Partnership synergy: a practical framework for studying and strengthening the collaborative advantage

A multistate examination of partnership activity among local public health systems using the National Public Health Performance Standards

This study examines whether partnership-related measures in the second version of the National Public Health Performance Standards (NPHPS) are useful in evaluating level of activity as well as identifying latent constructs that exist among local public health systems (LPHSs). In a sample of 110 LPHSs, descriptive analysis was conducted to determine frequency and percentage of 18 partnership-related NPHPS measures. Principal components factor analysis was conducted to identify unobserved characteristics that promote effective partnerships among LPHSs. Results revealed that 13 of the 18 measures were most frequently reported at the minimal-moderate level (conducted 1%-49% of the time). Coordination of personal health and social services to optimize access (74.6%) was the most frequently reported measure at minimal-moderate levels. Optimal levels (conducted >75% of the time) were reported most frequently in 2 activities: participation in emergency preparedness coalitions and local health departments ensuring service provision by working with state health departments (67% and 61% of respondents, respectively) and the least optimally reported activity was review partnership effectiveness (4% of respondents). Factor analysis revealed categories of partnership-related measures in 4 domains: resources and activities contributing to relationship building, evaluating community leadership activities, research, and state and local linkages to support public health activities. System-oriented public health assessments may have questions that serve as proxy measures to examine levels of interorganizational partnerships. Several measures from the NPHPS were useful in establishing a national baseline of minimal and optimal activity levels as well as identifying factors to enhance the delivery of the 10 essential public health services among organizations and individuals in public health systems.

Linkages between clinical practices and community organizations for prevention: a literature review and environmental scan

CONTEXT

A literature review and environmental scan were conducted to develop a framework for interventions that utilize linkages between clinical practices and community organizations for the delivery of preventive services, and to identify and characterize these efforts.

EVIDENCE ACQUISITION

A search was made of four major health services and social science electronic databases and an Internet search was conducted to identify examples of linkage interventions in the areas of tobacco cessation, obesity, nutrition, and physical activity.

EVIDENCE SYNTHESIS

In all, 49 interventions were identified, of which 18 examples described their evaluation methods or reported any intervention outcomes. Few conducted evaluations that were rigorous enough to capture changes in intermediate or long-term health outcomes. Outcomes in these evaluations were primarily patient-focused and did not include organizational or linkage characteristics.

CONCLUSIONS

An attractive option to increase the delivery of preventive services is to link primary care practices to community organizations; evidence is not yet conclusive, however, that such linkage interventions are effective. Findings provide recommendations to researchers and organizations that fund research, and call for a framework and metrics to study linkage interventions.

Linkages between clinical practices and community organizations for prevention: a literature review and environmental scan

OBJECTIVES

We conducted a literature review and environmental scan to develop a framework for interventions that utilize linkages between clinical practices and community organizations for the delivery of preventive services, and to identify and characterize these efforts.

METHODS

We searched 4 major health services and social science electronic databases and conducted an Internet search to identify examples of linkage interventions in the areas of tobacco cessation, obesity, nutrition, and physical activity.

RESULTS

We identified 49 interventions, of which 18 examples described their evaluation methods or reported any intervention outcomes. Few conducted evaluations that were rigorous enough to capture changes in intermediate or long-term health outcomes. Outcomes in these evaluations were primarily patient-focused and did not include organizational or linkage characteristics.

CONCLUSIONS

An attractive option to increase the delivery of preventive services is to link primary care practices to community organizations; evidence is not yet conclusive, however, that such linkage interventions are effective. Findings provide recommendations to researchers and organizations that fund research, and call for a framework and metrics to study linkage interventions.

"Changing the text": modeling council capacity to produce institutionalized change

Collaboration is a ubiquitous approach to change, but is notoriously difficult and not definitively linked to desirable outcomes. Not surprisingly, the collaboration literature is replete with numerous facilitators and barriers to collaborative efforts. The current study aimed to develop a parsimonious model of factors influencing the success of collaborative efforts both internal and external to the council, including, (a) features of the council environment, (b) intermediate outcomes including the empowerment of members in the council context and the degree to which councils have generated social capital and (c) the extent to which collaborative efforts are occurring in a community context supportive of their aims. In particular, this study examines whether these factors affect the extent to which councils are positioned to achieve institutionalized change, or changes "in the text" that govern front line providers' (e.g., police, advocates) practices in the community response to intimate partner violence. Results suggest that perceived member empowerment, generation of social capital, and supportive community context are the most important predictors of the extent to which councils foster shifts in institutionalized change. Features of the council environment are only indirectly related to the degree to which institutionalized change is ultimately fostered as mediated by the generation of social capital. This suggests that the ability of members to act as change agents and the extent to which those in power support council efforts figure more prominently to facilitate or constrain council efforts than council functioning itself.

A mixed-method exploration of functioning in Safe Schools/Healthy Students partnerships

This paper presents a mixed-method approach to measuring the functioning of Safe Schools/Healthy Students (SS/HS) Initiative partnerships. The SS/HS national evaluation team developed a survey to collect partners' perceptions of functioning within SS/HS partnerships. Average partnership functioning scores were used to rank each site from lowest to highest. Sites with the most favorable perceptions of partnership functioning were defined as having average scores in the top 10% (n=10) and sites with the least favorable perceptions of partnership functioning were defined as having average scores in the bottom 10% (n=10). Qualitative data for these 20 sites were inductively open coded for emergent themes and analyzed for patterns using grounded theory approach. Six themes emerged that distinguished sites reporting the most favorable and least favorable perceptions of partnership functioning: partner engagement, facilitators, barriers, shared decision making, partnership structure, and sustainability. Sites reporting the most favorable perceptions of partnership functioning effectively utilized collaboration processes that facilitate coalition building, such as shared decision making, effective communication, and developing a clearly defined structure. Qualitative themes from this analysis provide evidence of validity for the partnership functioning scale used and illustrate distinguishing features between sites with the most favorable and least favorable perceptions of partnership functioning.

