Voluntary Partnerships Research Articles

Collaborating for (Game) Change(rs): Negotiating and Building Meaningful Action Research Partnerships

Sport- and physical activity-related participatory action research (PAR) often involves voluntary partnerships spanning institutions, organizations, and jurisdictions. Negotiating and maintaining multi-stakeholder and multi-jurisdictional research partnerships can be likened to a delicate balancing act fraught with potential challenges and strains impacting project outcomes (e.g., waning commitment, emerging external factors, new and/or revised stakeholder/organizational requirements, fidelity to the necessary care given when working with community partners and participants). This article presents PAR as a methodology in sport and physical activity that can potentially engage all research participants as co-researchers, sharing power equitably. Recognizing the need for continued attention and action in this area, we provide an overview of PAR in practice, identifying significant ideas and principles. Additionally, we outline Game Changers—a PAR project involving students with various disabilities, schools, PE teachers, coaches, national and community sport partners, and university researchers. Based on lessons learned from this multi-stakeholder and multi-jurisdictional research project, we interrogate the possibilities associated with engaging in PAR by exploring challenges and opportunities related to sport and physical activity-focused PAR.

The effectiveness, cost-effectiveness and policy processes of regulatory, voluntary and partnership policies to improve food environments: an evidence synthesis.

Dietary factors are among the largest and costliest drivers of chronic diseases in England. As a response, the government implements a range of population interventions to promote healthy diets by targeting food environments. This study aimed to conduct a systematic review of the effectiveness, cost-effectiveness and policy process of real-world evaluations of national and state policies on improving food environments, with a focus on whether they were regulatory, voluntary or partnership approaches. Fourteen relevant English-language databases were searched in November 2020 for studies published between 2010 and 2020. Six separate evidence reviews were conducted to assess the evidence of effectiveness, cost-effectiveness and policy processes of policies to improve food environments. A total of 483 primary research evaluations and 14 evidence syntheses were included. The study reveals considerable geographic, methodological and other imbalances across the literature, with, for example, 81% of publications focusing only on 12 countries. The systematic reviews also reveal the effectiveness and cost-effectiveness of reviewed regulatory approaches designed to improve health, consumer behaviour and food environment outcomes while public-private partnerships and voluntary approaches to improve diets via reformulation, advertising and promotion restrictions or other changes to the environment were limited in their effectiveness and cost-effectiveness. The study also revealed key enabling and impeding factors across regulatory, voluntary and public-private partnership approaches. From the available evidence reviewed, this study finds that regulatory approaches appear most effective at improving the food environment, and voluntary agreements and partnerships have limited effectiveness. These findings should be carefully considered in future public health policy development, as should the findings of geographic imbalance in the evidence and inadequate representation of equity dimensions across the policy evaluations. We find that food policies are at times driven by factors other than the evidence and shaped by compromise and pragmatism. Food policy should be first and foremost designed and driven by the evidence of greatest effectiveness to improve food environments for healthier diets. This was a complex evidence synthesis due to its scope and some policy evaluations may have been missed as the literature searches did not include specific policy names. The literature was limited to studies published in English from 2010 to 2020, potentially missing studies of interest. Priorities include the need for guidance for appraising risk of bias and quality of non-clinical studies, for reporting policy characteristics in evaluations, for supporting evaluations of real-world policies equitably across geographic regions, for capturing equity dimensions in policy evaluations, and for guideline development for quality and risk of bias of policy evaluations. This study is registered as PROSPERO CRD42020170963. This awardproject was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR award ref: NIHR128607)and is published in full in Public Health Research; Vol. 12, No. 8. See the NIHR Funding and Awards website for further awardinformation.

Novel approaches to enable equitable access to monoclonal antibodies in low- and middle-income countries.

