The importance of vertical and horizontal integration in childhood overweight/obesity interventions
Increasingly, multiple intervention programming has been suggested as a key approach to developing public health initiatives and strategies [
1,
2]. Using socio-ecological and population health perspectives, multiple intervention program approaches endeavour to provide coordinated and strategic comprehensive programs operating over system levels and across sectors, allowing practitioners and decision makers to take advantage of synergistic effects. These approaches also require vertical and horizontal (v/h) integration of policy and practice in order to be maximally effective. This paper examines v/h integration of interventions for childhood overweight/obesity prevention and reduction, given the complex and multi-level nature of obesity, including environmental, social, community, organizational, and policy system levels.
In the past, obesity prevention and treatment programs have typically focused on health education and individual behaviour change, with emphasis on personal lifestyle and responsibility. Yet, advances in socio-ecological thinking over the last decade point to system change as the missing link in addressing the obesity increase [
3,
4].
Systemic environmental influences relate to socio-ecological features of the problem and include individual, home, school, community, national, and international components [
5]. As noted in the Doak
et al. [
5] review of child and adolescent obesity prevention programs, a wide array of multi-level factors have impact on the prevalence of overweight/obesity. For example, at the school, community, and national levels, environmental influences can include the school curriculum, transportation system, socio-economic status of aggregate populations, community recreation opportunities, community attitudes, imported and local goods, the economy, and the price and availability of food [
6]. There has been a call for a less medical, more preventative, public health approach to childhood obesity that focuses on upstream, more distal causes and interventions for prevention [
7‐
9]. Such a complex problem crossing many system levels would benefit from an integrated approach to intervention.
Key concepts
Key concepts for this paper include intervention, synergy, sector, intersectoral collaboration, and v/h integration. To clarify, we are not referring to the discussion of whether specific health problems should be dealt with separately or integrated with other health problems in a service delivery model [
10,
11]. Rather, we are looking at the integration of a system of players, policies, and programs within jurisdictions and across one or more related health issues, in order to maximize people's wellbeing.
For our discussion here, an intervention is a single public health activity meant to positively affect the health of target groups [
12], whether that be aimed towards prevention, control, or reduction of negative conditions, or enhancement or maintenance of positive ones. Multiple intervention programs are organized, funded sets of interventions with coordinated, interconnected intervention strategies targeting at least two different levels of a system (
e.g., individual behaviour change; organizational change; municipal by-law change) even if each level has only one intervention [
12]. Such programs are based on socio-ecological models that attest that health is determined by complex interactions between behavioural, biological, cultural, social, environmental, economic, and political factors. Determinants do not work independently but interact, and may mitigate or compound the effects of other determinants. Effective population health approaches often reflect a socio-ecological framework [
1,
12,
2].
Synergy is the interaction of two or more interventions, such that their combined effect is greater than the sum of their individual effects [
12].
The term 'sector' is often used to describe the division of organizations along economic lines into three major sectors: public, private, and non-profit [
13]. Other common uses of the term include describing different government ministries within the same level (
e.g., federal or provincial Ministry of Health, Ministry of Education) as well as describing communities of interest based on issue content (education, housing, public health). However, in this article we will be using 'sectors' to mean issue-based entities (
e.g., education), because this can include private, and non-profit organizations, as well as public ones with specific jurisdictions.
V/h integration refers to combining and coordinating efforts over multiple system levels, as well as across sector levels within the same system level [
14,
15]. Integration has structural components (such as a framework of aligned groups, policies, and goals) and process components.
Inter-sectoral collaboration is a term often used for integrated initiatives where both horizontal and vertical dimensions are key [
16]. We are using vertical integration in the Canadian sense, where for example multiple levels of government (municipal, regional, provincial, and federal) need to coordinate their efforts. When rapid responses and time-limited approaches are required, vertical integration of programs are effective [
17].
We are using horizontal integration to describe the engagement of several sectors (
e.g., health, education, agriculture, justice) at the same level. In Canada, horizontal integration occurs, for example, when one federal ministry becomes the lead agency of several federal ministries who work together to provide programs, policies, and research in an area of common interest and overlapping accountability. The purpose of horizontal integration is to increase capacity, maximize resources, and minimize duplication of effort [
15].