A national evaluation of Safe Schools/Healthy Students: outcomes and influences

The Safe Schools/Healthy Students (SS/HS) Initiative has awarded over $2 billion in grants to more than 350 school districts in partnership with local mental health, law enforcement, and juvenile justice agencies. To estimate the impact of grantee characteristics, grant operations, and near-term outcomes in reducing violence and substance use, promoting mental health, and enhancing school safety, logged odds ratios (LORs) were calculated contrasting Year 3 with Baseline performance from grantee-provided data on seven outcome measures. After comparing grantee performance across outcomes and outcomes across grantees, the LORs were entered as dependent variables in a series of meta-regressions in which grantee characteristics, grant operations, and near-term outcomes were tested after controlling for pre-grant characteristics. Findings indicate that the SS/HS Initiative significantly improved most outcomes, that within-grantee performance varied greatly by outcome, and that random-effects meta-regression appreciably decreased the variance available for modeling. The approach demonstrates that the SS/HS Initiative is effective and that locally collected performance data can be used to estimate grantee success in improving youth outcomes.

Action planning for daily mouth care in long-term care: the brushing up on mouth care project

Research focusing on the introduction of daily mouth care programs for dependent older adults in long-term care has met with limited success. There is a need for greater awareness about the importance of oral health, more education for those providing oral care, and organizational structures that provide policy and administrative support for daily mouth care. The purpose of this paper is to describe the establishment of an oral care action plan for long-term care using an interdisciplinary collaborative approach. Methods. Elements of a program planning cycle that includes assessment, planning, implementation, and evaluation guided this work and are described in this paper. Findings associated with assessment and planning are detailed. Assessment involved exploration of internal and external factors influencing oral care in long-term care and included document review, focus groups and one-on-one interviews with end-users. The planning phase brought care providers, stakeholders, and researchers together to design a set of actions to integrate oral care into the organizational policy and practice of the research settings. Findings. The establishment of a meaningful and productive collaboration was beneficial for developing realistic goals, understanding context and institutional culture, creating actions suitable and applicable for end-users, and laying a foundation for broader networking with relevant stakeholders and health policy makers.

A model of knowledge translation in health: the Active Healthy Kids Canada Report Card on physical activity for children and youth

The health of Canadian children and youth has deteriorated in the past few decades and physical inactivity is a powerful contributor. Active Healthy Kids Canada (AHKC; www.activehealthykids.ca) is a national not-for-profit organization with a mission to inspire the nation to engage all children and youth in physical activity by providing expertise and direction to policy makers and the public on how to increase and effectively allocate resources and attention toward physical activity for Canadian children and youth. Annually, for the past 7 years, the AHKC Report Card has consolidated and translated research knowledge to drive social action for policy change relating to physical activity among children and youth. Original published articles and key surveillance data from national and regional surveys are reviewed. A group of content experts from across Canada meet semiannually to review the evidence and assign letter grades. The AHKC Report Card has played a key role in informing discussions that have led to action on physical inactivity in Canada. Further evidence of the Report Card's influence is in the replication of the model in several other jurisdictions, including Saskatchewan and Ontario, Canada; Louisiana, United States; South Africa; Mexico; and Kenya.

Multilevel measurement of dimensions of collaborative functioning in a network of collaboratives that promote child and family well-being

Evaluating collaboration between community partners presents a series of methodological challenges (Roussos and Fawcett in Annu Rev Public Health 21:369-402, 2000; Yin and Kaftarian 1997), one of which is selection of the appropriate level of analysis. When data are collected from multiple members of multiple settings, multilevel analysis techniques should be used. Multilevel confirmatory factor analysis (MCFA) is an analytic approach that incorporates the advantages of latent variable measurement modeling and multilevel modeling for nested data. This study utilizes MCFA on data obtained from an evaluation survey of collaborative functioning provided to members of 157 community collaboratives in Georgia. This study presents a well-fitting measurement model that includes five dimensions of collaborative functioning, and a structural component with individual- and collaborative-level covariates. Findings suggest that members' role and meeting attendance significantly predicted their assessment of collaboration at the individual level, and that tenure of collaborative leaders predicted the overall functioning of the collaborative at the collaborative level. Dimensionality of collaborative functioning and implications of potentially substantial measurement biases associated with selection of respondents are addressed.

Addressing cancer disparities via community network mobilization and intersectoral partnerships: a social network analysis

Community mobilization and collaboration among diverse partners are vital components of the effort to reduce and eliminate cancer disparities in the United States. We studied the development and impact of intersectoral connections among the members of the Massachusetts Community Network for Cancer Education, Research, and Training (MassCONECT). As one of the Community Network Program sites funded by the National Cancer Institute, this infrastructure-building initiative utilized principles of Community-based Participatory Research (CBPR) to unite community coalitions, researchers, policymakers, and other important stakeholders to address cancer disparities in three Massachusetts communities: Boston, Lawrence, and Worcester. We conducted a cross-sectional, sociometric network analysis four years after the network was formed. A total of 38 of 55 members participated in the study (69% response rate). Over four years of collaboration, the number of intersectoral connections reported by members (intersectoral out-degree) increased, as did the extent to which such connections were reported reciprocally (intersectoral reciprocity). We assessed relationships between these markers of intersectoral collaboration and three intermediate outcomes in the effort to reduce and eliminate cancer disparities: delivery of community activities, policy engagement, and grants/publications. We found a positive and statistically significant relationship between intersectoral out-degree and community activities and policy engagement (the relationship was borderline significant for grants/publications). We found a positive and statistically significant relationship between intersectoral reciprocity and community activities and grants/publications (the relationship was borderline significant for policy engagement). The study suggests that intersectoral connections may be important drivers of diverse intermediate outcomes in the effort to reduce and eliminate cancer disparities. The findings support investment in infrastructure-building and intersectoral mobilization in addressing disparities and highlight the benefits of using CBPR approaches for such work.

