Sexual assault, one of the most prominent forms of gender-based violence globally, is a pressing public health and human rights concern.
Sexual assault can lead to a multitude of serious physical, mental health, and social consequences, complicating efforts to comprehensively address the needs of survivors. 1 This issue may be particularly salient for the care and support of the 25 million transgender (trans) persons living around the world—those who do not fully or in part identify with their sex assigned at birth—who experience sexual assault at lifetime rates as high as 50%. 2–6 Trans survivors routinely encounter barriers to appropriate supports post–sexual assault due to a lack of inclusive organizational policies and practices, as well as systemic stigma, pathologization, and violence in support settings. 7–10 These barriers can in turn result in low levels of trust in service providers and further social and economic marginalization. 11 7 , 12
Intersectoral networks can better address the complex needs of and negative responses to structurally marginalized groups by drawing on diverse organizational strengths
13 , to increase resource sharing, enhance community awareness of services, and reduce redundancies for involved organizations. 14 An intersectoral network was therefore established in 2019 in Ontario, Canada's largest province, to improve the response to trans survivors of sexual assault. 15–17 8 , 18 , The trans-LINK Network, as it is known, is informed by Robeson's lifecycle model of network development, comprising planning, formation, maturation, sustainability, and transition stages. 19 The network shares a common mission, vision, and set of values, and is currently composed of 130 trans-positive health care and community organizations from across Ontario. 20 19 , At present, the network has reached the maturation stage, which includes ongoing process evaluations and revisions to network structure, relevant technologies, and other resources as indicated by the findings. 21 20
Social network analysis, a common approach to evaluating network processes, has demonstrated effectiveness in public health and management research to evaluate the functionality of large-scale intersectoral networks.
Social network analysis is undertaken in several steps, including examining the distribution and flow of information to understand relationships between organizations, assessing collective impact on goals, and, based on evaluation findings, generating recommendations to improve structure, centralization, diversity, and quality of relationships. 22–29 By exploring network structures and characteristics of the “web of relationships,” it is possible to achieve a systems-level view that can extend, strengthen, and sustain health and community partnerships to support the care of trans survivors. 22–29 These partnerships are vital to a comprehensive response that seeks to address the structural challenges faced by trans communities. 30 12 The Current Study
As the first step in a multipart evaluation, we conducted a baseline social network analysis of the trans-LINK Network to enable a data-driven approach to network advancement.
31 , In this study, our specific objectives were to determine the nature and extent of collaboration, communication, and connection among member organizations within the trans-LINK Network. Our evaluation approach and findings can contribute to the evidence base on intersectoral networks and further illustrate their potential to improve the responses to complex public health and social equity issues. 32 Methods
This study was approved by Women's College Hospital Research Ethics Board in Toronto (REB#2020-0070-E).
Selection of organizations
Using a “bounded network” sampling approach to social network analysis, we invited representatives of 119 trans-LINK member organizations from across all 7 regions of Ontario to participate in a survey (see the study by Du Mont et al
for full list of invited organizations). 31 These organizations offered a diverse range of 33 direct services focused on, but not limited to, housing, immigration/settlement, HIV/AIDS, mental health, primary health care, hospital-based sexual assault care, and 2SLGBTQI+ (Two-Spirit, Lesbian, Gay, Bisexual, Transgender, Queer or Questioning, Intersex+) supports. 21 Survey measure
We adapted the validated 19-question Program to Analyze, Record, and Track Networks to Enhance Relationships (PARTNER) tool, modifying the tone and tense of language to suit the baseline nature of the evaluation and, where relevant, adding questions specific to the scope and purpose of the trans-LINK Network.
Although initially developed to evaluate public health collaboratives in the United States, PARTNER has since been employed across disciplines and in other jurisdictions to study other types of cross-sector partnerships. 34 15 , 24 , 35 , 36
The final survey contained 3 sections organized by type of variable: organizational, relational, and challenges and barriers to collaboration. Results pertaining to organizational and challenges and barriers to collaboration questions are detailed elsewhere
31 , ; this article focuses specifically on the relational-level section of the survey, which allowed participating organizations to select trans-LINK Network organizations with which they already had a relationship (either informal or formal) related specifically to supporting trans survivors of sexual assault. 32
Organizational representatives were then asked 9 questions regarding their organization's relationship with each other organization with which they interact, of which 8 were adapted from PARTNER. The first 2 questions focused on Areas of collaboration and Activities of engagement (cooperative, coordinated, or integrated activities. Questions 3 to 8 measured perceived Power (ability to impact the overall mission of the network), Level of involvement in the network, Reliability (following through on commitments), Mission congruence (sharing a mission with the network's mission and goals), Openness to discussion (willing to engage in frank, open, and civil discussion and consider multiple viewpoints), and Potential to contribute resources (eg, funding, information). One final question, which measured frequency of interactions, was added.
