recreated in project work when inadequate attention is paid to power imbalances within partnerships and structures themselves (Connaughton-Espino \u0026amp; Reese, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Enard et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Middleton et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Purcell \u0026amp; Kearns, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Schultz et al., 2001; Skvington et al., 2018). Lastly, there is need to develop joint evaluative frameworks to assist with evaluation, share educational resources and training programs to support the institutionalization within cross-sector integrated care (Lee et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Middleton et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Zhu et al., 2021).\u003c/p\u003e\n\u003ch3\u003eImplications For Research And Theory\u003c/h3\u003e\n\u003cp\u003eOver the past three decades, integrated care has taken strides toward community health and social services models, improving quality of care using patient centred measures, and addressing underlying cultural attitudes and norms within specific populations (Evans et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). Yet, the reality of establishing collaborative interagency relationships with communities as partners is a challenging, long term and complex process (van Eyk \u0026amp; Baum, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e2002\u003c/span\u003e). Stakeholders typically define integrated care around patient needs (Crocker et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) and research tends to highlight perspectives of single stakeholder groups in analysis rather than joint evaluations. This review contributes to these findings and highlights the lack of hospital perspectives as a key partner in collaborative care. Resultingly, there is a need to explore the concept of power inequity across hospital and community integrated care initiatives in greater detail, and how power influences proximal and distal relationships, capabilities, motivations, and opportunities for collaboration.\u003c/p\u003e \u003cp\u003eFindings from this integrative review support tenets of social cognitive theory (SCT), which considers the unique way individuals acquire and maintain behaviour within social environments (Bandura, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2005\u003c/span\u003e). The notion of trust amongst stakeholders as a recurring theme in this review highlights the merit of SCT\u0026rsquo;s concept of self-efficacy. Trust is integral to building efficacy and has the potential to generate social capital within communities grounded in these constructs (Foley \u0026amp; Edwards, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e1996\u003c/span\u003e). Findings from this review also contribute to the theory of mental models, as psychological representations consisting of knowledge and beliefs which enable action and interpretation in a specific domain (Mohammed et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). Less is known within this theory about how important beliefs/perspectives converge and diverge across stakeholder groups and influence inter-organizational relations. Therefore, shared stakeholder perspectives explored within this review, contribute to the literature supporting normative integration as pivotal in co-creating models of care.\u003c/p\u003e\n\u003ch3\u003eImplications For Policy And Practice\u003c/h3\u003e\n\u003cp\u003eHealth systems globally are reorienting services to achieve quadruple aim outcomes (Bachynsky, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Perspectives from stakeholders in this review support calls to promote collaborative governance models that are situated in trust, collaborative commitment, and a facilitative leadership style. The influence that policy makers have on this work is immense. In this regard, policy makers are encouraged to honour enduring collaborative governance structures among health and social service organizations, which is truly essential in the establishment of trust, equity, and sustainable integrated care practice (Gordon et al., 2020).