Organizational Collaborative Capacity in Fighting Pandemic Crises

Collaborative capacity serves for organizations as the capacity to collaborate with other network players. Organizational capacity matters as collaboration outcomes usually go beyond single-shot implementation efforts or a single-minded focus on either the vertical dimension of program or the horizontal component. This review article explores organizational collaborative capacities from the perspective of public management, in particular, network theory. By applying the 5 attributes of network theory—interdependence, membership, resources, information, and learning—to the explanation of collaborative capacity in fighting pandemic crises, I argue in some ways organizational collaborative capacity is very much like an organization in its own right. Studying collaborative capacity in the battle against pandemics facilitate our understanding of multisectoral collaboration in technical, political, and institutional dimensions, and greatly advances the richness of capacity vocabulary in pandemic response and preparedness.

Disease-management partnership functioning, synergy and effectiveness in delivering chronic-illness care

OBJECTIVE

This study explored associations among disease-management partnership functioning, synergy and effectiveness in the delivery of chronic-illness care.

DESIGN

This study had a cross-sectional design.

SETTING AND PARTICIPANTS

The study sample consists of 218 professionals (out of 393) participating in 22 disease-management partnerships in various regions of the Netherlands.

MAIN OUTCOME MEASURES

We assessed the relationships among partnership functioning, synergy and effectiveness in the delivery of chronic-illness care. Partnership functioning was assessed through leadership, resources, administration and efficiency. Synergy was considered the proximal outcome of partnership functioning, which, in turn, influenced the effectiveness of disease-management partnerships [measured with the Assessment of Chronic Illness Care (ACIC) survey instrument].

RESULTS

Overall ACIC scores ranged from 3 to 10, indicating basic/intermediate to optimal/comprehensive delivery of chronic-illness care. The results of the regression analysis demonstrate that partnership effectiveness was positively associated with leadership (β = 0.25; P≤ 0.01), and resources (β = 0.31; P≤ 0.001). No significant relationship was found between administration, efficiency and partnership effectiveness. Partnership synergy acted as a mediator for partnership functioning and was statistically significantly associated with partnership effectiveness (β = 0.25; P≤ 0.001).

CONCLUSION

Disease-management partnerships seemed better able to deliver higher levels of chronic-illness care when synergy is created between partners. Synergy was more likely to emerge with boundary-spanning leaders who understood and appreciated partners' different perspectives, could bridge their diverse cultures and were comfortable sharing ideas, resources and power. In addition, the acknowledgement of and ability to use members' resources are valuable in engaging partners' involvement and achieving synergy in disease-management partnerships.

Network formation, governance, and evolution in public health: the North American Quitline Consortium case

BACKGROUND

Collaborative networks of health organizations have received a great deal of attention in recent years as a way of enhancing the flow of information and coordination of services. However, relatively little is known about how such networks are formed and evolve, especially outside a local, community-based setting. This article is an in-depth discussion of the evolution of the North American Quitline Consortium (NAQC). The NAQC is a network of U.S. and Canadian organizations that provide telephone-based counseling and related services to people trying to quit smoking.

METHODOLOGY

The research draws on data from interviews, documents, and a survey of NAQC members to assess how the network emerged, became formalized, and effectively governed.

FINDINGS

The findings provide an understanding of how multiregional public health networks evolve, while building on and extending the broader literature on organizational networks in other sectors and settings. Specifically, we found that the network form that ultimately emerged was a product of the back-and-forth interplay between the internal needs and goals of those organizations that would ultimately become network members, in this case, state-, and provincial-level tobacco quitline organizations. We also found that network formation, and then governance through a network administrative organization, was driven by important events and shifts in the external environment, including the impact and influence of major national organizations.

PRACTICE IMPLICATIONS

The results of the study provide health care leaders and policy officials an understanding of how the activities of a large number of organizations having a common health goal, but spanning multiple states and countries, might be coordinated and integrated through the establishment of a formal network.

Practical steps to community engaged research: from inputs to outcomes

For decades, the dominant research paradigm has included trials conducted in clinical settings with little involvement from communities. The move toward community engaged research (CEnR) necessitates the inclusion of diverse perspectives to address complex problems. Using a relationship paradigm, CEnR reframes the context, considerations, practical steps, and outcomes of research.

Mapping synergy and antagony in North-South partnerships for health: a case study of the Tanzanian women's NGO KIWAKKUKI

North–South partnerships for health aim to link resources, expertise and local knowledge to create synergy. The literature on such partnerships presents an optimistic view of the promise of partnership on one hand, contrasted by pessimistic depictions of practice on the other. Case studies are called for to provide a more intricate understanding of partnership functioning, especially viewed from the Southern perspective. This case study examined the experience of the Tanzanian women's NGO, KIWAKKUKI, based on its long history of partnerships with Northern organizations, all addressing HIV/AIDS in the Kilimanjaro region. KIWAKKUKI has provided education and other services since its inception in 1990 and has grown to include a grassroots network of >6000 local members. Using the Bergen Model of Collaborative Functioning, the experience of KIWAKKUKI's partnership successes and failures was mapped. The findings demonstrate that even in effective partnerships, both positive and negative processes are evident. It was also observed that KIWAKKUKI's partnership breakdowns were not strictly negative, as they provided lessons which the organization took into account when entering subsequent partnerships. The study highlights the importance of acknowledging and reporting on both positive and negative processes to maximize learning in North–South partnerships.

Establishing a multicentre clinical research network: lessons learned

BACKGROUND

Within many health care disciplines, research networks have emerged to connect researchers who are physically separated, to facilitate sharing of expertise and resources, and to exchange valuable skills. A multicentre research network committed to studying difficult cancer pain problems was launched in 2004 as part of a Canadian initiative to increase palliative and end-of-life care research capacity. Funding was received for 5 years to support network activities.

METHODS

Mid-way through the 5-year granting period, an external review panel provided a formal mid-grant evaluation. Concurrently, an internal evaluation of the network by survey of its members was conducted. Based on feedback from both evaluations and on a review of the literature, we identified several components believed to be relevant to the development of a successful clinical cancer research network.

RESULTS

THESE COMMON ELEMENTS OF SUCCESSFUL CLINICAL CANCER RESEARCH NETWORKS WERE IDENTIFIED: shared vision, formal governance policies and terms of reference, infrastructure support, regular and effective communication, an accountability framework, a succession planning strategy to address membership change over time, multiple strategies to engage network members, regular review of goals and timelines, and a balance between structure and creativity.

