Mobilizing through dialogue: building interdisciplinary partnerships among forest health, wildland fire, and public health sectors to find solutions to address the impact of wildland fire smoke on communities

The impact of smoke from wildland fires on communities across the western United States is an interdisciplinary crisis that requires an interdisciplinary solution. There are increasing calls for cross-collaboration between forest, fire, air quality, and public health practitioners to best prepare communities for ever-worsening smoke seasons. However, opportunities to engage interdisciplinary groups of practitioners and stakeholders on this topic have been largely missing. We report on the development and implementation of a hybrid in-person and online workshop that brought together practitioners from Washington State to foster new interdisciplinary relationships and partnerships in order to integrate public health considerations into forest management during and beyond fire season. This workshop highlighted ways in which hybrid workshops can facilitate discussions across traditionally siloed stakeholders to address the community health crisis of wildfire smoke and illuminate tangible steps for further facilitating integrated discussions around a shared area of interest. Key lessons included the importance of introductory meetings for establishing strong collaborations and the strength of hybrid settings for fuller participation by diverse stakeholders. This manuscript outlines ways in which local practitioners from other smoke-impacted communities can begin to build and utilize interdisciplinary partnerships to prepare and adapt for longer and more severe wildland fire smoke seasons.


Introduction
The increasing frequency and severity of wildfires is a growing crisis that requires interdisciplinary action (D'Evelyn et al 2022). Lengthening wildfire seasons are contributing to increased area burned and severity of wildfires (Parks andAbatzoglou 2020, Abatzoglou, Juang et al 2021). In 2020, 25 million people were exposed to at least one day of smoke above 100 ug m −3 -an increase of 27-fold compared to smoke levels a decade earlier (Childs et al 2022). Extreme smoke events made national news in 2020 when dense smoke intruded large cities such as San Francisco and Seattle for multiple weeks (Savidge andHurd 2020, Rehman 2021). Increased attention from scientists, policymakers, community-based organizations, and the public has catalyzed discussions for interdisciplinary approaches to examine how wildfires impact both forest health and human health. This research overlap between the public health, forest ecology, and air quality disciplines will hereafter be referred to as the wildland fire -forest health -public health nexus (D'Evelyn et al 2022).
Before the exponential rise in megafires and large smoke events, the forest-health and human-health research spheres were, and to some extent remain, separated (Goss et al 2020, De Abreu 2022. However, due to the negative effects of smoke on human populations, there is mounting recognition of a need for integration of human health with forest management perspectives (National Academy of Sciences, National Academy of Engineering and Institute of Medicine of the National Academies 2005, Williamson et al 2016, Schweizer and Cisneros 2017, Davison et al 2021, Rice et al 2021, D'Evelyn et al 2022. Long-term wildland fuel reduction strategies such as forest thinning and prescribed burning have the potential to result in less severe wildfires and thus less severe smoke events (Martinson and Omi 2013). In recent years, interest in prescribed burning as an effective wildfire mitigation tool stemmed from the broader recognition that Indigenous communities have lived with fire for millennia and have cultural burning practices, often with much broader objectives than that of prescribed burning programs (Lake and Christianson 2019). Supporting and revitalizing these practices is increasingly recognized as critical for restoring western forest ecosystems and climate change adaptation (Kimmerer and Lake 2001, Lake et al 2018, Lake and Christianson 2019, Roos et al 2021. In the Comparative Assessment of the Impacts of Prescribed Fire Versus Wildfire released in 2021 by the EPA, fewer population exposures to smoke are attributed to prescribed fires than wildfires due to 'spatial extent of each prescribed fire and the meteorological characteristics of the days in which the prescribed fires occur' (United States Environmental Protection Agency 2021). Regardless, managing fire with fire increases the frequency of smoke outside of typical wildfire season, and smoke from any type of fire has the potential to cause adverse health effects (D'Evelyn et al 2022). To prepare communities for longer smoke seasons and improve the regulatory and political environment, we must increase interdisciplinary communications around the benefits of prescribed burning and its relative impact on smoke exposure.
To date, meetings to engage with interdisciplinary stakeholders on the impacts of fire and smoke have been largely missing (Lichtveld et al 2016, Errett et al 2019, Davison et al 2021. This is, in part, due to incongruent objectives and incentives around the primary interest of each set of actors. For instance, public health practitioners may focus primarily on reducing exposure to any smoke, while fire management practitioners may come from an understanding that elimination of any smoke exposure in the near term may result in greater fire and smoke risk in the future (D'Evelyn et al 2022). A primary hypothesis of interdisciplinary research and practice is that active engagement across disciplinary silos and stakeholder groups could illuminate overlapping interest areas or existing learning barriers (Ramey et al 2015, Ziegler et al 2016. While the literature so far on wildfires and community impacts has often called for interdisciplinary, multisector dialogue focused on problem definition and solutions (Miller 2020, Robarge et al 2020, evidence on the effective design, implementation, and subsequent results of such discussions is lacking. To our knowledge, this engagement workshop is one of the first to take intentional steps toward interdisciplinary collaborations at the practitioner level (National Academy of Sciences, National Academy of Engineering and Institute of Medicine of the National Academies 2005, Errett et al 2019, Davison et al 2021, Rice et al 2021. Here, we report on the development, implementation, and results from a workshop in Okanogan County, Washington facilitated by an interdisciplinary Wildfires and Health working group (WHWG) funded by the Science for Nature and People Partnership (The Nature Conservancy and Wildlife Conservation Society and National Center for Ecological Analysis and Synthesis 2022). The WHWG was created to bring together scientists from across the western United States and Canada to foster new interdisciplinary relationships and work toward integrating public health and health equity into forest and fire management. This group consisted mostly of academics in addition to a few policymakers from the region. Early discussions within the WHWG highlighted a broadly shared acknowledgment that the changes discussed must be implemented not at the academic level, but at the policy and practitioner level. Throughout this manuscript, practitioners are defined as individuals or organizations working in a local capacity to improve forest health, human health or air quality related specifically to wildland fire or prescribed burning.
To carry over work from WHWG discussions into the field, a practitioner engagement workshop was developed and coordinated to focus on the wildland fire -forest health -public health nexus. Here we describe a novel approach that brings together local practitioners to expand interdisciplinary action and cross-sector collaboration to improve both human and forest health. This approach is intended to be applicable to other smoke-impacted communities and settings. We conduct a qualitative content analysis of workshop participant notes and quotes to develop local recommendations and lay the groundwork for future research to understand the effectiveness of moving these relationships into interdisciplinary action.