Monoclonal antibodies (mAbs) are revolutionizing management of non-communicable diseases in high-income countries and are increasingly being advanced for a range of infectious diseases (IDs). However, access to existing mAbs is limited in low- and middle-income countries (LMICs), and investment in developing fit-for-purpose mAbs for IDs that disproportionately affect LMICs has been limited. Underlying these access barriers are systemic challenges, including a lack of commercial incentives to target LMIC markets and complexity in manufacturing and regulatory processes. Novel strategies are needed to overcome systemic access barriers for mAbs. We outline key areas where new approaches could address these barriers, based on a multistakeholder consultation in March 2023. Three disease-market archetypes are identified to guide thinking about business models tailored to different contexts. New business models are needed to incentivize development and manufacturing of ID mAbs and to ensure mAbs are optimized with a target product profile and cost of goods that enable use in diverse LMIC settings. Lessons can be applied from voluntary licensing strategies and product development partnerships that have shown success in catalysing development and affordable supply for a range of infectious diseases. Technology transfer will be key to expand LMIC research and manufacturing capacity and to enable sustainable and diversified supply. Improved market intelligence, demand aggregation mechanisms, and portfolio-based manufacturing models could be used to de-risk commercial investment and establish a sustainable manufacturing ecosystem for affordable mAbs. Novel regulatory approaches and robust technology transfer may reduce data requirements and timelines for biosimilar approvals. Trailblazer products, with coordinated "end-to-end" support from funders, can demonstrate proof of concept for pathways to accessible mAbs across a broader range of LMICs. Research funders; local, regional, global health agencies; and, private sector partners should commit to implementing innovative partnerships and end-to-end strategies that enable equitable access to mAbs for infectious diseases in LMICs.

Disruptive (dis)engagement: platformisation as a global social policy

Global digital platforms have become important actors for economy and work with social policy consequences. This article analyses strategies and actions of global digital platforms from the perspective of how and what kind of global social policy these represent. It draws from analysis of how platform company strategic approaches relate to rights, regulation, and redistribution, and then using abductive reasoning and mixed methods empirical case study in Europe, articulate challenges to future global social policy. It examines what priorities of platform companies imply to global social policy and identifies five political and strategic elements of importance for global social policy: (1) denial or avoidance of employer status, (2) identifying as a “tech company providing services”, (3) focus on private social insurance in contrast to statutory social security, (4) addressing social security as a market-based service through voluntary partnerships, and (5) investor driven business model and global engagement. Drawing from theoretical and empirical data, the article further examines potential countermeasures and solutions, which could be of relevance at different levels of governance. It concludes that social policy impacts of platform economy are more related to the business model than technology. Platform economy business models currently support upward redistribution and avoidance of regulatory measures to address minimum income, social protection, and workers’ rights, yet platform economy is data rich and also could provide scope for government and regulatory action.

Navigating or adding to complexity? Exploring the role of catchment partnerships in collaborative governance

An enduring challenge for environmental governance is how to coordinate multiple actors to achieve more collaborative and holistic management of complex socio-ecological systems. Catchment partnerships are often thought able to achieve this, so here we ask: do such partnerships actually help navigate complexity, or merely add to it? We answer this question by analysing the experiences of four voluntary UK catchment partnerships. Our data combined a structured desk-based analysis of partnership documents, with semi-structured interviews with partnership coordinators, chairs and partner representatives. These data were analysed using a qualitative thematic approach informed by the literatures on catchment management and collaborative governance of complexity. We found that partnerships both add to and help navigate the complexity of holistic and inclusive environmental management. Maintaining partnerships entails costs for partners, and partnerships connect messily and multitudinously to other initiatives. However, the partnerships were all judged as worthwhile, and made progress towards goals for water quality, biodiversity and river restoration. They were especially valued for envisioning and initiating complex activities such as Natural Flood Management. Communication and networking by partnership coordinators and partners underpinned these achievements. Aspects of pre-existing governance systems both enabled and constrained the partnerships: in particular, statutory agencies responsible for policy delivery were always important partners, and delivering partnership plans often depended on public-sector grants. This draws attention to the pervasive effect of governmentality in collaborative governance. More attention to analysing—and supporting—such partnerships is worthwhile, complemented by reflection on the limits to environmental governance in the face of complexity.

Online Appendix to 'Voluntary Partnerships and Cooperation: An Experimental Study'

Online Appendix to 'Voluntary Partnerships and Cooperation: An Experimental Study'

Voluntary Partnerships and Cooperation: An Experimental Study

Voluntary Partnerships and Cooperation: An Experimental Study

Improving access to mental health services for those experiencing multiple disadvantage