CONCLUSIONS

In establishing and conducting a multi-year, multicentre clinical cancer research network, network members were led to reflect on the factors that contributed most to the achievement of network goals. Several specific factors were identified that seemed to be highly relevant in promoting success. These observations are presented to foster further discussion on the successful design and operation of research networks.

[Diagnostic tool for action in partnerships: foundation, development and validation]

OBJECTIVES

Intervening on social determinants of health requires that public health stakeholders enter into intersectoral partnerships. The lack of valid tools to evaluate the quality of partnerships is a significant constraint to formulating convincing arguments for this kind of action. In light of this shortcoming, the tool described in this article evaluates processes of collective action based on key aspects of its effectiveness.

METHOD

The tool is based on a theoretical model that followed from case studies identifying the conditions associated with quality of partnerships. The tool was developed by operationalizing these conditions into a series of statements, and pretested using the cognitive interviewing method. Construct validity and ecological validity were verified.

RESULTS

The tool includes 18 items, with 3 answer choices provided for each item. It is sensitive to variations in judgement. It allows for good convergence among respondents from participating organizations within a partnership; it can also distinguish between partnerships that have difficulty meeting certain conditions and those that do not. The tool is suitable for self-evaluation of partnerships engaged in common projects that involve more than information exchange.

DISCUSSION

The tool's validity resides in its validation procedure and in the basic soundness of its theoretical model, which is supported by a number of literature reviews on how partnerships function and their results.

An Exploration of the Effect of Community Engagement in Research on Perceived Outcomes of Partnered Mental Health Services Projects()

Mental health research projects address sensitive issues for vulnerable populations and are implemented in complex environments. Community-Based Participatory Research approaches are recommended for health research on vulnerable populations, but little is known about how variation in participation affects outcomes of partnered research projects. We developed a conceptual model demonstrating the impact of community engagement in research on outcomes of partnered projects. We collected data on key constructs from community and academic leaders of 21 sampled partnered research projects in two cycles of an NIMH research center. We conducted empirical analyses to test the model. Our findings suggest that community engagement in research is positively associated with perceived professional development, as well as political and community impact.

Balancing the benefits and risks of public-private partnerships to address the global double burden of malnutrition

OBJECTIVE

Transnational food, beverage and restaurant companies, and their corporate foundations, may be potential collaborators to help address complex public health nutrition challenges. While UN system guidelines are available for private-sector engagement, non-governmental organizations (NGO) have limited guidelines to navigate diverse opportunities and challenges presented by partnering with these companies through public-private partnerships (PPP) to address the global double burden of malnutrition.

DESIGN

We conducted a search of electronic databases, UN system websites and grey literature to identify resources about partnerships used to address the global double burden of malnutrition. A narrative summary provides a synthesis of the interdisciplinary literature identified.

RESULTS

We describe partnership opportunities, benefits and challenges; and tools and approaches to help NGO engage with the private sector to address global public health nutrition challenges. PPP benefits include: raising the visibility of nutrition and health on policy agendas; mobilizing funds and advocating for research; strengthening food-system processes and delivery systems; facilitating technology transfer; and expanding access to medications, vaccines, healthy food and beverage products, and nutrition assistance during humanitarian crises. PPP challenges include: balancing private commercial interests with public health interests; managing conflicts of interest; ensuring that co-branded activities support healthy products and healthy eating environments; complying with ethical codes of conduct; assessing partnership compatibility; and evaluating partnership outcomes.

CONCLUSIONS

NGO should adopt a systematic and transparent approach using available tools and processes to maximize benefits and minimize risks of partnering with transnational food, beverage and restaurant companies to effectively target the global double burden of malnutrition.

Developing a scale to measure synergy in health promotion partnerships

Synergy is the degree to which a partnership combines the assets of all the partners in the search for better solutions and is generally regarded as the product of a partnership including vertical integration, shared know-how and shared resources. There has been very little research on the determinants and measurement of synergy in health promotion partnerships. This study was designed to describe how synergy is conceptualized in health promotion partnerships and to develop a synergy measurement tool. Five focus groups were organized with 36 health promotion partners in order to explore how synergy is conceptualized in their partnerships. Participants represented health, community, education, arts, sports and youth sectors. Focus groups were recorded and transcribed verbatim. A content analysis was carried out on the transcripts using counting and data reduction techniques. An item pool was generated from these findings and an eight-item five-point scale was developed called the Jones synergy scale. This scale was incorporated into an overall questionnaire on partnership functioning which was posted to 469 partners in 40 health promotion partnerships. A response rate of 72% was achieved for the postal survey (n = 337). The Jones synergy scale was subjected to reliability and validity tests. Cronbach's alpha was 0.91. Corrected item-total correlations ranged from 0.6 to 0.7 with a Cronbach's alpha if item deleted of 0.9 for all items. Principal components analysis (PCA) was the chosen factor analysis method. One component was extracted explaining 62% of the variance. Coefficients ranged from 0.83 to 0.70 with an initial eigenvalue of 4.94. The scale was subjected to item-convergent, item-discriminant and concurrent validity tests. All items correlated more strongly with their own scale than with any other scales used in the questionnaire. The Jones synergy scale was highly correlated (0.73, P < 0.01) with an existing synergy scale.

Closing the (service) gap: exploring partnerships between Aboriginal and mainstream health services

BACKGROUND

Although effective partnerships between Aboriginal and mainstream health services are critical to improve Aboriginal health outcomes, many factors can cause these partnerships to be tenuous and unproductive. Understanding the elements of best practice for successful partnerships is essential.

METHODS

A literature review was conducted in 2009 using keyword searches of electronic databases. Sourced literature was assessed for relevance regarding the benefits, challenges, lessons learnt and factors contributing to successful Aboriginal and mainstream partnerships. Key themes were collated.

RESULTS

Although there is much literature regarding general partnerships generally, few specifically examine Aboriginal and mainstream health service partnerships. Twenty-four sources were reviewed in detail. Benefits include broadening service capacity and improving the cultural security of healthcare. Challenges include the legacy of Australia's colonial history, different approaches to servicing clients and resource limitations. Recommendations for success include workshopping tensions early, building trust and leadership.