Methods
In this section we first describe the broader context and planning of the workshop. We then discuss the key workshop activities that informed our content analysis of emerging themes for advancing action around wildfires and human health within Okanogan County, Washington.

Context and planning
This practitioner engagement workshop took place in Okanogan County, Washington in early November 2021. The Methow, Wenatchee, and Okanogan Valleys and the Colville Reservation in north central Washington are often inundated with wildfire smoke from June through September and then again during the winter months with smoke from wood burning stoves (Walker 2020, Cova, Saberi andPrichard 2022). Smoke levels are predicted to worsen with increasingly worse wildfire seasons and increased calls for prescribed fire (National Research Council 2011, Franz 2017, McKenzie and Littell 2017, Abatzoglou, Battisti et al 2021. This region is also rich with community-based organizations and local agencies working diligently to address the problem of smoke exposure who could speak firsthand to their experiences with smoke, forest management and local collaboration. Members of the WHWG first identified the need to explore this wildland fire -forest healthpublic health nexus at the practitioner level, identified Okanogan County as a region of interest, facilitated conversations between W&H and Washington practitioners, and then developed the workshop goal, agenda, and invitation list. Each step of this development is described in the flowchart depicted in figure 1.
Originally planned as an in-person event, the workshop was converted to a hybrid workshop with the continuation of the Covid-19 pandemic, with strict Covid precautions. All participants had the option to attend in-person or virtually via Zoom. We designed the hybrid workshop with the intention that vaccinated, local, community members could gather safely in-person, and those attending virtually could have as similar of an experience as possible. A group leader facilitated each virtual group in breakout rooms, which matched the inperson discussion groups, and the final two activities allowed collaboration both within and between the inperson and virtual groups.