Purpose This paper aims to explore the barriers to accessing mental health support for people experiencing multiple disadvantage along with some potential solutions for attempting to overcome these. It draws on evidence and learning from 12 voluntary sector-led partnerships in England funded by the National Lottery Community Fund’s Fulfilling Lives programme. Design/methodology/approach Qualitative research was undertaken with frontline staff, senior leaders, volunteers, beneficiaries and stakeholders from Fulfilling Lives partnerships. This comprised focus groups (21 participants) and individual face-to-face interviews (41 participants), both of which explored barriers and local solutions to accessing statutory mental health services. Following a thematic analysis of transcripts, research participants and stakeholders were invited to a face-to-face workshop to review and validate emerging findings (34 participants). Findings People experiencing multiple disadvantage face significant barriers in accessing support for their mental health. These include a complex system that is difficult to navigate, long waiting lists, high eligibility thresholds and models of support that lack flexibility. Fulfilling Lives partnerships have had the funding and the flexibility to trial different approaches. Promising solutions to barriers include the use of navigators, person-centred support and multi-agency networks and training. However, overcoming systemic barriers remains the most difficult challenge. Originality/value Fulfilling Lives was a rare example of substantial and long-term (eight years) funding to work with people experiencing multiple disadvantage. This provided a unique opportunity to try different approaches and gather learning. The programme evaluation provides insights into the experiences of people facing multiple disadvantage and those who support them and offers evidence-based suggestions for policy and practice.

Meeting the housing needs of military veterans: exploring collaboration and governance

Veterans in the UK seek help from numerous, diverse organisations to navigate the housing system, in contrast to countries such as the US and Australia, which operate dedicated Veterans Administrations. Collaboration between organisations to support veterans is non-mandatory, yet influential on housing outcomes. This study utilised network governance theory to examine how local partnerships affect veterans’ housing pathways. The research approach involved five in-depth, area-based case studies across different housing contexts. The research contributes new findings on the positive impact of local partnerships and develops a conceptual model of veterans’ housing pathways, focused on collaboration. The study revealed a step change in partnership-working since the introduction of the UK Armed Forces Covenant in 2011, with the absence of mandatory collaboration requirements having nurtured trust-based network governance. The findings suggest this has been effective for veterans in housing need, but there are potential risks in terms of sustainability of voluntary partnerships and the temptation for central government of more hierarchical approaches.

Islam, Marriage Law and the Legal Framework of England and Wales

This article examines Islam and in Contemporary England and Wales, and asks what issues faced by Muslims may reveal about the legal landscape more widely, using marriage law as a case study. It opens with an overview of Religion, Islam and the Legal Framework in England and Wales, before addressing the modern Law on the solemnisation of marriages and current proposals for reform. It then moves to examine the conscious choice of some Muslims to enter into purely religious marriages, and asks what this reveals about Muslim communities and the overarching legal framework. In the concluding section, the piece then addresses what can be learnt about two observable realities from marriage law: 1) the Continued Problematisation of Muslims and Muslim Communities in popular and academic perception, and 2) the significance of unregistered religious marriages for other voluntary adult partnerships outside of the system of state registration.

Building voluntary partnerships for climate action: An exploratory study from Iceland

The Paris Agreement called for voluntary cooperation between firms, NGOs, and the state, to meet global climate goals. This study examines the development of voluntary carbon projects (VCPs) in Iceland – a country aiming to be carbon neutral by 2040. There is little empirical evidence on what catalyzes voluntary and inter-organizational climate cooperation. To fill this gap, we use a mixed methods research design, surveying firms to understand their awareness and commitment to VCPs, and interviewing state and non-state actors involved in VCPs. In interviews, we tested a cooperation framework with six ‘levers’ to enable cooperation: a superordinate goal, group identity, trust, accountability, communication, and reward distribution . Individualist and collectivist cultural dynamics influence these mechanisms. Survey results showed a general awareness of and support for VCPs, but concerns around their robustness. In interviews, the six cooperation mechanisms offered structured pathways for enabling and strengthening VCPs. • Iceland aims to be carbon neutral through voluntary carbon projects (VCPs). • There is broad awareness of VCPs among firms, but concerns on their robustness. • A shared group identity focused on climate action, is critical for cooperation. • Group identity and trust are strengthened by face-to-face communication. • Explicit goals are foundational for group accountability and cooperation.