CONCLUSION

Although successful partnerships are crucial to optimise Aboriginal health outcomes, failed collaborations risk inflaming sensitive Aboriginal-non-Aboriginal relationships. Factors supporting successful partnerships remind us to develop genuine, trusting relationships that are tangibly linked to the Aboriginal community. Failure to invest in this relational process and push forward with 'business as usual' can ultimately have negative ramifications on client outcomes.

The role of community context in planning and implementing community-based health promotion projects

The current study examines how community context affected collaborative planning and implementation in eight sites participating in a healthy cities and communities initiative in California. Data are from 23 focus groups conducted with coalition members, and 76 semi-structured interviews with local coordinators and community leaders. Multiple case study methods were used to identify major themes related to how five contextual domains influenced collaborative planning and implementation. Results showed that history of collaboration can influence resources and interpersonal and organizational connections available for planning and implementation, as well as priorities selected for action. Community politics and history can affect which segments of the community participate in a planning process and what issues are prioritized, as well as the pool of partners willing to aid in implementation. Some community norms and values bring people together and others appear to limit involvement from certain groups. Community demographics and economic conditions may shape outreach strategies for planning and implementation, and may also shape priorities. Geography can play a role in assessment methods, priority selection, partners available to aid in implementation, and participation in activities and events. Results suggest that community context plays a substantive role in shaping how community-based health promotion projects unfold.

[Diagnostic tool for action in partnerships: foundation, development and validation]

OBJECTIVES

Intervening on social determinants of health requires that public health stakeholders enter into intersectoral partnerships. The lack of valid tools to evaluate the quality of partnerships is a significant constraint to formulating convincing arguments for this kind of action. In light of this shortcoming, the tool described in this article evaluates processes of collective action based on key aspects of its effectiveness.

METHOD

The tool is based on a theoretical model that followed from case studies identifying the conditions associated with quality of partnerships. The tool was developed by operationalizing these conditions into a series of statements, and pretested using the cognitive interviewing method. Construct validity and ecological validity were verified.

RESULTS

The tool includes 18 items, with 3 answer choices provided for each item. It is sensitive to variations in judgement. It allows for good convergence among respondents from participating organizations within a partnership; it can also distinguish between partnerships that have difficulty meeting certain conditions and those that do not. The tool is suitable for self-evaluation of partnerships engaged in common projects that involve more than information exchange.

DISCUSSION

The tool's validity resides in its validation procedure and in the basic soundness of its theoretical model, which is supported by a number of literature reviews on how partnerships function and their results.

Development and validation of a short version of the Partnership Self-Assessment Tool (PSAT) among professionals in Dutch disease-management partnerships

BACKGROUND

The extent to which partnership synergy is created within quality improvement programmes in the Netherlands is unknown. In this article, we describe the psychometric testing of the Partnership Self-Assessment Tool (PSAT) among professionals in twenty-two disease-management partnerships participating in quality improvement projects focused on chronic care in the Netherlands. Our objectives are to validate the PSAT in the Netherlands and to reduce the number of items of the original PSAT while maintaining validity and reliability.

METHODS

The Dutch version of the PSAT was tested in twenty-two disease-management partnerships with 218 professionals. We tested the instrument by means of structural equation modelling, and examined its validity and reliability.

RESULTS

After eliminating 14 items, the confirmatory factor analyses revealed good indices of fit with the resulting 15-item PSAT-Short version (PSAT-S). Internal consistency as represented by Cronbach's alpha ranged from acceptable (0.75) for the 'efficiency' subscale to excellent for the 'leadership' subscale (0.87). Convergent validity was provided with high correlations of the partnership dimensions and partnership synergy (ranged from 0.512 to 0.609) and high correlations with chronic illness care (ranged from 0.447 to 0.329).

CONCLUSION

The psychometric properties and convergent validity of the PSAT-S were satisfactory rendering it a valid and reliable instrument for assessing partnership synergy and its dimensions of partnership functioning.

Practical strategies for promoting full inclusion of individuals with disabilities in community-based participatory intervention research

Community-based participatory research (CBPR) with disability communities is directed toward facilitating full inclusion of individuals with disabilities and disability community organizations in all aspects of the research process. Within the CBPR framework, academic-disability community partners may value and wish to use experimental designs to test interventions. Being aware of and proactively addressing barriers and challenges to inclusion in the areas of human resources, training, productivity, accommodation, and inadequate funding for disability community organizations are critical for success. Some of the strategies discussed in this article for addressing these challenges include creating redundant systems, providing benefits counseling and individualized payment options for employment, designing trainings to be disability friendly, and carefully considering selection of partners in light of available community resources.

Integrating an ecological approach into an Aboriginal community-based chronic disease prevention program: a longitudinal process evaluation

BACKGROUND

Public health promotes an ecological approach to chronic disease prevention, however, little research has been conducted to assess the integration of an ecological approach in community-based prevention programs. This study sought to contribute to the evidence base by assessing the extent to which an ecological approach was integrated into an Aboriginal community-based cardiovascular disease (CVD) and type 2 diabetes prevention program, across three-intervention years.

METHODS

Activity implementation forms were completed by interview with implementers and participant observation across three intervention years. A standardised ecological coding procedure was applied to assess participant recruitment settings, intervention targets, intervention strategy types, extent of ecologicalness and organisational partnering. Inter-rater reliability for two coders was assessed at Kappa = 0.76 (p < .0.001), 95% CI (0.58, 0.94).

RESULTS

215 activities were implemented across three intervention years by the health program (HP) with some activities implemented in multiple years. Participants were recruited most frequently through organisational settings in years 1 and 2, and organisational and community settings in year 3. The most commonly utilised intervention targets were the individual (IND) as a direct target, and interpersonal (INT) and organisational (ORG) environments as indirect targets; policy (POL), and community (COM) were targeted least. Direct (HP→ IND) and indirect intervention strategies (i.e., HP→ INT→ IND, HP→ POL → IND) were used most often; networking strategies, which link at least two targets (i.e., HP→[ORG-ORG]→IND), were used the least. The program did not become more ecological over time.