Workshop structure
Throughout the workshop, we split both in-person and virtual participants into discussion groups of 4-6 people, intentionally organized to include participants from distinctly different disciplines. Each discussion group had a group leader who was a member of the SNAPP working group who had been instructed on how to take notes and facilitate the discussion.
The workshop began with two ice-breaker questions to engage participants, share why they attended, and help participants get to know each other. The meeting then moved into a series of short presentations. Three local experts, one in the field of fire ecology and forest management, another in community air quality, and a third in public and community health gave a 15-minute presentation on their work and what next steps they wanted to see related to smoke from both wildland and prescribed fires. After each presentation, participants were asked to reflect on what they had heard and were prompted with discussion questions by their group leaders (table 1).

Next steps activity
After the presentations and discussion, participants engaged in an activity outlined by Liberating Structures, a selection of microstructures developed for facilitating meetings and conversations (Lipmanowicz and McCandless 2014). The first activity was designed to Discover and Focus on What Each Person Has the Freedom and Resources to Do Now. Participants were asked: Reflect on the talks you just heard, and the strategies you discussed, and think about things you could do right now without any additional resources. Where do you have discretion and freedom to act? What can you do without more resources or authority?
After five minutes of self-reflection and sharing with partners, each discussion group was given access to a shared digital slide deck to write their group responses. This collection of responses was then read out loud to all participants, and participants were given the chance to give verbal feedback to the group. The shared slide deck was created on Google Slides and was used so both virtual and in-person participants could jointly engage throughout the course of the workshop.

Big idea activity
Having just shared what they could already do with their existing resources, participants were then prompted to propose what they would do if they had unlimited resources and access to collaborations. This activity was again based on a Liberating Structures activity to Rapidly Generate and Sift a Group's Most Powerful Actionable Ideas (Lipmanowicz and McCandless 2014). Each participant was given a notecard and asked: If you were ten times  bolder, what big idea would you recommend? Once they had written their idea on the notecard (or shared slide for virtual participants), participants swapped cards with their neighbor and were asked to rank the idea from 1-5 (1 low score, 5 high). A 20/20 score indicated everyone that reviewed the idea gave it the highest possible score. The cards were passed around until each idea had four scores. The final card holder was then asked to add up the scores and all ideas with the top ten scores were shared out loud with the full group.
The meeting concluded with a chance for all participants to share their takeaways from the day. All in-person participants were invited to a networking dinner to continue discussions from the day and to a field trip the following day to observe various forest management practices on the Confederated Tribes of the Colville Reservation. The field trip was hosted, organized, and led by staff from the Natural Resources Department of the Confederated Tribes of the Colville Reservation.

Analysis of workshop content
Qualitative coding Data collected from the workshop included direct quotes from participants and summarized notes taken by each group leader. All notes and quotations were combined and organized, and names were removed for a blind thematic analysis. These notes were analyzed using a simplified version of the Framework Method (Gale et al 2013). First, three research team members individually conducted inductive coding (MB, MP, and SD) and then met to discuss all identified codes which were organized into a matrix. As our data included only notes and quotations, the identified codes were less descriptive and more summative. As data were entered into the matrix, it became clear that our codes more closely resembled themes as defined by Gale et al (2013): interpretive concepts or propositions that describe or explain aspects of the data. This thematic matrix was further analyzed to identify recommendations and next steps.