\u003c/p\u003e \u003cp\u003eConsidering that the benefits and necessity of collaborative care are increasingly recognized across health systems, a significant opportunity presents for hospitals, community health and social service organizations to devise collective strategies for partnership. Creation of joint evaluative frameworks and collaborative training programs, with community partners, to support knowledge transfer and establish leadership within community-centred integrated care are needed (Barraclough et al., 2021). Organizations and institutions involved in integrated care would benefit in viewing themselves as a complex and adaptive system, with agility and readiness to respond to local circumstance, through reliance on emergent ways of thinking and sense making (Edgren \u0026amp; Barnard, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). Moreover, when organizations recognize their role as a collective learning partner, effective cross-sector partnerships emerge (Montigny et al., 2016). Despite well intentions of CBPR to develop equitable partnership between academic researchers and community members, review findings demonstrate this is not always the case. The foundation of community-centred integrated care lies in recognizing where unearned advantage and disadvantage are placed within social structures. Those involved in cross-sector care need to recognize their positions of privilege and work in solidarity to collectively act against systems of inequity (Nixon, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Organizations and instructions embarking on cross-sector integrated care would benefit in exploring principles of critical allyship with community partners and acknowledge the possibility of institutionalized tension before the collaboration process begins (Gordon et al., 2020).\u003c/p\u003e\n\u003ch3\u003eLimitations And Strengths\u003c/h3\u003e\n\u003cp\u003eOne of the strengths of this study is the unique combination of the RMIC conceptual framework, taxonomy and Community Engagement Continuum used for coding and analysis. The widespread use and recognition of the RMIC as validated framework adds value to the expanding body of research on normative integration included in this study and current literature. Limitations of this study include that data extraction was completed by one researcher, however the coding review process through matrices was systematic and repeated three times in sequence. In addition, only English language studies were reviewed. Another limitation of this study is that all 13 studies analyzed were predominately written from an academic perspective. The academic author of one study also identified as a community member, however given the lack of community or professional authorship, hard conclusions regarding stakeholder\u0026rsquo;s perspectives of community-centered integrated care is challenging to deduce. This could be a topic for additional research.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis review identified the collective influence community engagement has on stakeholder perspectives involved in cross-sector integrated care. Positive stakeholder perspectives were noted to a greater degree when the community is engaged in a collaborative sense or when shared leadership ensues. Diverse stakeholder management, government and political support, secure funding structures, collective governance and facilitative leadership were seen to foster the trust and build relationships necessary for positive stakeholder experiences in cross-sector integrated care. Community-centred integrated care requires a multifaceted approach, situated in critical allyship, to advance population health outcomes through research, education, policy, and practice. This