We launched the PARTNER survey on June 22, 2021, via email invitations distributed to the 119 trans-LINK Network organizations. The survey closed July 22, 2021, following the last of several weekly email reminders.
Email invitations contained an individualized link to the PARTNER survey, specific to a representative of each organization. The link directed them to review an information sheet and consent form, which explained the background and purpose of the study and the rights, responsibilities, risks, and benefits of participating. The consent form also specified that sensitive data, such as individual scores for power, reliability, and openness, would not be reported by organization name. Once informed consent was provided, they gained access to the PARTNER survey.
Network scores were generated by PARTNER Analyzer using sociometric survey data (whole network data). A score for density was generated at the network level of analysis, reflecting the proportion of existing versus potential ties within the trans-LINK Network.
Organizational degree of centrality was generated at the individual level based on the relative number of ties/connections held by each node (ie, organization). 37 37 , Eight other network-level scores were generated on the nature of collaborations with other organizations within the network: Power, Level of involvement, Potential resource contribution, Reliability, Mission Congruence, Openness to discussion, Value (a composite measure of Power, Level of involvement, Potential resource contribution), and Trust (a composite measure of Reliability, Mission congruence, Openness to discussion). 38 38
PARTNER Analyzer was also used to generate network maps illustrating relationship composition between member organizations. Maps were color-coded by region and organized according to degree of centrality and type of collaborative activities (cooperative, coordinated, and integrated) to visualize patterned connections between organizations.
Further descriptive analyses of PARTNER data were conducted using Excel including median and range for degree of centrality scores and frequencies and proportions for areas of collaboration, activities of engagement, and frequency of interactions.
39 Consultation session
We held a consultation session on July 28, 2021, to share PARTNER survey findings with network member organizations and, arising from these, generate action items to move the trans-LINK Network forward. A consultative approach is consistent with some previous social network analyses, which have employed participatory methods such as feedback sessions or “data dialogues” to disseminate findings and elicit strategic insights from key stakeholders.
15 , Twenty-two representatives from 21 distinct organizations attended the session (to enable successful facilitated discussion, the group was kept small and was composed of the first organizations expressing interest following an email invitation). These organizations provided a diverse array of services (sexual assault, 2SLGBTQI+, counseling and mental health, health care, social and/or youth, other forms of violence, HIV/AIDS, advocacy and outreach, and education and training). 23
After providing an overview of key findings from the PARTNER survey, we posed 4 questions to the group, 2 of which we present in this article: (1) What specific action items could we adopt to enhance collaboration, communication, and connection among network member organizations? (2) How do we measure or evaluate the longer-term success of the network in accomplishing these action items? Other questions are described elsewhere.
31 , 32
Representatives were given 8 to 10 minutes to provide their responses to each question using the sticky note feature on Jamboard, a digital interactive whiteboard application.
All responses from the session were exported into a spreadsheet for conventional content analysis, in which the presence of certain words or phrases is quantified and analyzed to identify relationships and produce larger clusters and themes. 40 Twenty-eight individual insights related to the enhancement of the nature and extent of collaboration, communication, and connection among network member organizations were voiced. Insights were read word-by-word to derive 28 unique codes using specific language from participants (eg, “increase partnerships among a variety of regionally specific 2SLGBTQI+ services”; “create a singular space to enhance access to network resources and projects”). Through iterative, consensus-based discussion, authors N.L., J.F.B., and J.D.M. sorted the 28 codes into meaningful clusters and then sorted clusters into 6 broader themes to inform network recommendations. Code frequencies were then calculated across themes and summed to ascertain the prominence and rank order of each theme. 41
Twenty-one individual insights were provided in response to the question on evaluating the longer-term success of the network, from which 18 codes were created (eg, “Share existing 119 frameworks for similar projects”; “Conduct client-based evaluations”) and then, through the same process described earlier, consolidated into 6 themes to inform network recommendations.
