Sexual assault, one of the most prominent forms of gender-based violence globally, is a pressing public health and human rights concern.1 2–6 7–10 11 7 , 12
Intersectoral networks can better address the complex needs of and negative responses to structurally marginalized groups by drawing on diverse organizational strengths13 , 14 15–17 8 , 18 , 19 20 19 , 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.22–29 22–29 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 , 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 al31 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.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 elsewhere31 , 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.
Procedure
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.
Data analysis
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.37 37 , 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.38
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 , 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.40 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.
Results
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
Region
N = 78
%
Central
14
17.9
Central West
16
20.5
Central East
9
11.5
Southwest
16
20.5
East
13
16.7
Northwest
5
6.4
Northeast
5
6.4
Total
78
100
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 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 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 ).
TABLE 2 -
Nature and Extent of Relationships Among trans-LINK Network Member Organizations
N = 192
%
Areas of Collaboration a
Client referral and consultation
135
70.3
Knowledge sharing and exchange
109
56.8
Advocacy and awareness
97
50.5
Education and training
97
50.5
Collection and storage of data
38
19.8
Research and evaluation
23
12.0
New technologies
7
3.6
Technical assistance
3
1.6
Activities of Engagement a
N = 153
%
Cooperative activities
148
96.7
Share resources
131
85.6
Attend the same meetings
83
54.2
Coordinated activities
70
45.8
Develop new resources (eg, guidelines, standards, tools)
46
30.1
Host joint events
32
20.9
Develop new programs or share existing programs
31
20.3
Integrated activities
21
13.7
Share funding and apply for joint funding
11
7.2
Share administrative processes
10
6.5
Frequency of Interactions
N = 220
%
Once a year or less
80
36.4
About once a quarter
80
36.4
About once a month
43
19.5
Every week
16
7.3
Every day
1
0.5
a Responses 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 https://links.lww.com/JPHMP/B125 Figure ).
FIGURE: Perceived Value of and Trust in the trans-LINK Networka The Value score is a composite measure of Power, Level of involvement, and Potential resource contribution.b The 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 ).
TABLE 3 -
Recommendations Derived From the Content Analysis of Data From the Consultation Session With trans-LINK Network Member Organizations
Question Posed
Representative Quotes
Themes Generated
Recommendations
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).
Communication and knowledge exchange channels
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).
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.
Funding opportunities
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.
Indicators of success
Identify key measures of trans-LINK Network success, including number of new partnerships, formal agreements, advocacy initiatives, and social media engagements.
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.
Accountability mechanisms
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.
Existing frameworks
Build upon existing frameworks to evaluate trans-LINK Network processes and outcomes.
Discussion
The discipline of public health management and practice has increasingly acknowledged the promise of networks to enhance care and support for underserved communities.42–45 46–48 23 , 30 , 35 , 49 15 , 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 , 52 14 , 15 , 23 , 24 , 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 , 54 38 , 42 , 53 36 , 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 , 36 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 , 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 , 23 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.”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%.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.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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