review demonstrates the need to further evaluate the roles that hospitals play in micro, meso and macro level community-centred integrated care, and their impacts and perspectives as integrated care partners. The application of the Rainbow Model of Integrated Care within this paper, provides a foundation to explore the experience of community-centred integrated care among diverse stakeholders, in novel and established programs. Such findings will continue to advance our understanding of core tenants needed to enact equitable community-centred integrated care to promote community health and well-being.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank Mikaela Mitchell (University of Toronto Libraries) for her expert assistance in supporting the search strategy as well as Sioban Nelson (University of Toronto) and Jennifer Price (Women\u0026rsquo;s College Hospital) for their contributions in guiding the conceptualization and review of this manuscript. We also thank the peer reviewers for their constructive comments on the original manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eV.W. contributed to data collection, analysis, and interpretation and drafting the manuscript.\u003c/p\u003e\n\u003cp\u003eV.W., K.M., and W.B. contributed to data interpretation and editing the article.\u003c/p\u003e\n\u003cp\u003eAll authors approved the final version of the submitted manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone to declare\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAlderwick, H., \u0026amp; Gottlieb, L.M. (2019). Meanings and misunderstandings: a social determinants lexicon for health care systems. \u003cem\u003eMillbank Quarterly, 97\u003c/em\u003e(2), 407-419. DOI: 10.1111/1468-0009.12390\u003c/li\u003e\n \u003cli\u003eAlderwice, H., Hutchings, A., Briggs, A., \u0026amp; Mays, N. (2021). The impacts of collaboration between local health care and non-health care organizations and factors shaping how they work: a systematic review of reviews. \u003cem\u003eBMC Public Health, 21\u003c/em\u003e, 753-769. DOI: 10.1186/s12889-021-10630-1\u003c/li\u003e\n \u003cli\u003eAnsell C, Gash A. (2008). Collaborative Governance in Theory and Practice. \u003cem\u003eJournal of Public Administration Research and Theory\u003c/em\u003e, \u003cem\u003e18\u003c/em\u003e(4): 543\u0026ndash;571. doi.org/10.1093/jopart/mum032\u003c/li\u003e\n \u003cli\u003eBachynsky, N. (2020). Implications for policy: the triple aim, quadruple aim and interprofessional collaboration. \u003cem\u003eNursing Forum, 55\u003c/em\u003e, 54-64. DOI: 10.1111/nuf.12382\u003c/li\u003e\n \u003cli\u003eBarraclough F, Smith-Merry J, Stein V, Pit S. Workforce Development in Integrated Care: A Scoping Review. \u003cem\u003eInternational Journal of Integrated Care, 21\u003c/em\u003e(4): 23-37. doi.org/10.5334/ijic.6004\u003c/li\u003e\n \u003cli\u003eBandura, A. (2005). The evolution of social cognitive theory. In K.G. Smith \u0026amp; M.A. Hitts (Eds). \u003cem\u003eGreat Minds in Management\u003c/em\u003e. (pp 9-35). Oxford: Oxford University Press. Retrieved from http://www.uky.edu/~eushe2/BanduraPubs/Bandura2005.pdf\u003c/li\u003e\n \u003cli\u003eBreton, M, et al. Multiple Perspectives Analysis of the Implementation of an Integrated Care Model for Older Adults in Quebec. \u003cem\u003eInternational Journal of Integrated Care, 19\u003c/em\u003e(4), 6-19. doi.org/10.5334/ijic.4634\u003c/li\u003e\n \u003cli\u003eBurton, G., Thomas, J., O\u0026rsquo;Mara-Eves, A., Jamal, F., Oliver, S., \u0026amp; Kavanagh, J. (2017). Narratives of community engagement: a systematic review-derived conceptual framework for public health interventions. \u003cem\u003eBMC Public Health, 17\u003c/em\u003e, 944-959. DOI: 10.1186/s12889-017-4958-4\u003c/li\u003e\n \u003cli\u003eButterfoss, F.D, \u0026amp; Kegler, M.C. (2002). Toward a comprehensive understanding of community coalitions: moving from practice to theory. In: DiClemente R, Crosby R, Kegler