Of the 119 trans-LINK Network members invited to participate in the survey, 78 (65.5%) responded. Responding organizations were located across all 7 regions of Ontario (
Table 1). As reported by the 78 respondents, almost all 119 organizations (n = 116, 97.5%) had at least 1 working relationship with another organization within the network, either formal or informal, representing 378 unique connections.
TABLE 1 -
Location of Participating trans-LINK Network Member Organizations
N = 78
The trans-LINK Network achieved a density score of 2.7%, indicating that more than 97.0% of potential network ties have yet to be developed. At the organizational level, scores on their degree of centrality ranged from a low of 0.0% to a high of 25.4%, with a median score of 1.7%. As seen in Supplemental Digital Content 1, available at
, a relatively small group of organizations—for example, ORG47 (hospital-based organization) and ORG36 (community-based organization)—have comparatively high centrality scores of 25.4% and 20.3%, respectively. Indeed, nearly half (163/378, 43.1%) of the unique relationships identified within the network included an organization ranked among the top 10 for degree of centrality (8.5%-25.4%). https://links.lww.com/JPHMP/B124
There is a high degree of regional clustering in the network, also represented in Supplemental Digital Content 1, available at
. More than two-thirds (261/378, 69.0%) of relationships were among organizations in the same region. The remaining relationships (n = 117, 31.0%) occurred across regions and, of these, 67.5% (79/117) were within an immediately neighboring region. https://links.lww.com/JPHMP/B124
Organizations were found to interact infrequently: most commonly once a quarter (36.4%) or once a year or less (36.4%). When organizations did interact, the predominant areas of collaboration were client referral and consultation (70.3%) and knowledge sharing and exchange (56.8%). Only a small proportion of organizations were collaborating in the following areas: research and evaluation (12.0%), new technologies (3.6%), or technical assistance (1.6%;
TABLE 2 -
Nature and Extent of Relationships Among trans-LINK Network Member Organizations
N = 192
Areas of Collaboration a
Client referral and consultation
Knowledge sharing and exchange
Advocacy and awareness
Education and training
Collection and storage of data
Research and evaluation
Activities of Engagement a
N = 153
Attend the same meetings
Develop new resources (eg, guidelines, standards, tools)
Host joint events
Develop new programs or share existing programs
Share funding and apply for joint funding
Share administrative processes
Frequency of Interactions
N = 220
Once a year or less
About once a quarter
About once a month
aResponses are not mutually exclusive.
Among the relationships identified, engagement in cooperative activities was most common (attendance at the same meetings and/or sharing of resources; 96.1%), followed by coordinated activities (hosting joint events and/or developing new resources; 45.8%), and integrated activities (sharing administrative processes, funding, and/or applying for joint funding; 13.7%;
Table 1; see Supplemental Digital Content 2, available at ). Overall, the network achieved high scores for value (70.4%) and trust (83.4%) ( https://links.lww.com/JPHMP/B125 Figure). FIGURE:
Perceived Value of and Trust in the trans-LINK Network
aThe Value score is a composite measure of Power, Level of involvement, and Potential resource contribution. bThe Trust score is a composite measure of Reliability, Mission congruence, and Openness to discussion.
Six themes were derived from the insights of stakeholders in the consultation session related to enhancing collaboration, communication, and connection among network member organizations, of which the most prominent were “Communication and knowledge exchange channels” and “Clearer roles and contributions.” Six themes were also identified from the data on measuring/evaluating the longer-term success of the network, of which the most prominent were “Indicators of success” and “Client voices at the centre” (
TABLE 3 -
Recommendations Derived From the Content Analysis of Data From the Consultation Session With trans-LINK Network Member Organizations
What specific action items could we adopt to enhance collaboration, communication, and connection among network member organizations?
An easy channel for communication that doesn't bog down emails (maybe Slack, or a Google teams).
A clear breakdown listing what organizations DO want to contribute, and WHAT they are looking for so we can fill gaps. Formal support with bringing together organizations within regional areas. Communication and knowledge exchange channels
Roles and contributions Regional collaboration Create new communication and knowledge exchange channels for trans-LINK Network members, including an interactive virtual platform to enable regular check-ins and casual training opportunities (eg, lunch and learns).
