by Mauri A. Ziff, Nancy Willard, Gary W. Harper, Audrey K. Bangi, Jason Johnson, Jonathan M. Ellen and the Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN)
Fifteen research sites within the Adolescent Medicine Trials Network for HIV/AIDS Interventions launched Connect to Protect community coalitions in urban areas across the United States and in Puerto Rico. Each coalition has the same overarching goal: Reducing local youth HIV rates by changing community structural elements such as programs, policies, and practices. These types of transformations can take significant amounts of time to achieve; thus, ongoing successful collaboration among coalition members is critical for success. As a first step toward building their coalitions, staff from each research site invited an initial group of community partners to take part in Connect to Protect activities. In this paper, we focus on these researcher-community partnerships and assess change in collaboration factors over the first year. Respondents completed the Wilder Collaboration Factors Inventory at five time points, approximately once every two to three months. Results across all fifteen coalitions show significant and positive shifts in ratings of process/structure (p<.05). This suggests that during the first year they worked together, Connect to Protect researcher-community partners strengthened their group infrastructures and operating procedures. The findings shed light on how collaboration factors evolve during coalition formation and highlight the need for future research to examine change throughout subsequent coalition phases. (Peer Reviewed)
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INTRODUCTION
Community coalitions play a role in addressing a broad range of complex public health concerns (e.g., Roussos & Fawcett, 2000). Examples include asthma (Peterson, Lachance, Butterfoss, Houle, Nicholas, Gilmore, Lara & Friedman, 2006), pregnancy and parenting (Tandon, Parillo, Jenkins, Jenkins & Duggan, 2007), and HIV/AIDS (Ramos, Hernandez, Ferreira-Pinto, Ortiz & Somerville, 2006). Collaborative efforts such as these are often characterized by synergistic unions of varied community sectors including government, faith-based, families, business, and others (e.g., Weiss, Anderson & Lasker, 2002). Far from being static entities, community coalitions move through stages of change (i.e., formation, implementation, maintenance, goal achievement) and different factors may have an impact on coalition success at each phase (Butterfoss, Goodman & Wandersman, 1993).
There has been much written about what contributes to coalition success or failure. In their review of the extant literature published in the quarter-century from 1980 to 2004, Zakocs and Edwards (2006) summarize key factors as those related to governance procedures, leadership, active and diverse membership, collaboration, and group cohesion. Despite the attention this topic has received over the last two decades, there is still much to be learned—particularly with regard to generalizability and change over time. In large part, these two aspects are challenging to study due to the nature of coalitions themselves. The considerable variability in goals, infrastructures, communities, and target populations (Zakocs & Edwards, 2006) make it difficult to generalize findings. Additionally there are often significant barriers to examining change over time, including limited resources (e.g., lack of funding for long-term evaluation) and the reality that community coalitions are difficult to form let alone sustain (Kadushin, Lindholm, Ryan, Brodsky & Saxe, 2005).
Successfully completed longitudinal studies unequivocally point to the need for further research. For instance, a seven-year (1995–2002) project funded by the Centers for Disease Control and Prevention involving teen pregnancy prevention coalitions in thirteen communities found that good coalition processes—though associated with short-term success—did not appear to influence coalition survival (Kegler, Williams, Cassell, Santelli, Kegler, Montgomery, Bell, Martinez, Klein, Mulhall, Will, Wyatt, Felice & Hunt, 2005). Such results underscore the value of assessing coalitions during various developmental stages; doing so will enhance understanding of how collaborative efforts evolve and are sustained.
Focus of the Present Study
Connect to Protect® (C2P): Partnerships for Youth Prevention Interventions is a six-year community mobilization HIV intervention project initiated by the Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN). The ATN is a collaborative network established in 2001 by the National Institutes of Health to implement clinical, biological, and behavioral research with youth at risk for or with HIV/AIDS.
C2P offers the opportunity to closely follow the formation, evolution, outcomes, and sustainability of fifteen community coalitions located in urban areas with high concentrations of youth HIV (see Ziff, Harper, Chutuape, Griffin-Deeds, Futterman, Francisco, Muenz & Ellen, 2006 for project overview). Each coalition aims to decrease HIV rates among youth by catalyzing community structural change. This strategy focuses on creating new or modifying existing policies, programs, and practices in ways that are expected to curb the spread of the disease. Each coalition examines their city’s particular situation and determines which structural changes, taken together, are likely to ultimately have an overall impact on youth HIV rates. There are many examples; here we list just a few: altering local zoning to disrupt open-air drug markets, extending neighborhood clinic hours to include more youth-friendly hours, changing physical structures so that high-risk behavior is discouraged (e.g., install lighting in public areas where risky behaviors are known to occur), and improving provider testing and counseling practices. Pursuing and achieving structural changes can take a great deal of time and other resources, thereby making ongoing successful collaboration among coalition members essential to the process.