MC, eds. \u003cem\u003eEmerging theories in health promotion practice and research, 2\u003csup\u003end\u003c/sup\u003e ed\u003c/em\u003e. (pp. 157-193). San Francisco, CA: Jossey-Bass. https://soh.iums.ac.ir/uploads/emerging_theories.pdf\u003c/li\u003e\n \u003cli\u003eCicognani, E., Albansi, C., Valletta, L., \u0026amp; Pratti, G. (2018). Quality collaboration within health promotion partnerships: impact on sense of community, empowerment and perceived projects\u0026rsquo; outcomes. \u003cem\u003eJournal of Community Psychology, 48\u003c/em\u003e, 323-336. DOI: 10.1002/jcop.22254\u003c/li\u003e\n \u003cli\u003eClinical and Translational Science Awards Consortium. (2011). \u003cem\u003ePrinciples of community engagement\u003c/em\u003e. (2\u003csup\u003end\u003c/sup\u003e Ed.). NIH Publication No. 11-7782. Bethesda, MD: National Institutes of Health. Retrieved from https://www.atsdr.cdc.gov/communityengagement/index.html\u003c/li\u003e\n \u003cli\u003eConnaughton-Espino, T., \u0026amp; Reese, B.M. (2021). North Carolina youth connected: lessons learned in engaging community leaders in preventing teen pregnancy. \u003cem\u003eProgress in Community Health Partnerships: Research, Education, and Action, 15\u003c/em\u003e(4), 517-524. doi.org/10.1353/cpr.2021.0064\u003c/li\u003e\n \u003cli\u003eCrocker, H., Kelly, L., Harlock, J., Fitzpatrick, R., \u0026amp; Peters, M. (2020). Measuring the benefits of the integration of health and social care: qualitative interviews with professional stakeholders and patient representatives\u003cem\u003e. BMC Health Services Research, 20\u003c/em\u003e, 515-524. doi.org/10.1186/s12913-020-05374-4\u003c/li\u003e\n \u003cli\u003eCronin, C., Franz, B., \u0026amp; Garlington, S. (2021). Population health partnerships and social capital: facilitating hospital-community partnerships. \u003cem\u003eSMM-Population Health, 13,\u0026nbsp;\u003c/em\u003e1-7. doi.org/10.1016/j.ssmph.2021.100739\u003c/li\u003e\n \u003cli\u003eCrooks, C.V., Exner-Cortens, D., Siebold, W., Moore, K., Grassgreen, L, Owen, P., Rausch, A., \u0026amp; Rosier, M. (2018). The role of relationships in collaborative partnership success: lessons from the Alaska Fourth R project. \u003cem\u003eEvaluation and Program Planning, 67\u003c/em\u003e, 97-104. doi.org/10.1016/j.evalprogram.2017.12.007\u003c/li\u003e\n \u003cli\u003ede Montigny, J.G., Desjardin, S., Bouchard, L. (2017). The fundamentals for cross-sector collaboration for social change to promote population health. \u003cem\u003eGlobal Health Promotion, 26\u003c/em\u003e(2), 41-50. DOI: 10.11/77/1757975917714036\u003c/li\u003e\n \u003cli\u003eDykes, P.C., Carroll, D.L., Hurley, A.C., Benoit, A., \u0026amp; Middleton, B. (2009). Why do patients in acute care hospitals fall? Can falls be prevented? \u003cem\u003eJournal of Nursing Administration,\u003c/em\u003e \u003cem\u003e39\u003c/em\u003e(6), 299-304. doi:10.1097/NNA.0b013e3181a7788a.\u003c/li\u003e\n \u003cli\u003eEdgren, L., \u0026amp; Barnard, K. (2012). Complex adaptive systems for management of integrated care. \u003cem\u003eLeadership in Health Services, 25\u003c/em\u003e(1), 39-51. DOI: 10.1108/17511871211198061\u003c/li\u003e\n \u003cli\u003eEnard, K.R., Nicks, S.E., Campbell, B.A., \u0026amp; McClure, S.M. (2021). In pursuit of equity: partnering to improve breast and prostate cancer outcomes among African Americans. \u003cem\u003eCancer Causes \u0026amp; Control, 32\u003c/em\u003e, 473-482. doi.org/10/1007/s10552-021-01412-6\u003c/li\u003e\n \u003cli\u003eEvans, J.M., Baker G.R., Bertha, W., \u0026amp; Barnsely, J. (2013). The evolution of integrated care strategies. \u003cem\u003eAdvances in Health Care Management, 15\u003c/em\u003e, 125-161. doi:10.1108/S1474-8231(2013)0000015011\u003c/li\u003e\n \u003cli\u003eEvans, J.M., Baker G.R., Bertha, W., \u0026amp; Barnsely, J. (2014). A cognitive perspective on health systems integration: results of a Canadian delphi study. \u003cem\u003eBMC Health Service Research, 14\u003c/em\u003e, 