Clarify trans-LINK Network member roles, contributions, and needs through the establishment of a live, member-facing repository of this information. Design and implement strategies to enhance regional collaboration across the trans-LINK Network, including the formation of regional working groups and establishment of new partnerships with 2SLGBTQI+ services.
Tailored communication products that member agencies may use to build awareness of the network—easily reproduced and leveraged within agency staff work plans.
Awareness of the network
Promote awareness of the trans-LINK Network through social media and the development of tailored communication products.
Create committees and teams that can help better connect regions and projects together; more hands on board means room for specific goals.
Subcommittees and teams
Establish trans-LINK Network subcommittees of organizations for program design and coordination.
Create more funding opportunities that we can share amongst each other for solidarity and to reduce redundancy.
Disseminate relevant funding opportunities that could support collaborative activities of the trans-LINK Network.
How do we measure or evaluate the longer-term success of the network in accomplishing these action items?
Measure how well members connect or link with each other because it's important we team up together and not feel like we have to individually create results, a specific evaluation for that.
Maybe by evaluating the services through our own clients who have been referred. Indicators of success
Client voices at the center Identify key measures of trans-LINK Network success, including number of new partnerships, formal agreements, advocacy initiatives, and social media engagements.
Center the voices of clients and service users in trans-LINK Network evaluations.
Regular evaluation form check-ins not just online but also through individual interviews + community evaluations (seeing what impact we are making).
Diverse methodological approaches
Utilize diverse methods to conduct trans-LINK Network evaluations, including focus groups, interviews, and social network analysis tools.
Evaluating each other's programming, and creating feedback on how to have greater impact with our service populations.
Improvements in the delivery of care of member organizations
Examine improvements in the delivery of care through trans-LINK Network member-based program evaluations.
Transparency around what accountability to this project may look like .... What is the ASK so that can define how participation is measured. For example each agency is to make 5 tweets/year and this is evaluated through an annual survey. This speaks to awareness as a SMART [specific, measurable, achievable, relevant and time-bound] objective.
Establish accountability mechanisms for trans-LINK Network member organizations, including use of SMART [specific, measurable, achievable, relevant, and time-bound] objectives and development of annual trans-LINK Network goals.
Member agencies can definitely share their evaluation frameworks from similar projects if possible. There's similar projects that could speak to some process or outcome eval frameworks.
Build upon existing frameworks to evaluate trans-LINK Network processes and outcomes.
The discipline of public health management and practice has increasingly acknowledged the promise of networks to enhance care and support for underserved communities.
Intersectoral networks have been framed as an opportunity to address the holistic needs of marginalized groups but are rarely evaluated at early stages of development. 42–45 Social network analysis is an ideal tool for such evaluations, as it can deepen understanding of a developing network's structural features, instill accountability among members, and ultimately increase impact. 46–48 23 , 30 , 35 , Moreover, social network analysis can provide a foundation from which to facilitate stakeholder-engaged development of policy and practice recommendations to enhance existing partnerships and increase the potential impact of networks focused on addressing complex health and social equity issues. 49 15 , Our baseline evaluation of a novel intersectoral network to improve the response to trans survivors of sexual assault revealed several key areas for growth, as well as strengths in collaboration, communication, and connection among members. 23 50 , 51
Our network achieved a density score of only 2.7%, lower than density scores reported in similar evaluations of public health collaboratives; however, larger and more diverse networks tend to be less dense and often face challenges in fostering new ties among members.
14 , 15 , 23 , 24 , 36 , With over 100 diverse member organizations, our network is relatively large in the size of its membership and breadth of organizations as compared with many collaboratives previously evaluated. 52 14 , 15 , 23 , 24 , In addition, despite a relatively low density score, our findings show that approximately 97.5% of network members are collaborating in the care and support of trans survivors across Ontario through 378 unique relationships. 36
There is also high variability in the degree of centrality in the trans-LINK Network, with some organizations assuming a more central position and others located more peripherally.
53 , Rather than one central node, however, our network has several different central organizations that could assume leading roles in bridging regional gaps, disseminating information through the network, and fostering collaboration among other clusters of organizations. 54 38 , 42 , These findings are positive, as previous studies have indicated that highly centralized or “star-shaped” network configurations can introduce vulnerability, such that central organizations often become inundated with information, referrals, and other issues that they cannot address alone. 53 36 , In contrast, our relatively decentralized network, comprising more widely distributed regional clusters with several highly connected bridgepoints, lends itself to a greater dispersal of responsibilities and more collaborative service delivery, which together are generally more effective in addressing complex issues. 55 33 , 55–57
Current collaborations within the trans-LINK Network are largely infrequent and superficial in nature, as the majority of organizations engage each other once a quarter or less, typically in cooperative activities such as client referral and/or knowledge sharing. These findings mimic those from earlier social network analysis studies, in which more integrated and frequent levels of interaction were less commonly documented.