The goal of the present study is to shed light on how collaboration evolves during coalition formation stages. Specifically, we examine changes in collaborative factors during the first year that the research site staff and their community partners worked together on C2P endeavors.
METHODS
ATN Sites: The participating clinical research sites are based out of universities and hospitals in Baltimore, Boston, Chicago, Fort Lauderdale, Los Angeles, Miami, New Orleans, New York (Bronx and Manhattan), Philadelphia, San Diego, San Francisco, San Juan, Tampa, and Washington, DC.
Study Population: The study population consists of the researcher-community partners from each of the fifteen coalitions. Researchers include ATN site staff such as adolescent medicine specialists, C2P project coordinators, and outreach workers. The number of staff members per site ranged from two to five, with an average of three. Each site staff group established formal relationships with an initial set of local community partners (referred to here as “charter” community partners). For complete details on how site staff identified and established relationships with community partners, see Straub, Griffin-Deeds, Willard, Castor, Peralta, Francisco and Ellen (2007). To provide needed context for this paper we briefly summarize the main steps below.
First, site staff worked to establish C2P’s presence in the community by participating in relevant local events and meetings, networking with leaders and gatekeepers, talking to adolescents and young adults for their perspectives, and so forth. Second, while continuing to raise awareness of C2P in their respective cities, site staff assessed and catalogued existing local resources to better understand where, how, and when young people at higher risk for HIV are (or are not, as the case may be) reached. The work ultimately resulted in a printed directory of current resources for youth and those who care for and about them. Third, site staff conducted in-depth interviews with a subset of the catalogued community resources. The interviews served two purposes: (1) they provided site staff with additional data on which entities may be a good fit as a charter community partner in terms of interest, experience, knowledge, time available, etc. and (2) the process provided a built-in opportunity to grow and strengthen relationships, regardless of whether the entity subsequently formed formal ties with C2P.
When drawing up their lists of potential charter community partners site staff were asked to consider not only agencies and organizations, but also to think more broadly about particular individuals who may need to be involved during the early stages in order to help legitimize the coalition and create a groundswell of support. Site staff approached those on their lists and, for interested parties, outlined initial expectations of community partners and discussed the various degrees to which they could be involved. Entities and individuals who agreed to play a more significant role in C2P activities as a “main” partner (in contrast to those who wanted to participate in more of a supporting or advisory role) signed a memorandum of understanding that detailed partnership responsibilities at this level (e.g., attending meetings; identifying venues where youth can be reached for C2P activities; helping to increase buy-in and ownership from community members).
Overall, the number of charter community partners per site ranged from thirteen to twenty-one, with an average of nineteen. In response to a multi-factorial question, community partners described themselves as the following : community-based organizations (e.g., agencies providing case management, mental health and substance abuse care centers; 67%); government agencies (e.g., health and housing departments; 13%); spiritual/faith-based institutions (9%) and others (e.g., after school programs, local bar/club owners; 17%).
Measures: The Wilder Collaboration Factors Inventory (Mattessich, Murray-Close & Monsey, 2001; see Table 1) assesses the presence of twenty successful collaboration factors, organized into six domains:
The items within each domain were rated on a five-point scale from strongly agree to strongly disagree. Higher mean domain scores point to greater strengths in that area.
A range of practitioners have used the Wilder inventory in applied settings to guide and improve collaboration (refer to Mattessich, Murray-Close, & Monsey, 1992). The inventory is applicable in the present study because it assesses our variables of interest; that is, those factors associated with successful collaboration. Moreover, as the inventory’s results can provide useful information at all phases of a coalition’s development and functioning, it works will with C2P’s longitudinal design.
Procedures: Sites were required to hold five meetings with community partners throughout the year (every two to three months). The meetings were intended to foster successful coalition building and included activities designed to reinforce a shared understanding of purpose and increase readiness to take on complex collaborative tasks (Wolff, 2001). Examples of meeting activities included: (1) debating city-specific youth HIV prevention needs and opportunities; (2) sharing information on community risks and protective factors; and (3) utilizing ATN-provided instructional materials on topics such as selecting a decision-making model, building coalitions, and developing leadership.