222-235. http://www.biomedcentral.com/1472-6963/14/222\u003c/li\u003e\n \u003cli\u003eFarmanova, E., Baker, G.R., Cohen, D. (2019). Combining integration of care and a population health approach: a scoping review of redesign strategies and interventions, and their Impact. \u003cem\u003eInternational Journal of Integrated Care, 19\u003c/em\u003e(2), 5-30. doi.org/10.5334/ijic.4197\u003c/li\u003e\n \u003cli\u003eFoley, M.W., \u0026amp; Edwards, B. (1996). The Paradox of Civil Society. \u003cem\u003eJournal of Democracy\u003c/em\u003e \u003cem\u003e7\u003c/em\u003e(3), 38-52. doi:10.1353/jod.1996.0048.\u003c/li\u003e\n \u003cli\u003eGordon, D., McKay, S., Marchildon, G., Bhatia, R.S., \u0026amp; Shaw, J. Collaborative governance for integrated care: insights from a policy stakeholder dialogue. \u003cem\u003eInternational Journal of Integrated Care, 20\u003c/em\u003e(1), 3-14. doi.org/10.5334/ijic.4684\u003c/li\u003e\n \u003cli\u003eGrant, M, G., \u0026amp; Booth, A. (2009). A typology of reviews: an analysis of 14 review types and associates methodologies. \u003cem\u003eHealth information and libraries journal, 26\u003c/em\u003e, 91-108. DOI: 10.1111/j.14711842.2009.00848.x\u003c/li\u003e\n \u003cli\u003eGriese, L., Berens, E. M., Nowak, P., Pelikan, J. M., \u0026amp; Schaeffer, D. (2020). Challenges in navigating the health care system: development of an instrument measuring navigation health literacy. \u003cem\u003eInternational journal of environmental research and public health\u003c/em\u003e, \u003cem\u003e17\u003c/em\u003e(16), 5731-5748. doi.org/10.3390/ijerph17165731\u003c/li\u003e\n \u003cli\u003eHealth Quality Ontario. (2020). \u003cem\u003eTransitions between home and hospital.\u003c/em\u003e https://www.hqontario.ca/Portals/0/documents/evidence/quality-standards/qs-transitions-between-hospital-and-home-quality-standard-en.pdf\u003c/li\u003e\n \u003cli\u003eHong, Q.N., Pluye, P., Fàbregues, S., Bartlett, G., Boardman, F., Cargo, M., Dagenais., P., Gagnon M.P., Griffiths, F., Nicolau, B., O\u0026rsquo;Cathain, A., Rousseau, M.C., \u0026amp; Vedel, I. (2008). \u003cem\u003eMixed Methods Appraisal Tool (MMAT).\u0026nbsp;\u003c/em\u003ehttp://mixedmethodsappraisaltoolpublic.pbworks.com/w/file/fetch/127916259/MMAT_2018_criteria-manual_2018-08-01_ENG.pdf\u003c/li\u003e\n \u003cli\u003eJohns, S. (2010). Early childhood service development and intersectoral collaboration in rural Australia. \u003cem\u003eAustralian Journal of Primary Health Care, 16\u003c/em\u003e, 40-46. DOI: 10.1071/PY09050\u003c/li\u003e\n \u003cli\u003eLee, R.E., Parker, N.H., Hallet, A.M., Kao, D., Modelska, M.J., Rifai, H., Soltero, E.G., \u0026amp; O\u0026rsquo;Connor, D.P. (2021). Stakeholder perspectives and sustainability of an integrated care model for the prevention and management of obesity: the childhood obesity research demonstration project. \u003cem\u003eTheory of Behavioural Medicine, 11\u003c/em\u003e, 393-407. doi: 10.1093/tbm/ibaa058\u003c/li\u003e\n \u003cli\u003eMays, G.P., Mamaril, C.B., \u0026amp; Timsina, L.R. (2016). Preventable death rates fell where communities expanded population health activities through multisector networks. \u003cem\u003eHealth Affairs, 35\u003c/em\u003e, 2005\u0026ndash;2013. DOI: 10.1377/hlthaff.2016.0848\u003c/li\u003e\n \u003cli\u003eMiddleton, G, Henderson, H, \u0026amp; Evans, D. (2013). Implementing a community-based obesity prevention programme: experiences of stakeholders in the north east of England. \u003cem\u003eHealth Promotion International, 29\u003c/em\u003e(2), 201-211. doi: 10.1093/heapro/das072\u003c/li\u003e\n \u003cli\u003eMilligan, C., \u0026amp; Berta, W. (2021). Reimagining community relationships for organizational learning: a scoping review with implication for a learning health system. \u003cem\u003eBMC Health Services Research, 21\u003c/em\u003e, 603-613. doi.org/10.1186/s12913-021-06640-9\u003c/li\u003e\n \u003cli\u003eMirsa, V., Sedig, K., Dixon, D., \u0026amp; Sibbald, S. (2020). Commentary. \u003cem\u003eCanadian Family Physician, 66\u003c/em\u003e, 399-403. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7292521/pdf/0660399.pdf\u003c/li\u003e\n \u003cli\u003eMohammed, S., Ferzandi, L., \u0026amp; Hamilton, K. (2010). Metaphor no more: a 15-year review of the team mental model construct. \u003cem\u003eJournal of Air Waste Management Association, 36\u003c/em\u003e(4), 876\u0026ndash;910. doi.org/10.1177/0149206309356804\u003c/li\u003e\n \u003cli\u003eMoher, D., Liberati, A., Telzlaff, J., Altman, D. G., \u0026amp; the PRISMA Group (2009). Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. \u003cem\u003eAnnals of Internal Medicine, 151\u003c/em\u003e(4), 264\u0026ndash; 269. doi.org/10.7326/0003-4819-151-4-200908180-00135\u003c/li\u003e\n \u003cli\u003eMOHLTC (Ministry of Health and Long Term Care). (2015). Bringing Care Home. https://health.gov.on.ca/en/public/programs/lhin/docs/hcc_report.pdf\u003c/li\u003e\n \u003cli\u003eMontigny, J.G., Desjardins, S., \u0026amp; Bouchard, L. (2017). The fundamentals of cross-sector collaboration for social change to promote population health. \u003cem\u003eGlobal Health Promotion, 26\u003c/em\u003e(2), 41-50. DOI: 10.1177/1757975917714036\u003c/li\u003e\n \u003cli\u003eNixon, S. (2019). The coin model of privilege and critical allyship: implications for health. \u003cem\u003eBMC Public Health, 19\u003c/em\u003e, 1637-1650. doi.org/10.1186/s12889-019-7884-9\u003c/li\u003e\n \u003cli\u003eNowel, L.S., Norris, J, M., Deborah E.W., \u0026amp; Moules, N.J. (2017). Thematic analysis: striving to meet the trustworthiness criteria. \u003cem\u003eInternational Journal of Qualitative Methods, 16\u003c/em\u003e, 1-13. Doi: 10.1177/1609406917733847\u003c/li\u003e\n \u003cli\u003ePfaff, K., Baxter, P., Jack, S., \u0026amp; Ploeg, J. (2014). An integrative review of the factors influencing new graduate nurse engagement in inter-professional collaboration. \u003cem\u003eJournal of Advanced Nursing, 70\u003c/em\u003e, 4\u0026ndash;20. \u003cstrong\u003edoi.org/10.1111/jan.12195\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003ePowell, D.G., Williams, A.M., Larsen K., Perkins, D., Roland, M., \u0026amp; Harris, M.F. (2008). Coordinating primary health care: an analysis of the outcomes of a systematic review. \u003cem\u003eMedical Journal of Australia, 188\u003c/em\u003e(8), 65-8. doi: 10.5694/j.1326-5377.2008.tb01748.x\u003c/li\u003e\n \u003cli\u003eProvan, K.G., Nakama, L., Veazie, M.A., Teufel-Shone, N.I., \u0026amp; Huddleston, C. (2003). Building community capacity around chronic disease service through collaborative interorganizational network. \u003cem\u003eHealth Education and Behavior, 30(\u003c/em\u003e6), 646-662. DOI: 10.1177/10901981032255366\u003c/li\u003e\n \u003cli\u003ePurcell, L., \u0026amp; Kearns, N. (2012). Impacts of an HIA on inter-agency and inter-sectoral partnerships and community participation: lessons from a local level HIA in the Republic of Ireland. \u003cem\u003eHealth Promotion International, 28(\u003c/em\u003e4), 522-532. doi: 10.1093/heapro/das032\u003c/li\u003e\n \u003cli\u003eRoussos, S.T., \u0026amp; Fawcett, S.B. (2000). A review of collaborative partnerships as a strategy for improving community health. \u003cem\u003eAnnual Review Public Health, 21\u003c/em\u003e, 369-402. doi: 10.1146/annurev.publhealth.21.1.369.\u003c/li\u003e\n \u003cli\u003eSchulz, A.J., Israel, B.A., Parker, E.A., Lockett, M., Hill, Y., \u0026amp; Rochelle, W. (2001). The east side village health worker partnership: integrating research with action to reduce health disparities. \u003cem\u003ePublic Health Reports, 116\u003c/em\u003e, 548-557. DOI: 10.1093/phr/116.6.548\u003c/li\u003e\n \u003cli\u003eShahzad, M., Upshur, R., Donnelly, P. Bharmal, A., Wei, X., Feng, P., \u0026amp; Brown, A.D\u003cem\u003e.