Municipal stakeholders’ perceptions of the importance and outcomes of multi-sector recreation partnerships

ABSTRACT Research Question: Recreation partnerships, often characterized by the pooling, exchange, or sharing of resources, information, capabilities, or initiatives, may help communities to more effectively address complex problems and deliver recreation services. Despite the attention given to recreation partnerships as a management strategy, little research has focused on how various community stakeholders perceive partnerships. This study sought to address this gap. Methods: This quantitative study (n=161) in the U.S. analyzed perceptions of partnership importance and outcomes among a state-wide sample of municipal stakeholders including recreation leaders, conservation commissioners, elected officials, and town administrators. Results and Findings: All stakeholders placed high importance on municipal partnerships for recreation, but perceptions of importance for education, business, health/human services, outdoor, and voluntary community group partnerships differed significantly by stakeholder group. All stakeholders generally recognized positive partnership outcomes, although recreation leaders rated improvement of services higher than elected officials. Implications: Differences in perceptions of importance and outcomes of recreation partnerships by stakeholder groups suggest a need for recreation leaders to more effectively communicate strategies for effective partnerships as well as positive outcomes of partnerships to other stakeholders. Research Contribution: Through the framework of stakeholder theory, this paper provides evidence of municipal stakeholders’ perceptions of partnerships.

APOL1 Long-term Kidney Transplantation Outcomes Network (APOLLO): Design and Rationale

IntroductionMuch of the higher risk for end-stage kidney disease (ESKD) in African American individuals relates to ancestry-specific variation in the apolipoprotein L1 gene (APOL1). Relative to kidneys from European American deceased-donors, kidneys from African American deceased-donors have shorter allograft survival and African American living-kidney donors more often develop ESKD. The National Institutes of Health (NIH)–sponsored APOL1 Long-term Kidney Transplantation Outcomes Network (APOLLO) is prospectively assessing kidney allograft survival from donors with recent African ancestry based on donor and recipient APOL1 genotypes.MethodsAPOLLO will evaluate outcomes from 2614 deceased kidney donor-recipient pairs, as well as additional living-kidney donor-recipient pairs and unpaired deceased-donor kidneys.ResultsThe United Network for Organ Sharing (UNOS), Association of Organ Procurement Organizations, American Society of Transplantation, American Society for Histocompatibility and Immunogenetics, and nearly all U.S. kidney transplant programs, organ procurement organizations (OPOs), and histocompatibility laboratories are participating in this observational study. APOLLO employs a central institutional review board (cIRB) and maintains voluntary partnerships with OPOs and histocompatibility laboratories. A Community Advisory Council composed of African American individuals with a personal or family history of kidney disease has advised the NIH Project Office and Steering Committee since inception. UNOS is providing data for outcome analyses.ConclusionThis article describes unique aspects of the protocol, design, and performance of APOLLO. Results will guide use of APOL1 genotypic data to improve the assessment of quality in deceased-donor kidneys and could increase numbers of transplanted kidneys, reduce rates of discard, and improve the safety of living-kidney donation.

Memoranda of understanding: a tobacco industry strategy to undermine illicit tobacco trade policies

ObjectiveAnalyse the transnational tobacco companies’ (TTCs) memoranda of understanding (MoUs) on illicit trade and how they could undermine the WHO Framework Convention on Tobacco Control (FCTC) and the Protocol to...

Meeting the Challenge of Effectiveness in Nonprofit Partnerships: Examining the Roles of Partner Selection, Trust, and Communication

Human services nonprofits increasingly provide a social safety net through interorganizational collaboration, and the effectiveness of these partnerships has important implications for the quality and sufficiency of those services. The purpose of this study is to investigate whether partner selection is related to partnership effectiveness and, if so, how. More specifically, the study examines the impact of partner selection on partnership effectiveness and the mediating roles of trust and communication in that relationship. Based on surveys on 201 voluntary human services nonprofit partnerships, trust, and communicative effectiveness are related to satisfaction with partnership outcomes. Trust and communicative effectiveness fully mediated the effects of prior experience and reputation on partnership effectiveness and communication. Interestingly and contrary to some findings from previous research, resource complementarity, homophily, and social networks across organizations’ members, as partner selection factors, were not found to be related to partnership effectiveness. We derived implications for partnership effectiveness research from the results.