24 , Although there is room for growth in our network vis-à-vis more intensive collaborative work, 36 referral and knowledge-sharing activities, though categorized as lower levels of engagement, are important to innovation and capacity-building in addressing comprehensive needs of specific populations. 38 35 , 51 , 58
Importantly, trans-LINK Network members highly value one another, as indicated by their perceived influence over the mission of the network, sharing of resources, and commitment to accomplishing related work. Our network also achieved a strong trust score reflecting a common vision, respectful engagement, and follow-through on commitments among members—a score comparable with or substantially greater than those reported in prior studies.
15 , 24 , As key antecedents of network success, high value and trust indicate that network member organizations could be fostering new connections with each other, addressing potential conflicts that may arise, effectively sharing information, enhancing the integration of collaborative activities, and, ultimately, achieving shared goals. 36 14 , 24 , 36 , 46 , 51
Stakeholder engagement in social network analysis-based process evaluations aids in the contextualization of quantitative data and has shown promise to enhance intersectoral collaboration in previous studies.
15 , Combining a social network analysis survey with more participatory research methods, wherein member organizations actively review and interpret findings to improve network function, can facilitate the generation of strategic and context-specific recommendations that are unlikely to emerge from conventional knowledge dissemination strategies (eg, circulating a lengthy report to members). 23 The 12 themes synthesized from our stakeholder consultation session, which reflected the critical insights and perspectives of engaged member organizations, provided a solid foundation from which policy and practice recommendations to advance the trans-LINK Network have been developed ( 15 Table 3).
Recommendations focused on, among other important actions, creating new communication channels, clarifying roles and contributions, deepening regional collaboration, and working in subcommittees could address some of the identified gaps in the quantity and quality of relationships, particularly given the network's high value and trust scores. Member organizations with higher degrees of centrality could serve as facilitators of new connections and early adopters or disseminators of our recommendations, as studies have suggested that centralized organizations yield high “innovation potential.”
Moving forward, representatives also wish to see the voices of trans service users centered in identifying key measures of network success. 59 Limitations
As we utilized the PARTNER tool, only 1 representative from each invited organization could respond to the survey. Although we advised respondents to consult with a manager or director where necessary, our data could nonetheless reflect perspectives from respondents lacking the knowledge and experience to adequately identify and evaluate a given organization's collaborations in the network. In addition, although we achieved a robust response rate (65.5%) from a sample representing all 7 regions of Ontario and a wide array of services and supports, our findings may not reflect the perspectives or experiences of all trans-LINK Network members. However, previous studies have demonstrated that network scores (eg, density) are sufficiently robust in analyses with response rates less than 100%.
Although there is considerable dispute on adequate response rates in social network analysis, scholars have suggested that rates between 50% and 70% are acceptable and unlikely to significantly bias results. 60 61 , 62 Conclusion
The trans-LINK Network is currently sparsely connected and composed largely of scattered and shallow collaborations. However, given the baseline nature of this study, the size and diversity of our network, and the exceedingly high trust and value scores achieved, our network appears to be performing well and has demonstrated an encouraging prospect for further growth. To ensure the sustainability of our network, we intend to foster this development by implementing and evaluating progress on the stakeholder recommendations derived from our consultation session.
These recommendations hold the potential to address the gaps and capitalize on the strengths identified through the PARTNER survey and, in doing so, optimize the functioning of the network. This, in turn, will bring the network closer to achieving its goal of improving the supports provided to trans survivors of sexual assault. 42 Implications for Policy & Practice
Sexual assault against trans persons is a complex public health and human rights problem that cannot be appropriately addressed by any single sector.
Large intersectoral networks among diverse trans-positive health care and community organizations with a common mission hold the potential to enhance the care and supports for trans survivors.
Recommendations to advance such networks in their early stages include increaseing communication among network members, clarifying their roles and contributions, and centering the voices of trans survivors in developing key measures of success.
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