\u003c/em\u003e (2019). A population-based approach to integrated healthcare delivery: a scoping review of clinical care and public health collaboration. \u003cem\u003eBMC Public Health\u003c/em\u003e, \u003cem\u003e19\u003c/em\u003e, 708-723. doi.org/10.1186/s12889-019-7002-z\u003c/li\u003e\n \u003cli\u003eShan, H., Muhajarine, N., Lopston, K., \u0026amp; Jeffery, B. (2012). Building social capital as a pathway to success: community development practices of an early childhood intervention program in Canada. \u003cem\u003eHealth Promotion International, 2\u003c/em\u003e, 244-255. DOI: 10.1093/heapro/das063\u003c/li\u003e\n \u003cli\u003eSkivington, K., Smith, M., Rui Chng, N., Mackenzie, M., Wyke, S., \u0026amp; Mercer, S.W. (2018). Delivering a primary-care based social prescribing initiative: a qualitative study of the benefits and challenges. \u003cem\u003eBritish Journal of General Practice, 68\u003c/em\u003e(672), 487-494. DOI: 10.3399/bjgp18X696617\u003c/li\u003e\n \u003cli\u003eThe Commonwealth Fund. (2019). \u003cem\u003eInternational health care system profiles: what is being done to promote delivery system integration and care coordination?\u0026nbsp;\u003c/em\u003ehttps://international.common wealthfund.org/features/integration\u003c/li\u003e\n \u003cli\u003eUittenbroek, R.J., Kremer, H.P., Spoorenberg, S.L., Reijneveld, S.A., \u0026amp; Wynia, K. (2017). Integrated care for older adults improves perceived quality of care: results of a randomized controlled trial of embrace. \u003cem\u003eJournal of General Internal Medicine\u003c/em\u003e, \u003cem\u003e32\u003c/em\u003e(5), 516\u0026ndash;23. DOI: 10.1007/s11606-016-3742-y\u003c/li\u003e\n \u003cli\u003eUN (United Nations).(2015). \u003cem\u003ePartnerships for sustainable development goals: a legacy review towards realizing the 2030 Agenda\u003c/em\u003e. https://sustainabledevelopment.un.org/content/documents/2257Partnerships%20for%2 0SDGs%20-%20a%20review%20web.pdf\u003c/li\u003e\n \u003cli\u003eValentijn, P.P., Schepman, S.M., Opheij, W., \u0026amp; Bruijnzeels, M.A. (2013). Understanding integrated care: a comprehensive conceptual framework based on the integrative functions of primary care. \u003cem\u003eInternational Journal of Integrated Care, 13\u003c/em\u003e, 1-12. doi: 10.5334/ijic.886\u003c/li\u003e\n \u003cli\u003eValentijn, P.P., Vrijhoef, H.J.M., Ruwaard, D, Boesveld, Arends, R, Y., \u0026amp; Bruijnzeels, M.A. (2015). Towards an international taxonomy of integrated primary care: a delphi consensus approach. \u003cem\u003eBMC Family Practice, 16\u003c/em\u003e, 64-79. DOI: 10.1186/s12875-015-0278-x\u003c/li\u003e\n \u003cli\u003evan Dijk, H.M., Cramm, J.M., \u0026amp; Nieboer, A.P. (2016). How to build an integrated neighbourhood approach to support community-dwelling older people. \u003cem\u003eInternational Journal of Integrated Care, 16\u003c/em\u003e(2), 4-19. doi.org/10.5334/ijic.1596\u003c/li\u003e\n \u003cli\u003evan Eyk, H., \u0026amp; Baum, F. (2002). Learning about interagency collaboration: trialling collaborative projects between hospital and community health services. \u003cem\u003eHealth and Social care in the Community, 10\u003c/em\u003e(4), 262-269. DOI: 10.1046/j.1365-2534.2002.00369.x\u003c/li\u003e\n \u003cli\u003eVangen, S., Hayes, J.P., \u0026amp; Cornforth, C. (2015). Governing cross-sector, inter-organizational collaborations. \u003cem\u003ePublic Management Review, 17\u003c/em\u003e, 1237\u0026ndash;1260. doi.org/10.1080/14719037.2014.903658\u003c/li\u003e\n \u003cli\u003eWhittemore, R., \u0026amp; Knafl, K. (2005). The integrative review: updated methodology. \u003cem\u003eJournal of Advanced Nursing, 52\u003c/em\u003e(5), 546\u0026ndash;553. \u003cstrong\u003edoi.org/10.1111/j.1365-2648.2005.03621.x\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003eWHO (World Health Organization).