Evaluation
After the workshop, we asked all participants to respond to a 12-question survey to evaluate the workshop format, content, and impact on each participant's work and future collaboration goals (Supplement 3). The first questions gauged participants' reactions to the hybrid format of the day, then focused on the content of the workshop and identified if the workshop had shifted participants' thinking on a certain topic. The survey concluded by asking participants about interactions they had with others and if they saw these relationships moving forward into a future collaboration.

Results
The final distribution of attendees is depicted in figure 2. An overrepresentation of forest and fire practitioners was due to last-minute cancellations and a set of unplanned invitations that is acknowledged as a limitation in the discussion below.
We organize our results into two sections. First, we outline the six themes that emerged during discussion questions and group exercises (i.e., Next Steps and Big Idea activities). The emergent themes highlight how different stakeholders from various sectors could work towards a common goal related to fire and smoke management (table 2). These themes were then synthesized into a list of recommendations for on the ground practitioners to expand interdisciplinary action and collaboration opportunities. Second, we present evaluation findings that include summarized participant feedback as it relates to the workshop format, workshop content, and interdisciplinary collaborations.

Themes
We identified six themes through the inductive coding process (table 2): 1) improving communication, awareness, and understanding, 2) improving community and individual prevention and response, 3) working toward interdisciplinary collaboration, 4) developing and improving tools, resources, and their distribution, 5) infrastructure improvements, and 6) minimizing adverse health impacts during wildfire smoke events.
In total, the six themes were coded a total of 216 times within the 149 quotations and notes for an average of 1-3 themes per note or quotation. The most frequent theme across the discussion questions was improving communication, awareness, and understanding. This theme was connected with a total of 80 notes or quotations, almost twice as many as the next theme, improving community and individual prevention and response. The theme that was least represented across participant responses was minimizing adverse health impacts during wildfire smoke events. The authors hypothesize that this finding may be a result of discussion questions not explicitly referencing health impacts, but rather focusing on community exposure as a whole. As groups were purposefully created to be representative of varying interests and backgrounds, the lower frequency of quotes attributed to the last theme is unlikely due to group composition driving discussions around key themes.

Recommendations for interdisciplinary advancement
Activities were designed to receive at least one response from each workshop participant. As these responses were organized into the themes, anything repeated or emphasized (noted by other participants with a +1 in the slide deck or with a high score of 15 + in the Big Ideas activity) were sorted and summarized as a list of recommendations for interdisciplinary action and collaboration opportunities in table 3.

Workshop evaluation findings
Sixty percent of all 54 attendees (virtual and in-person) responded to the evaluation survey. Feedback on the workshop format, content, and the potential for interdisciplinary collaboration was overwhelmingly positive (Supplement 3). Survey feedback demonstrated the hybrid workshop format was well received. Seventy-one percent said the format worked well, and 29% said they would have preferred an all in-person meeting.
The content of the workshop including the agenda of speakers and the discussion topics were intentionally planned to both foster collaboration and encourage participants to think outside of their discipline. In the evaluation, participants were asked if, by the end of the day, their thinking had shifted or changed. Responses to this question were mixed. A quarter of participants who responded to the evaluation said their perspective had in fact shifted: 'Yes. And from a practitioner perspective, it was surprising on the amount of positive support for prescribed burning smoke'. Another 25% did not think their thinking had shifted but rather had been expanded: 'It didn't shift my thinking, but it did provide additional nuances. I think I have a deeper understanding of the issues'. Those that said their thinking had not changed said that the meeting had reinforced what they already knew to be important: 'Not really. I know that smoke is a major human health issue and that we have tough decisions ahead to make with Rx burning and wildfire management.' The main workshop goal to foster new interdisciplinary relationships was accomplished. When asked if they were able to form new meaningful connections during this workshop, 28.6% of participants who responded to the survey strongly agreed, 57.1% agreed and 14.3% were neutral. When asked if they planned on following up with anyone they met, 76.2% of participants who responded to the survey said they would. Of that 76.2%, 90.5% said that the planned follow-up would involve crossing sectors/disciplines. One participant commented that they 'feel like I know who to contact if I need more information.' Another participant was able to grow their understanding and network within their own field: 'I was able to interact with individuals in the same field but with widely different applications and backgrounds. Felt a greater understanding/appreciation of the context I work within.' Figure 2. The final breakdown of attendees separated into forest & fire and public health expertise areas, and further categorized by profession. There were an additional four attendees who worked in local government but whose area of expertise did not fall into the disciplinary categories and therefore were not included in this figure. Includes education, raising awareness of resources or smoke exposure, and promoting the spread of information over news outlets, social media platforms, and within community groups.