CONCLUSIONS

The quantity of activities with IND, INT and ORG targets and the proportion of participants recruited through informal cultural networking demonstrate community commitment to prevention. Integration of an ecological approach would have been facilitated by greater inter-organisational collaboration and centralised planning. The upfront time required for community stakeholders to develop their capacity to mobilise around chronic disease is at odds with short-term funding cycles that emphasise organisational accountability.

Integration of social epidemiology and community-engaged interventions to improve health equity

The past quarter century has seen an explosion of concern about widening health inequities in the United States and worldwide. These inequities are central to the research mission in 2 arenas of public health: social epidemiology and community-engaged interventions. Yet only modest success has been achieved in eliminating health inequities. We advocate dialogue and reciprocal learning between researchers with these 2 perspectives to enhance emerging transdisciplinary language, support new approaches to identifying research questions, and apply integrated theories and methods. We recommend ways to promote transdisciplinary training, practice, and research through creative academic opportunities as well as new funding and structural mechanisms.

A 4-year sequential assessment of the Families First Edmonton partnership: challenges to synergy in the implementation stage

This article assesses the partnership functioning of Families First Edmonton, a multisectored collaborative effort formed to determine the best health and recreation service delivery model for families with low income. Partners' evaluations of the collaborative process are examined across the formation, implementation, and maintenance stages of development. Statistical analyses of questionnaire data reveal a significant decrease in the partnership's capacity to maximize synergy-a main indicator of a successful collaborative process-in the implementation stage of the partnership. Implications for partnership practice are addressed.

An initial attempt at operationalizing and testing the Community Coalition Action Theory

The Community Coalition Action Theory (CCAT) blends practice wisdom with empirical data to explain how community coalitions achieve community change and community capacity outcomes. The current study uses data from an evaluation of 20 California Healthy Cities and Communities coalitions to test relationships between coalition factors and outcomes as predicted by CCAT in two stages of coalition development. Data are from two rounds of coalition member surveys, interviews with local coalition coordinators, and semiannual progress reports. Consistent with CCAT predictions and prior research, shared decision making and leadership were correlated with participation; staff competence, task focus, and cohesion were correlated with member satisfaction. Coalition size was associated with participation and dollars leveraged. Also, consistent with CCAT, diversity of funding sources was associated with new leadership opportunities and program expansion; dollars leveraged was correlated with new leadership opportunities and new partners. Findings provide preliminary support for many, but not all, of the relationships predicted by CCAT.

Proximal outcomes matter: a multilevel examination of the processes by which coordinating councils produce change

Communities are engaged in efforts to create a coordinated response to intimate partner violence. Though coordinating councils are commonly employed vehicles for such efforts, research provides only equivocal support regarding their effectiveness. These mixed findings may reflect methodological and conceptual challenges. Specifically, there is an over-reliance on conceptualizing council effectiveness in terms of distal outcomes (e.g., behavior change), rather than the intermediary processes by which councils affect change. A direct assessment of councils' proximal outcomes may highlight change mechanisms. To that end, this study investigates the extent to which councils impact proximal outcomes and examines the processes through which proximal outcomes are interrelated and linked to distal community change. Study findings suggest that perceived proximal outcomes do significantly predict variability in perceived distal community change across councils. Specifically, promotion of social capital and institutionalized change predict achievement of distal community change, and promotion of social capital also predicts achievement of institutionalized change.

Exploring the relationship between synergy and partnership functioning factors in health promotion partnerships

Intersectoral partnerships have been identified as a useful mechanism for addressing the health challenges that face society. In theory, partnerships achieve synergistic outcomes that amount to more than can be achieved by individual partners working on their own. This study aimed to identify key factors that influence health promotion partnership synergy. Data were collected from 337 partners in 40 health promotion partnerships using a postal survey. The questionnaire incorporated a number of multidimensional scales designed to assess the contribution of factors that influence partnership synergy. New validated scales were developed for synergy, trust, mistrust and power. Pearson's correlations and multiple regression analysis were used to identify the significance of each factor to partnership synergy. Trust, leadership and efficiency were shown to be the most important predictors of partnership synergy. Synergy is predicated on trust and leadership. Trust-building mechanisms need to be built into the partnership forming stage and this trust needs to be sustained throughout the collaborative process. We need to develop systems where the best leaders are put forward for intersectoral partnerships. This should be consistent across all sectors and organizations.

The roles of law, client race and program visibility in shaping police interference with the operation of US syringe exchange programs

AIMS

To determine the comparative levels of and associations between policing interference and characteristics of US syringe exchange programs (SEPs).

DESIGN

Cross-sectional.

SETTING

A national survey of US SEPs.

PARTICIPANTS

A total of 111 program managers (representing 59% of all US SEPs).

MEASUREMENTS

Program manager self-report.

FINDINGS

With overall interference profiles ranging from systematic to totally interference-free, 43% of respondents reported at least monthly client harassment, 31% at least monthly unauthorized confiscation of clients' syringes, 12% at least monthly client arrest en route to or from SEP and 26% uninvited police appearances at program sites at least every 6 months. In multivariate modeling, legal status of SEP, jurisdiction's syringe regulation environment and affiliation with health department were not associated with frequency of police interference. Programs serving predominantly injection drug users (IDUs) of color were 3.56 times more likely to report frequent client arrest en route to or from SEP and 3.92 times more likely to report unauthorized syringe confiscation. Those serving more than three sites were 3.96 times more likely to report client harassment, while stationary operation was protective against uninvited police appearances. The majority (56%) reported not documenting adverse police events; those who did were 2.92 times more likely to report unauthorized syringe confiscation from clients.

CONCLUSIONS

Findings highlight limitations of the impact of legal reforms on aligning police activities with SEP operations. Systematic adverse event surveillance and evidence-based structural interventions are needed to maximize the benefits of public health prevention targeting IDUs and other criminalized populations. SEPs that report no adverse events may represent programs already working in harmony with law enforcement agencies, a priority highlighted in US Centers for Disease Control's new SEP guidelines. The significance of mechanisms translating criminal justice disparities into health disparities is discussed.