Listen, Learn, Liaise: Taking the Species Out of Species-At-Risk Through Engagement

On the Ground • Over the past 150 years, cultivation, urbanization, and industrial activity have replaced much of North America's native prairie. As such, native prairie ecosystems are of vital importance to many species at risk. If society wants to conserve the North American prairie ecosystem, including the many species at risk, then partnerships between public agencies, nongovernmental organizations, and private landholders need to be established and strengthened. • To benefit the most species at risk, this partnership should metamorphose from the typical single-species management into one that addresses the needs of multiple species. To that end, we present a framework that is achieved through voluntary partnerships with the ranching community that alleviates their fear of species at risk and enhances their ability to manage multiple species at risk on their properties. • We use the MULTISAR program, delivered since 2002 in the grasslands of southern Alberta, Canada, as the example of an effective and functioning multiple-species conservation program that has applied the framework. Conservation is achieved through the development of a Habitat Conservation Strategy that is based on the 4 pillars of 1) engagement, 2) respect, 3) empowerment, and 4) monitoring and evaluation. • We discuss the strengths and weaknesses of the framework and program based on 15 years’ experience. As the program built trust and acceptance in the ranching community, the number of participants has continuously grown from 1 cooperator to 39 by 2018, conserving 1,600 km2 of prairie habitat in southern Alberta. • The process outlined here can be applied across the grasslands of North America and the world as an effective approach for engaging landholders in the conservation of a suite of species at risk.

In the pursuit of economic growth: drivers and inhibitors of place-based partnerships

ABSTRACTIn the pursuit of economic growth, England has historically retained a level of centralized control despite policy attempts to decentralize. Consequently, attempts to create a subnational tier have struggled to establish a durable alternative. Reporting on the episode of localism, which began in 2010 and has involved the abolition of regional development agencies (RDAs) in favour of 38 voluntary local enterprise partnerships (LEPs) alongside the construction of a growing number of combined authorities, the research investigates a complex place-based economic landscape whereby the provision of guidance and sharing of practice in England remains limited. This paper draws on the existing literature to propose a conceptual model of place-based partnership that formed a scaffold for an empirical study involving 10 LEPs in the Midlands. A soft systems methodology was adopted to understand the factors that help and hinder these place-based partnerships. The paper advances the argument that the persistence of centralism limits the LEPs’ capacity to fill the missing space and observes a strong influence of central government and reliance on local government. Beyond the LEPs, given the global trend of decentralization, further research into the interplay between the factors in the conceptual model is encouraged to support the development of place-based partnerships as they work towards securing collaborative advantage.

Developing community based models of Corporate Social Responsibility

In this article, grounded theory was used to develop models of Corporate Social Responsibility (CSR) that can generate benefits for communities impacted by the Australian resource sector. Interviews were conducted with community representatives who interacted with a range of resource companies located in three Australian jurisdictions. Separate conceptual models were developed for Indigenous communities with legislated land rights as opposed to local communities nearby resource development. This was because they had different priorities in terms of model elements. Indigenous people sought to maintain cultural and environmental values through CSR whilst accepting a need for some social change. These values were expressed in cases where legislative frameworks enabled their protection and sufficient resources were available, such as financial capital, policy commitments and stakeholder support. Local communities were seeking to maintain their viability and to ensure companies were accountable for their impacts. CSR in this context relied on company policy and the formation of voluntary partnerships which differed according to the organisation’s culture. In this paper, it is argued that participatory CSR provided a mechanism to express community values linking it to perceptions of empowerment and capacity to provide long-term value to communities. The study also helps identify where improvements can be made to the Australian resource sector.