Copies of the Wilder inventory were distributed at each meeting (T1 to T5). Site staff and their community partners confidentially completed the inventories each time via paper and pencil and sealed their responses in unmarked envelopes. This process took approximately fifteen minutes. The sealed envelopes were subsequently mailed to Johns Hopkins University for data management and analysis.
ANALYSIS
In order to measure the internal consistency reliability of items within each specific domain on the Wilder inventory, Cronbach's alphas were calculated on the baseline scores (T1). Cronbach's alpha is a coefficient of reliability/consistency that indicates how well a set of items measure a single unidimensional construct; thus the Cronbach's alpha value increases when the correlations between the items increase. Next, we examined whether time predicted mean domain scores (i.e., the association among all time points and domain mean scores) by conducting linear regression and general estimating equations (GEE) to adjust for repeated measures. To determine whether the findings were a result of differential meeting attendance by community partners over the course of the year, we also did a sensitivity analysis.
RESULTS
The number of inventories completed at each time point, T1 to T5, is as follows (average per coalition in parentheses): T1, N = 196 (13.1); T2, N = 191 (12.7); T3, N =194 (12.9); T4, N = 145 (9.7); and T5, N = 139 (9.3). The coalitions maintained on average a 71% response rate from the first coalition meeting to the fifth meeting. [Note: While it is difficult to predict why there was a gradual attrition of attendees, there are likely several reasons. We suspect that the earlier meetings drew some of the local leaders who contributed to providing clout, legitimacy, and broader community buy-in. Their attendance and participation may not have been needed throughout the entire first year of the coalitions’ work. Additionally, in the early phase of the coalition formation there is likely to be natural attrition and shifting of participants as the group more clearly defines its direction, intentions and roles of its members.]
The majority of Wilder inventory domains had alphas approaching or exceeding .80, indicating high internal consistency reliability: purpose (.75), member characteristics (.74), communication (.79), and process/structure (.82). The environment and resource domains had low alphas (.63 and .50, respectively) and thus were excluded from subsequent analyses. Table 2 summarizes the domain mean, range, and standard deviation at each time point for the included domains. Table 3 summarizes linear regression and GEE results, which are significant for the process domain (p<. 05). The findings suggest that aspects such as decision-making opportunities and strategies, workload management, and understanding of roles and responsibilities improved over time.
It is noted here that the composition of attendees at any given meeting may have differed, for any number of reasons (e.g., weather; out of town on business). Thus, we conducted a sensitivity analysis to determine whether varying participation accounted for the findings shown in Table 3. First, we examined frequency of community partners’ meeting attendance (Table 4). Over 30 % attended one meeting, 43 % attended two to three, and approximately a quarter attended four or five. Next regression analyses were conducted revealing results of the same effect size. This indicates that the findings summarized in Table 3 are unlikely to be a by-product of different people sitting at the table throughout the year.
DISCUSSION
We utilized the Wilder Collaboration Factors Inventory to examine if (and how) various domains considered essential for success changed over the first year researchers and community partners worked together on C2P endeavors. Results across fifteen coalitions show that process/structure domain underwent significant and positive change. This is of import because it has been noted by others that building successful community coalitions is difficult because organizations of different sizes and affiliations often have problems working together (Kadushin, et al., 2005). During C2P coalition formation stages, researcher-community partners succeeded in improving factors related to operational procedures and group infrastructure. This progress was likely facilitated by mandated meeting agenda items that required site staff and their community partners to discuss related aspects such as setting ground rules and guidelines.
Whereas process/structure appeared to evolve over time in Year 1, changes in the other domains we examined—communication, member characteristics and purpose—were not significant. This may be a result of the selected instrument used to measure collaboration. Alternatively, it is possible that changes in these three particular aspects as assessed by the Wilder inventory simply may not have yet occurred. Future analyses using additional time points will reveal whether (and at what stage of coalition development) shifts in these domains occur. Along the same vein, process/structure may not show change in future waves of analysis. This is possible if, for example, the group feels that it has these types of aspects “ironed out” from the groundwork laid during the first year. Such findings would be consistent with the notion that at each developmental stage different factors may be important for successful coalition functioning (Butterfoss, et al., 1993).