Systematic Review

The aim of our systematic review was to retrieve and integrate relevant evidence related to the process of formation and implementation of the academic–service partnership, with the aim of reforming the clinical education program. Despite a plethora of research evidence about implementing the academic– service partnership, no one to date has undertaken a robust systematic review about its process. An electronic search was performed to identify published studies between 1995 and 2008. Search strategies adapted from the University of York’s Centre for Reviews and Dissemination were used. Fifteen papers were accepted based on the inclusion criteria and assessed for quality. Data were summarized thematically. Four main stages emerged: Mutual Potential Benefits, Moving From Being Competitors to Collaborators, Joint Practice, and Beneficial Outcomes. This study’s findings can provide practical guidelines to steer partnership programs within the academic and clinical bodies, with the aim of providing a collaborative partnership approach to clinical education.

The role of leadership and management in six southern public health partnerships: a study of member involvement and satisfaction

Research has led to greater understanding of what is needed to create and sustain well-functioning public health partnerships. However, a partnership's ability to foster an environment that encourages broad member involvement in discussions, decision making, and activities has received scant empirical attention. This study examined the relationship between partnership members' perceptions of how well leadership and management facilitated their involvement, and their satisfaction with their role and influence within the partnership. Data came from 60 individuals who participated in two waves of a quantitative process evaluation of six southern interorganizational partnerships, formed as part of a national pilot project to increase cervical and breast cancer screening rates. Results suggested that environments fostering broad partner involvement were associated with measures of member satisfaction, controlling for other partnership characteristics. Findings indicated that facilitation of member involvement deserves increased consideration from researchers and practitioners as an indicator of the quality of partnership functioning.

Moving toward synergy: lessons learned in developing and sustaining community-academic partnerships

BACKGROUND

Community-academic partnerships are an increasingly popular approach to addressing community health problems and engaging vulnerable populations in research. Despite these altruistic foci, however, partnerships often struggle with fundamental issues that thwart sustainability, effectiveness, and efficiency.

OBJECTIVES

We adapted a synergy-promoting model to guide the development and evaluation of a community-academic partnership and share lessons learned along the way.

METHODS

We analyzed the partnership process over time to determine the interaction of trust, collaboration, and engagement in creating partnership synergy and promoting sustainability.

LESSONS LEARNED

Few community-academic partnerships use a conscious and systematic approach to guide and evaluate their progress. We argue that this is an important first step in creating a partnership, sustaining a milieu of open dialogue, and developing strategies that promote trust and equalize power dynamics. Still, as we learned, the best laid plans can go awry, challenging partnership synergy throughout its lifespan.

Evaluation of community-academic partnership functioning: center for the elimination of hepatitis B health disparities

BACKGROUND

Process evaluation of community-academic partnership function and fidelity to principles of community-based participatory research (CBPR) is essential to achievement of intermediate and long term partnership goals.

OBJECTIVES

This article describes the evaluation of B Free CEED, a community-academic partnership created to address hepatitis health disparities in Asian American and Pacific Islander (API) communities.

METHODS

A mixed methods approach with an online survey and qualitative key informant interviews was conducted with all partnership members at baseline and follow-up, 18 months later.

RESULTS

Survey findings showed stability over time, with some consistent differences in community and academic perspectives. Academic members were somewhat more satisfied with the partnership functioning. Key informant interviews provided contextual data key to further defining partnership functioning.

CONCLUSIONS

Conducting ongoing partnership evaluations is necessary to reassess and align processes and protocols to enhance partnership functioning and strengthen group cohesion.

Actualizing a provider alliance to expand health services access to a low-income urban community

Social change to facilitate health care access for vulnerable populations sometimes involves model-driven innovative structures and innovative planning and implementation approaches. This paper described and analyzed the rationale, conceptual framework, program components, and implementation of the South Central Health Care Alliance (SCHCA) implemented in South Los Angeles from January 2002 to December 2004. The program development and implementation was guided by an integrated framework linking the Open Systems Theory, the Social Cognitive Theory, the Health Belief Model, and the Preventive Health Education and Medical Home Project. The performance of the SCHCA as a social system, partnership, and participatory implementation program is also presented. While the SCHCA was found to be a dynamic social system that responded well to contingencies, its performance as a partnership and participatory implementation program was wanting in many respects.

Evaluation of a collaborative program on smoking cessation: translating outcomes framework into practice

INTRODUCTION

Although evaluating at multiple outcome levels has been proposed for continuing education activities and programs, it is a complex undertaking and is not done routinely, especially in collaborative, multicomponent programs. This article reports on strategies used and results obtained in an evaluation project that examined multiple outcomes of a US-based collaborative, multicomponent smoking cessation educational program for clinicians.

METHODS

Evaluation was organized conceptually around the 6 levels of an outcomes-based evaluation model and was conducted using registration data, postactivity evaluations, clinical vignettes with questions assessing knowledge and competence in participants and in a comparison group, a commitment to change approach, data from patient charts to assess clinician compliance on 8 performance measures, and tobacco cessation rates. Additional methods included a success case method study of 9 practices participating in performance improvement (PI) activities and assessment of partner collaboration using a written survey and interviews.

RESULTS

The program reached more than 43,000 clinicians who participated in a variety of activities. Participants indicated a high level of satisfaction with the program's educational activities and demonstrated higher scores than a comparison group on 6 of 7 competencies. The majority of participants who responded to commitment to change questions reported intended and implemented practice changes consistent with desired outcomes. Performance outcomes of 3 PI activities varied, with greater improvements observed in 1 activity (9.0% to 36.2% improvement across 8 measures). Lower performance outcomes, but a smoking quit rate of 46.8%, was observed in 2 other PI activities.

DISCUSSION

The program had an overall positive impact on the measured variables for clinicians and their patients. Use of 1 outcomes assessment framework acceptable to all members of the collaborative, common measures and evaluation techniques, and centralized data repositories contributed to the success of the program evaluation reported here and is recommended to others who are considering a collaborative program evaluation.

Addressing unmet mental health and substance abuse needs: a partnered planning effort between grassroots community agencies, faith-based organizations, service providers, and academic institutions

OBJECTIVE

To conduct a process evaluation of the Restoration Center Los Angeles, a community-academic partnered planning effort aimed at holistically addressing the unmet mental health and substance abuse needs of the Los Angeles African American community.