'[we need improved] communication from clinical medicine to their high-risk patients'
'We need more timely communications with the public to identify when and where the public may be exposed to smoke from prescribed burns. We also need to identify where people get information and who all the partners are. We don't know everyone, and we meet new groups and new people all the time'. 'smoke and prescribed fire communication need to be trauma-informed and community-led' Individual and community prevention and response Includes individual and community-wide levels with any mention of planning, prevention strategies to be implemented before smoke events, and response plans to provide support after smoke events.
'Burn strategies should be implemented during times of adequate ventilation in communities' '[there is a need to] support forest restoration activities that address both climate and human impacts and also to protect communities [from smoke exposure]'.

Working toward interdisciplinary collaboration
includes codes that capture mentions of partnerships between sectors and stakeholders or any type of broad or close collaboration. Responses captured participants' desire to 'learn from others', the 'exchange of knowledge' and 'innovative solutions come from collaborative spaces'.
'Create a website with a 'one place for all' information that would require collaboration between both government and advocacy groups and would be built with high integrity for quality information and resources.' 'Create a multi-sector, multi-disciplinary, expert task force'. '[We need] long-lasting collaborative partnerships with a foundation of trust among participants.' Developing and improving tools, resources, and their distribution Includes mention of communication or education tools or proposed improvements to the distribution of such tools and resources.
Responses included conversations about the current online resources for air quality education, such as airnow.gov and the Washington Smoke blog, and areas in which physical tools and resources were lacking: 'We don't have equitable access to [information about] clean air' 'burners must provide the air purifiers to communities'. 'How can I best put these data together to build tools to keep everyone healthy and informed?'

Infrastructure improvements
Includes responses related to the creation of physical community or individual infrastructure enhancements and ideas for how to acquire government or other funding for such projects.

Discussion
Early in the workshop, one participant noted: 'At times we have been accidental adversaries. We must build bridges between forest/fire and health communities'. This workshop was intentionally created to break down assumptions and work toward collaborative interdisciplinary relationships. Several individuals started the workshop with preconceptions-'this person is completely against prescribed burning', or 'this person doesn't consider the health impacts of smoke'-these preconceptions were no longer present by the end of the day. To our knowledge, this engagement workshop is the first in the Pacific Northwest to take these intentional steps to make these collaborations happen and the first to do so at the local practitioner level. Our workshop lowered barriers and created new relationships. It moved the conversation from hypothetical academic discussions into grounded discussions at the practitioner-level that were rooted in political, economic, and social realities of the local context. However, the actionable steps that have been taken since these discussions have not been measured. Measuring the implementation of these actionable steps is an area for future work.
Since the workshop, both the workshop format and the resulting output from the data synthesis have been shared with two local, and one non-local, forest and health-related working groups, and with numerous seminars for smoke-prone audiences across the United States. While the specific recommendations and lessons learned are likely most applicable in the local context, we believe the format of this workshop can be applied in other smoke impacted communities in the Western US that interact with stakeholder groups with different interests and are grappling with similar challenges of growing megafires and the use of forest thinning and prescribed burning. The content of this manuscript is designed to help practitioners, such as community based or government organizations-replicate this type of facilitated workshop or meeting with the goal of generating tailored recommendations for their communities. In addition to our recommendations for interdisciplinary action, we have compiled a list of lessons learned (Supplement 1). These lessons, in addition to the planning specifics included in figure 1, the discussion questions and facilitation techniques provided through 'Liberating Structures', and the sample agenda (Supplement 2) are provided to guide practitioners in the facilitation of their own meetings.