The relative stability in communication, member characteristics, and purpose may also be a function of mandated C2P protocol tasks. First, pre-partnership activities such as formalized processes and procedures and clarity on roles and responsibilities could have fostered stable communication ratings (Foster-Fishman, Berkowitz, Lounsbury, Jacobson & Allen, 2001). Knowing that interpersonal relationships and a greater sense of inclusiveness have an impact on coalitions (Suarez-Balcazar, Harper & Lewis, 2005; Wells, Ford, McClure, Holt & Ward, 2007), all sites were expected to foster effective communication before formally establishing any partnerships within the community (see Straub, et al., 2007). Second, the lack of change in the member characteristics domain is unsurprising given that during the first year coalition membership was, by design, largely fixed and generally consisted of site staff and charter community partners. This requirement stemmed from previous research supporting active involvement of organizational representatives prior to cultivating broad support from a wide range of community sectors (Zakocs & Guckenburg, 2007). And third, the C2P general mission and purpose was made clear to all participants before sitting at the table. At the required meetings each coalition was, however, encouraged to modify the mission so that it included language specific to their communities. This likely contributed to the trend of increased shared purpose.
Future Considerations
As described in Ziff, et al. (2006), each C2P coalition is expected to grow from the initial set of charter community partners and site staff to involve more and a greater diversity of community sector representatives. Admittedly, this can be a tricky endeavor. Adding new participants may help increase ownership, boost trust and buy-in from the general community, and facilitate goal attainment. On the other hand, achieving synergy across diverse groups can be difficult and some experts suggest that smaller groups may in the end accomplish more (e.g., Kubisch, Weiss, Shorr & Connell, 1995). As outlined by Straub and colleagues (2007), the C2P process attempts to address this by encouraging each coalition to maintain a core group of main partners who have designated roles, regardless of how or when the coalition as a whole expands; as new members do become part of the endeavor, new dynamics will be encountered. Ratings of collaboration factors may therefore vary according to time spent in the coalition and other critical factors, such as how tasks are delineated and decisions are made.
Thus far, site staff members have adopted more of a leadership role (e.g., driving/executing many of the goals and activities) and community partners generally have played more of a consultative role (e.g., providing input and feedback on goals, activities, community perception). As the coalitions firm their foundations and expand in size and breadth, it will be necessary for site staff and their community partners to revisit leadership models and to determine the best fit. As just one example, a coalition may strive for more distributed or shared leadership in hopes of increasing the chances of coalition sustainability. This change in dynamics will almost certainly affect perceptions of process/structure among the group.
Another consideration to be explored is that over a longer period of time, changes in collaboration factors may be non-linear. For instance, perceptions may fluctuate as the coalition achieves stated structural change objectives and then adds new ones that come with different facilitators and barriers. They may likewise vary non-linearly as some coalition members cycle in and out of the group as a function of coalition needs and/or natural attrition.
CONCLUSIONS AND LESSONS LEARNED
The findings across all fifteen coalitions point to the importance of establishing methods for operating and managing researcher-community partnerships. Central to this is having a stable set of core partners working together on these specific aspects throughout the first year. Continuity and commitment of these partners are linchpins to building a coalition’s infrastructure; in turn, a strong infrastructure will buttress coalition growth. Another decisive element is having a mechanism whereby process/structure (as well as other collaborative factors) are assessed over time. This will allow site staff and their entire group of community partners, whether filling main or other roles, to take notice of needed improvements and to make adjustments.
Researchers and community partners will have differing perceptions of process/structure aspects depending on the institutions and agencies they represent. We recommend that at the outset participants treat the coalition its own separate organizational unit – one that requires its own organizational structure/processes. Such an undertaking requires time and other resources, but the investment can help to avoid typical pitfalls young coalitions are prone to experience. Attending to these rudimentary issues early on—and monitoring them and addressing needs for change over time – can foster the solid infrastructure needed for effective functioning and long-term survival, so that coalition members can better focus on the larger issue at hand: facilitating community structural change to protect youth from HIV/AIDS.
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Mauri A. Ziff, Nancy Willard, Gary W. Harper, Audrey K. Bangi, Jason Johnson, Jonathan M. Ellen and the Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN)
This research is funded by grant #U01 HD040533 from the National Institutes of Health through the National Institute of Child Health and Human Development, with supplemental funding from the National Institute on Drug Abuse, National Institute on Mental Health, and National Institute on Alcohol Abuse and Alcoholism. Connect to Protect has been scientifically reviewed by the ATN’s Behavioral and Community Prevention Leadership Groups (CPLG). The authors wish to acknowledge the input and support of ATN and CPLG leadership; the ATN Coordinating Center; Westat, Inc.; Connect to Protect’s National Coordinating Center; participating ATN clinical research sites; community partners; and youth involved in local and national community advisory boards.
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