DESIGN

Semi-structured interviews with open-ended questions on key domains of partnership effectiveness were conducted with a random stratified sample of participants varying by level of involvement.

PARTICIPANTS

Eleven partners representing grassroots community agencies, faith-based organizations, service providers, and academic institutions.

MEASURES

Common themes identified by an evaluation consultant and partners relating to partnership effectiveness, perceived benefits and costs, and future expectations.

RESULTS

Findings underscore the importance of considering the potential issues that may arise with the increasing diversity of partners and perspectives. Many of the challenges and facilitating factors that arise within academic-community partnerships were similarly experienced between the diverse set of community partners. Challenges that affected partnership development between community-to-community partners included differences in expectations regarding the final goal of the project, trust-building, and the distribution of funds. Despite such challenges, partners were able to jointly develop a final set of recommendations for the creation of restoration centers, which was viewed as a major accomplishment.

CONCLUSIONS

Limited guidance exists on how to navigate differences that arise between community members who have shared identities on some dimensions (eg, African American ethnicity, Los Angeles residence) but divergent identities on other dimensions (eg, formal church affiliation). With increasing diversity of community representation, careful attention needs to be dedicated to not only the development of academic-community partnerships but also community-community partnerships.

Interdisciplinary research training in a school of nursing

Although interdisciplinarity has become a favored model of scholarly inquiry, the assumption that interdisciplinary work is intuitive and can be performed without training is short-sighted. This article describes the implementation of an interdisciplinary research training program within a school of nursing. We describe the key elements of the program and the challenges we encountered. From 2007-2010, eleven trainees from 6 disciplines have been accepted into the program and 7 have completed the program; the trainees have published 12 manuscripts and presented at 10 regional or national meetings. The major challenge has been to sustain and "push the envelope" toward interdisciplinary thinking among the trainees and their mentors, and to assure that they do not revert to their "safer" disciplinary silos. This training program, funded by National Institute of Nursing Research (NINR), has become well-established within the school of nursing and across the entire University campus, and is recognized as a high quality research training program across disciplines, as exemplified by excellent applicants from a number of disciplines.

The urban context: a place to eliminate health disparities and build organizational capacity

This study seeks to examine the process of building the capacity to address health disparities in several urban African American neighborhoods. An inter-organizational network consisting of a research university, community members, community organizations, media partners, and foundations was formed to develop a community-based intervention designed to provide health promotion and disease prevention strategies for type 2 diabetes and hypertension. In-depth qualitative interviews (n = 18) with foundation executives and project directors, civic organization leadership, community leaders, county epidemiologist, and university partners were conducted. Our study contextualizes a process to build a public health partnership using cultural, community, organizational, and societal factors necessary to address health disparities. Results showed 5 important factors to build organizational capacity: leadership, institutional commitment, trust, credibility, and inter-organizational networks. These factors reflected other important organizational and community capacity indicators such as: community context, organizational policies, practices and structures, and the establishment of new commitments and partnerships important to comprehensively address urban health disparities. Understanding these factors to address African American health disparities will provide lessons learned for health educators, researchers, practitioners, foundations, and communities interested in building and sustaining capacity efforts through the design, implementation, and maintenance of a community-based health promotion intervention.

The Reality of Resistance: The Experiences of Rural Parturient Women

The closure of many local maternity services has given rise to contemporary realities of care for many rural parturient women in Canada, which, in turn, determines their experience of birth. To date, we do not have an understanding of the realities influencing the birthing experiences of rural parturient women. This qualitative investigation explored these issues with women from four rural British Columbian communities through semistructured interviews and focus groups. Women in this study articulated four realities that influenced the nature of their experience of birth, including geographic realities, the availability of local health service resources, and the influence of parity and financial implications of leaving the community to give birth. When these realities were incongruent with participants' needs in birth, participants developed strategies of resistance to mitigate the dissonance. Strategies included trying to time the birth at the referral hospital by undergoing an elective induction and seasonal timing of pregnancies to minimize the risk of winter travel. Some women showed up at the local hospital in an advanced stage of labor to avoid transfer to a referral center, or in some instances, had an unassisted homebirth.

Dissolving the Patient Bermuda Triangle

Summary

The differentiation of roles, tasks and responsibilities in health care has gradually increased because of efforts to decentralize, specialize and professionalize our health-care systems. These development approaches can on the one hand be regarded as successful, although there is also a negativeflipside. Increased differentiation has concurrently fragmented the delivery of health care, which, in turn, can be divided into structural, clinical and cultural fragmentation. Patients are lost as a result of these conditions of fragmentation. This phenomenon can metaphorically be described as a'Patient Bermuda Triangle’. Actions to dissolve the Patient Bermuda Triangles are commonly termed ‘Integrated health care’, a global buzzword that includes integrated care pathway as well as other integrated health-care strategies. Moreover, integrated care is a means to an end: improved patient outcome. To achieve this, it is crucial to have necessary prerequisites in place: both functional and interactional conditions. This procedure seems to be an organic process where the stakeholders go through gradual changes until the optimum level of integration, as well as mutualistic interactions, is established. If these conditions are concealed or impossible to achieve, developmental work should be ended to avoid the evolvement of antagonistic relations between the stakeholders concerned. This state will likely establish a Patient Bermuda Triangle or reinforce an existing one.

Research collaboration in the discovery, development, and delivery networks of a statewide cancer coalition

This study examines and evaluates collaborative network involvement among 18 organizations within the Arizona Cancer Coalition. All were involved in one or more of three types of research activity: discovery, development, and delivery, consistent with the 3D continuum developed by the National Cancer Institute. Data were collected in 2007 using surveys of key informants in each organization. Using network analysis methods, we examined the structure of each type of network as well as the relationship between network position and the importance of cancer research to each organization's mission. Findings indicated that while both the discovery and delivery networks were comparably densely connected, their centrality structures were quite different. In contrast, the structures of both these networks were similar to the development network. Centrality in the discovery and development networks was positively related to the importance of cancer research to the organization, but not in the delivery network. Implications of the findings for future research, policy, and planning are discussed.