Strengths and limitations
One of the main strengths of this research was the emphasis on the local context -the workshop included 39 local representatives from the Pacific Northwest, mostly from north central Washington. While many decisions can be made at state or regional scales, the impacts, and actions of those within local contexts can be a powerful entry Build community support and advocacy for prescribed and cultural burning by celebrating successes. Develop partnerships to create tools and resources such as web maps to predict fire acres and smoke emissions. Develop educational resources on forest health. Disseminate information on strategies for reducing smoke exposure through education and utilization of various communication channels (ensure messages and materials are available in multiple languages). Improving community and individual prevention and response Develop individual and community-wide smoke-ready and response plans.
Develop an interactive decision-making tool that can support individuals and communities to make decisions about their health Working towards interdisciplinary collaboration Develop long-lasting collaborative partnerships established on a foundation of trust across disciplines. Developing and improving tools, resources, and their distribution Support with identifying the most vulnerable households and households with the most vulnerable members (e.g., substandard, inadequate filtration, pre-existing health conditions, low-income) and allocate resources, subsidies, and supplies to help retrofit homes. Improving infrastructure Improve filtration systems (e.g., HVAC) inside homes by allocating resources and supplies such as air purifiers or box fan filters. Make improvements to the infrastructure of building facilities in the community (e.g., schools), which could serve as cooling or clean air centers/shelters. Minimizing adverse health impacts during wildfire smoke events Encourage participation in health studies that parse out the impact of smoke from prescribed fire and wildfire and occupational versus community exposure. Develop education programs to improve awareness of the health impacts of smoke exposure and encourage mask use during smoke events. point for collaborative discussions and insights. This workshop format of bringing local, on-the-ground practitioners together in a space to share and brainstorm should be shared with other smoke-impacted communities as a model approach to facilitating collaborative discussions and solutions. This is a first step toward interdisciplinary action. To make decisions for a smoke-impacted community, relationships between the local forest and fire managers, local community-based organizations, and local public health departments must be strong. Without this, the status quo is that sectors are not working together. Modern fire seasons are increasingly severe, and they are impacting people near and far. To date, policies and efforts to address wildfire smoke impacts are reactive rather than planned and strategic. This indicates that other approaches are needed. Our work solidified these cross-disciplinary relationships in Okanogan County. Future research should identify not whether greater collaboration will lead to improved outcomes for communities, but how and what shape these collaborations have taken to have the most immediate impact on fire and land management and the health and well-being of their communities. This research also had several limitations. Although all notetakers were given the same instructions on how to record small group discussions, there was some variation between groups in the volume and level of detail of notes recorded. Additionally, although in the original invitation list we were intentional about including an equal number of participants from each sector, this was not reflected in the final count the day of the workshop (figure 2). This imbalance could be avoided in future events by setting a concrete closing date for invitations. In our case, forest and fire practitioners were overrepresented in our participant pool compared to public health practitioners. The morning of the event, as we realized more forest and fire participants were in attendance, we did our best to spread people out between the different discussion groups. However, it is still possible that in the larger group conversations that this over-representation may have shifted the conversations toward forest and fire. Both stated limitations may have contributed to the fact that the theme of minimizing adverse health impacts during wildfire smoke events was the least recorded theme across the data collected. However, we do not believe that this impacted the validity of recommendations made, or the impact of this workshop overall.

Conclusion
Our case study on a local practitioner engagement workshop at the wildlife fire -forest health -public health nexus advances the broader literature about interdisciplinary work. While several working groups have begun to integrate these disciplines via research collaborations, reports of on-the-ground work to integrate practitioners, community, and other local voices have been limited. Our workshop set the stage for local practitioners to begin to work together in north central Washington and laid the foundation to develop other similar workshops to instigate collaboration and change in smoke-impacted communities across the country and for future research evaluating the effectiveness of this approach.