(2012). \u003cem\u003eHealth promotion: the first international conference on health promotion, 1986\u003c/em\u003e. Retrieved April 10, 2022, from https://www.who.int/teams/health-promotion/enhanced-wellbeing/first-global-conference\u003c/li\u003e\n \u003cli\u003eZhu, X., Weigel, P., Baloh, J., Nataliansyah M., Gunn, N., \u0026amp; Mueller, K. (2019). Mobilising cross-sector collaborations to improve population health in US rural communities: a qualitative study. \u003cem\u003eBMJ Open, 9\u003c/em\u003e, 1-8. doi: 10.1136/bmjopen-2019-030983\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"integrated care, cross-sector collaboration, community engagement ","lastPublishedDoi":"10.21203/rs.3.rs-2148586/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2148586/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eCommunity engagement represents a highly relevant way to integrate care across sectors and address social and structural determinants of health with populations. Yet, advancement of integrated care remains a challenge, particularly across health and social service organizations. Situating social cognition as a key element of integrated care, this paper explores the act community engagement within cross-sector integrated care.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eAn integrative review was conducted to determine what is known about the influence of community engagement on stakeholder perspectives in cross-sector integrated care, and to contribute to a more comprehensive evidence base for building and operationalizing equitable integrated care. In March 2022, four data bases were systematically searched, applying no date limits, for English language articles that described community engagement in relation to integrated care and resulting stakeholder perspectives. Using matrices, numerous variables were extracted and synthesized using thematic analysis derived from the Rainbow Model of Integrated Care and a continuum of community engagement.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eIn total, 13 studies were included in this analysis. Two studies included the hospital as a partner, and the rest were a mix of public, private health and social service sectors. Positive stakeholder perspectives (N\u0026thinsp;=\u0026thinsp;6) were found in studies that were consultative or collaborative, and led with social capital, shared reciprocity, and trust. Moderate and negative perspectives (N\u0026thinsp;=\u0026thinsp;7) were found in studies that led with a utilitarian stance and lacked collective leadership, governance, longitudinal planning, and joint evaluations.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThis review makes a singular contribution to cross-sector integrated care literature, utilizing perspectives from health and social service organizations to map what is known about the influence of community engagement on cross-sector integrative care. Perspectives from this review support calls for additional integrative care research exploring community-hospital relationships, and how power dynamics influence proximal and distal relationships, capabilities, motivations, and opportunities for collaboration.\u003c/p\u003e","manuscriptTitle":"The influence of community engagement on stakeholder perspectives in cross-sector integrated care: an integrative review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-01-04 14:54:51","doi":"10.21203/rs.3.rs-2148586/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2023-09-05T06:27:43+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-09-04T05:02:05+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2022-12-30T19:22:58+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2022-10-09T19:22:40+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8966b6ae-1d99-4179-aad1-97258deee169","owner":[],"postedDate":"January 4th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-07-13T12:24:53+00:00","versionOfRecord":[],"versionCreatedAt":"2023-01-04 14:54:51","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-2148586","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2148586","identity":"rs-2148586","version":["v1"]},"buildId":"WrCJVZZCHTDjtuVLN7oU0","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}