Combining vertical or horizontal approaches may have benefits when the health issue is complex, requiring a multi-sectoral response that spans both governmental and non-governmental actors [
18]. Benefits from adding vertical integration include: enhanced opportunities for sustainability; opportunity to work with more of the underlying determinants; prevention of negative spinoff effects for health systems and non-targeted populations; decreased duplication of services; and pooling of funding or resources [
17]. If horizontal integration is involved, key factors that are operating simultaneously in the various contexts of children's lives are more likely to be included. For example, if only the health sector is involved, important issues in education, community involvement, and social welfare may be ignored. Horizontal involvement brings opportunities to develop complementary, supportive, synergistic programs and policies. Furthermore, other programs and policies in these sectors that may work in opposition to the health initiative are more likely to be identified or modified.
With solely horizontal approaches, intervention discussions may remain at either the policy level across sectors or at the service delivery sector, without attention to differing levels of jurisdiction [
17]. When vertical integration is not part of the picture, important opportunities to provide consistent inter-sectoral policy regulation and resources may be lost. Different kinds of interventions, with targets ranging from broad social determinants of health dealt with at a federal level, down through provincial and municipal levels may not be provided in a consistent fashion. For example, the provision of tax deductions for fees paid by parents for children's sports and fitness activities in Canada is a federal government initiative meant to increase accessibility to active living. Its effects would be undermined if, at the municipal level, cities raised user fees for sports and recreational activities and venues.
Besides the additive advantages of combining v/h integration, there is also the possible advantage of producing synergistic results. Such results could occur across system levels and sectors, in terms of the impacts of the various staged, strategic interventions, the development of committed initiative teams, and the potential spread of salience of the issues and interventions beyond those immediately involved [
1]. Most multiple intervention programs rely on the effect of synergy that should come as result from the combined presence of both types of integration [
1,
17].
The findings on complex programs involving v/h integration have been mixed, partly due to a variety of methodological difficulties in evaluating multiple components, providing interventions of sufficient breadth and strength, lack of sufficient penetration and reach in communities, lack of theoretical underpinnings, and by insufficient intervention in policy and regulation [
2]. However, the HIV/AIDS work in Africa is often cited as an example of v/h integration of complex and multiple interventions showing success [
2,
18]. In Kenya, for example, interventions have occurred in the areas of health policy, education for individuals, schools, and communities; increased accessibility to treatment and management, infrastructure to support same, and counselling and social support for families [
19]. Part of a national framework, these activities were aimed at national, provincial, district, community, household, and individual levels, and involved people from the public, private, civil, and community sectors [
19]. Improvements in HIV/AIDS transmission rates and treatment accessibility have been attributed to this coordinated response. The Sub-Saharan African countries, including Kenya, have National AIDS Commissions-coordinating bodies, often sitting outside the Ministry of Health that work with creating and maintaining v/h integration, among other things. In an evaluation of all the National AIDS Commissions in this region, Morah and Ihalainen conclude that, by and large, these commissions have worked well in providing multi-sectoral coordination, strong leadership, advocacy for national frameworks, and engagement of non-governmental actors [
18].
However, the commissions have had their difficulties. Issues relevant to this paper, beyond the commissions' unique structures and relationships to government, suggest that the process of maintaining v/h integration is important. Challenges in process include monitoring and evaluation of interventions, and difficulty reaching and acting on decisions quickly, due to an accompanying lack of authority and accountability.
Thus, various functions and processes are required to keep integrated programs and policies cohesive, coordinated, and evolving towards their goals and objectives. Positive and beneficial alignments require more than common goals; to be maintained and function properly, they require information flow and communication among and over levels, as well as coordination, compromise, and sharing boundaries. Without coherence in decisions over levels, not only may integration not work, but the system may lose authority and legitimacy [
20].
For example, programming at the community or individual level should be supported by provincial and national activities. Progress toward a goal is enhanced by a common understanding of the problem and of the strategies to address it. Strategies are complementary to and support each other and build on each other. Communication among different levels is such that each jurisdiction can see how its role fits into a coordinated continuum of services, with mechanisms in place to identify and address any deviation from goals and functions. This communication and its feedback mechanisms help to plan integration, establish workable processes, and identify when the integration is not working.
When developing policy and practice involving v/h integration, several considerations are central. Including both horizontal and vertical levels are important for program success, as this maximizes reinforcing and synergistic effects [
12]. Including all the key players is also critical. Communication and feedback about system components, their coordination, and effectiveness are important [
14], and structures are necessary for planning, designing, and monitoring [
21]. Coherence in decisions, plans, goals, and processes is the underlying purpose of this complex undertaking, and must be maintained [
22]. Finally, relationship building and maintenance are key to integration effectiveness over time and players [
23].
The question then becomes, what does v/h integration look like? What does it look like in the area of childhood overweight/obesity intervention? And what are the implications for research, practice, and policy?