The effects of an intervention program for promoting interorganizational network building between multidisciplinary agencies and community-based organizations: a cluster trial in Japan

The growth of medical and nursing care costs has been recognized as a social problem in Japan today because of its aging population, which is aging more rapidly than other nations. It is apparent that a single health and welfare agency cannot address this issue and that various kinds of organizations must work together. Strengthening interorganizational collaboration in the community to leverage both social and material resources for problem solving has become an increasingly valuable strategy to improve public health in recent years [1, 2]. An interorganizational network can enhance collaborative problem solving by pooling knowledge and insights, sharing resources, and seeking common solutions. Other major benefits of collaboration include the ability to deliver services more efficiently and effectively by minimizing duplication and providing services that meet the multiple needs of clients; the potential to maximize power and influence by combining forces; and the shared responsibility across organizations for complex or controversial issues [3–7]. A positive attitude toward collaboration, mutual shared goals, regular funding, and resources such as staff, time and expertise to maintain the network are other factors associated with fostering organizational networks [3, 8, 9]. These factors have important implications when evaluating the current coalitions or alliances and when discussing improvements in the present systems. In reality an intervention strategy to foster interorganizational networks in the community is needed, but has yet to be devised.

Japan has community comprehensive support centers (CCSCs), which function as hubs for the provision of healthcare and welfare for the elderly in the community. These centers were established in 2006 in response to the rapidly aging population throughout the country. They are multidisciplinary organizations in which three professions (public health nurses (or registered nurses), certified social workers and care managers) work together to provide support to the elderly. One important function of CCSCs is to build an organizational network with community-based organizations (CBOs). Local residents, rather than professionals, run these CBOs and they are expected to provide informal, voluntary and practical services for the elderly. CBOs are, for example, neighborhood associations and district welfare commissions. CCSCs and CBOs often share information about the elderly who need to be looked after or supported, and discuss issues in community support through the organizational networks. CCSCs are expected to connect the elderly to these CBOs and then share with them the provision of the care to the elderly. However, staff in CCSCs have found it difficult to build networks with CBOs and wanted to know how to form such networks because they had little knowledge or experience in network building with CBOs [10].

Against such a background, we developed an intervention program for staff of the CCSCs to promote interorganizational network building between those multidisciplinary agencies and CBOs [10]. This program, based on Social Cognitive Theory (SCT) [11–13], aimed to enhance recognition of the importance of networking, to provide networking skills development, and to encourage network building with CBOs. SCT has provided a foundation for many intervention programs. The theoretical concept is reciprocal determinism, which maintains that there is constant interaction among personal (including cognition), behavioral and environmental factors [11]. For example, as the recognition and the motivation of an individual in the CCSC for interorganizational network building with CBOs increases, he/she will engage positively in the work of network building. This can also motivate the other staff in the same CCSC to get involved in that work, and as a result, the organizational environment and system of the CCSC will change. Therefore, the study focused on knowledge of and attitude toward interorganizational network building with CBOs (a personal factor), involvement in interorganizational network building with CBOs, such as negotiation with CBOs and provision of joint care (a behavioral factor) at an individual level, and enhancement of momentum for network building with CBOs by the entire CCSC, such as frequent staff meetings concerning network building in the organization (an environmental factor at the organizational level).

The purpose of this study was to examine the effects of the intervention program provided for members of CCSCs. We proposed two hypotheses. First, the attendees at the program will experience a significant improvement in recognition of the value of building networks with CBOs and increased involvement in the work of network building with CBOs in comparison with non-attendees (individual personal and behavioral factors). Second, the entire staff of the CCSC to which the attendee at the program belonged will also experience the same advantages to a significant degree in comparison with the staff of a CCSC without an attendee (an organizational environmental factor). In this study we defined interorganizational network building between the CCSC and the CBOs as follows: to build any formal and organization-conscious connection or relationship with CBO members. This excluded any informal and personal connections or relationships.

From our results, we concluded that the intervention led to a significant and positive effect for individual participants in terms of interorganizational network building between the multidisciplinary agencies and CBOs. The scores regarding the recognition of the knowledge and skills required for network building with CBOs for program attendees increased significantly compared to those for non-attendees in the intervention group and the control group. This was substantially greater among attendees compared with those who did not attend the program. Our previous study showed that CCSC staff felt they had little opportunity to learn exactly how to build an interorganizational network with CBOs [10]. The importance of having expertise in maintaining collaborative interorganizational networks has been suggested in previous research [1]. The program we presented followed the developmental model for organizational collaborative relationships proposed by Florin et al. [15], and the attendees were able to learn the essential steps in building an interorganizational network with CBOs. This contributed to an increase in knowledge and skills related to interorganizational network building with CBOs.