Local Immigration Enforcement and Arrests of the Hispanic Population

Section 287(g) of the Immigration and Nationality Act (INA), which was added to the INA by the Illegal Immigration Reform and Immigrant Responsibility Act of 1996 (IIRIRA), allows the federal government to enter into voluntary partnerships with state and local law enforcement agencies to enforce immigration law. Upon entering these agreements, law enforcement officers are trained by Immigration and Customs Enforcement (ICE) and receive delegated authority to enquire about an individual's immigration status and, if found to be removable, to detain the individual while ICE makes a determination of whether to initiate deportation proceedings. In some instances, this inquiry about immigration status takes place as part of the intake process when a criminal defendant is arrested and placed into a criminal jail. In other instances, task force officers are trained to inquire in the field about immigration status and enforce immigration law against people who have not committed any criminal offense. The key difference between the two models is that task force agents can arrest for immigration violations undocumented individuals who have not committed any criminal offense, whereas in the jail model individuals must be arrested on some other criminal charge before immigration status can be determined. The 287(g) program has raised several concerns regarding its implementation and results. First, the program could lead to racial and ethnic profiling. In particular, given that the majority of undocumented immigrants hail from Latin American countries, it is highly plausible that Hispanics, regardless of immigrant status, might be disproportionally affected by this program. That is, in a jurisdiction that participates in the jail model, an officer might arrest a Hispanic individual for a very minor offence in order to process them through the jail and determine their immigration status, when perhaps without the program they may have only issued a citation. Another concern with the program is that it may lead to tensions between state and local law enforcement and the local community. If the program creates an atmosphere of suspicion and distrust by community members toward state and local law enforcement agents, even law abiding individuals may choose to avoid interaction with law enforcement agents. This can make victims and witnesses hesitant to come forward, for fear that their undocumented status will be uncovered. Such a situation inhibits law enforcement's ability to do its job and can, ironically, make communities less safe. This study explores the effects of implementation of the 287(g) program in Frederick County, Maryland on the arrests of Hispanics. Using data from individual arrest records from the Frederick County Sheriff's Office, which has a 287(g) agreement with ICE, and the Frederick Police Department, which does not, I analyze the changes in arrests between the two agencies before and after the 287(g) program was implemented in 2008. I find that overall, the arrests of Hispanics fell, suggesting that the Hispanic community avoided interaction with law enforcement when the program began. However, I also find that the program led to a significantly higher number of arrests of Hispanics by the Sheriff's Office than would have occurred in its absence, indicating that attention was focused toward the Hispanic community as a result of the program. These results suggest that, if the program is to continue, additional safeguards are needed to prevent abuses and civil rights violations.

Can complexity dynamics be harnessed to improve integration of care? The implementation of the Health Links in Ontario, Canada

Introduction: Attempts to understand the emergence of integrated care using traditional approaches provide limited insights. Increasingly, scholars are applying complex adaptive systems (CAS) theory to explain the implementation of integrated care policies and interventions. A CAS perspective suggests that integrated care efforts designed to support sensemaking, which allows staff to give meaning to their experience and efforts, self-organizing, and adaptive approaches are more likely to be successful than efforts which are more ‘mechanistic’ and ‘linear’. We examined the implementation of the ‘Health Links’ (HLs), a provincial integrated care initiative in Ontario, Canada. Launched in 2012, there are currently 82 operational HLs, consisting of voluntary partnerships among organizations aimed at improving care for the top 5% of health system users in terms of costs. The HLs were introduced in a ‘low rules’ policy framework to stimulate grass-roots networks and approaches. In this study, we explored the extent to which this approach has generated interconnections, sensemaking, self-organization, emergence and coevolution, key aspects of CAS. Theory/Methods: We used key terms from CAS theory to deductively code transcripts from 37 interviews conducted in 2014/2015 with managers and clinicians from 24 HLs in all 14 regional health authorities in Ontario. Two reviewers coded a subset of interview data, in duplicate, that had been coded as addressing CAS themes in an earlier study. Results: Health Links generated novel interconnections between organizations and professionals across health and social services. These interconnections stimulated sensemaking, as individuals came together to understand, interpret, and adapt the initiative within their own contexts. Several self-organizing processes were identified as staff designed, tested and refined their structures and processes, and at the regional level where some regions standardized HLs within their borders. Despite enthusiasm for the ‘low-rules’ environment, some participants struggled with the lack of guidance or consistency from the province, and all agreed that some standardization was necessary. Early signs of emergence and co-evolution were identified, however, many HLs were still in early stages of implementation. Discussions: Our results show that a flexible policy environment encouraged interconnections, sensemaking, and self-organization among actors in the system. However, there were different capacities and preferences for self-organizing, and limits to what could be achieved through self-organization. Successful implementation required leadership and some operational consistency across HLs. Barriers to self-organization persisted in the form of pre-existing organizational and regional regulations. Conclusions: A ‘low-rules’ integrated care policy can generate novel interconnections, adaptive sensemaking, and productive self-organization among actors. Lessons learned: Operationalizing CAS theory domains is challenging and requires clarification of definitions and the level of analysis. Limitations: As a qualitative study, the results are limited in their generalizability. Interviews were conducted within three years of HLs launch and are limited to the initial implementation. Suggestions for future research: Future research should develop clear and applied definitions of CAS domains to support empirical studies of complexity dynamics in integrated care.