Another outcome of the recognition of importance of building networks with CBOs on the cognitive dimension had ceiling effects at baseline scores. Therefore, we could not confirm the positive effect of this outcome. The other outcome of recognition of ease of working through networking with CBOs also had a high score at baseline already. The improvement of these outcomes must be measured in a future study.

In an additional analysis after dividing the participants into two groups according to baseline outcome scores, we found a clearly significant effect, particularly on program attendees who had a lower baseline score, for recognition of knowledge and skills. This indicates that attendees of the program, who at baseline felt deficient in this area, considered attendance had increased their knowledge and skills in building an interorganizational network. Similarly, the attendees of the program with lower baseline scores on recognition of the importance of building an interorganizational network with CBOs came to recognize the importance of this after the intervention to a greater degree than those who did not attend. These two outcomes correspond to behavioral capability and expectancy, which are constructs of the SCT [11–13]. The attendees could obtain knowledge and skills in relation to a behavior and expect that network building with CBOs was likely to be improved by participating in the program. The additional analyses showed that an advantage of this intervention program would be raising the level of the recognition of the importance of building interorganizational networks with CBOs as well as recognition of the knowledge of skills required to do so. This outcome could be expected particularly among the program attendees who had lower baseline scores for these outcomes.

However, there was no significant difference in the behavioral variable among the three groups. No positive effects of the program on the overall intervention group compared with the control group were found in contrast to our hypothesis. The lack of, or otherwise modest, effects of the intervention on the hypothesized outcomes may be explained in several ways. It may be that an intervention of a longer duration is needed to generate greater behavioral and environmental changes in the outcomes. Furthermore, it takes time and a substantial commitment of CCSC staff to build organizational relationships with CBOs. Therefore, we should monitor the effect of our program with a long-term follow-up survey. Bandura explained the importance of the interaction among personal, behavioral and environmental components to make behavioral changes as a construct of reciprocal determinism [11–13]. At the same time, he emphasized that a change in one component has implications for the other two components [11]. That is, improvements in both the recognition of knowledge and skills as well as the importance of network building with CBOs through attendance at the program possibly trigger changes in behavioral and environmental factors. These individuals with growing recognition could increase their actual involvement in interorganizational network building (a behavioral change), and inspire the other staff of the CCSC to get involved in network building with CBOs (an environmental change). Therefore, to have an impact on behavioral and environmental outcomes a more intensive intervention must be designed, and follow-up monitoring of study participants must be conducted to evaluate the medium- and long-term effects of the program on these outcomes.

Overall, we clearly demonstrated positive effects of the intervention only on the attendees of the program. To our knowledge, this is the first report of a program for promoting interorganizational network building between multidisciplinary agencies and CBOs. Several studies have described interorganizational collaborative relationships using network analysis [8, 18–20] and described the development of a theoretical model for the formation of collaborative relationships between organizations [3, 9, 15]. However, in practical situations, those working in the community, such as public health nurses and care workers in CCSCs, had difficulty in building networks with CBOs and desired to learn of ways of building such networks [10]. We believe that this intervention program can encourage staff of multidisciplinary agencies such as CCSCs to engage in the work of building networks with CBOs in the community.

We must consider several limitations of the present study. First, the study had a cluster non-randomized design. At baseline, there was a significant difference between the intervention and control groups in that the control group staff had more working hours than those in the intervention group. Staff of CCSCs in the control group might have had less time to participate in the program. We used this variable as a covariate in the analysis to adjust for such a difference between the intervention and control groups. A cluster randomized design is more robust and suitable than a non-randomized design in a community-based intervention [21]. Therefore, a future study should be a cluster randomized trial if possible. Second, the attendees of the program were not randomly selected from each CCSC in the intervention group. They might have had an interest in and desire to engage in activities of organization network building. Therefore, selection bias would exist. Third, all subjects of this study were not blind to the group's assignment. This may have affected the results. Fourth, this intervention program focused on the interorganizational network between multidisciplinary agencies and CBOs, but the participants were only the staff of multidisciplinary agencies (CCSCs). To promote effective interorganizational networks between these two types of organizations, the collaboration between both organizations would be essential. The program should be modified to include members from the CBOs. Fifth, the program was carried out at two different times (2007 and 2009), although the same program was implemented. Therefore, the period effect may affect the results of this study. Finally, this trial was conducted only in an urban area in Japan. The community context, such as community politics, history, norms and values, can influence coalition membership [22]. Therefore, it is difficult to generalize this study's findings to areas with other characteristics (e.g. rural areas) and to other countries.

We examined the effects on members of an organization of an intervention program to promote interorganizational network building between multidisciplinary agencies and CBOs. The intervention increased the program attendees' recognition of the knowledge and skills required for promoting interorganizational network building with CBOs. This study provides practical evidence of a strategy to foster the development of interorganizational networks in the community, especially between multidisciplinary agencies and CBOs. Further work in this area could focus on the development of a comprehensive study involving both multidisciplinary agencies and CBOs.