Funding agencies are increasingly focused on community coalitions as effective entities for promoting public health programs. Yet, there has been no conceptual model for understanding how effective coalition infrastructure works to facilitate a learning environment, wherein coalition members and leaders receive ongoing training and technical assistance needed to accomplish their external programing goals. This article presents a conceptual model for measuring the internal effectiveness of coalitions [Internal Coalition Outcome Hierarchy (ICOH)]. The ICOH model served as the basis for development of the evaluation instrument, Internal Coalition Effectiveness, which measures internal coalition effectiveness based on achievement of organizational outcomes at each of the model's seven hierarchical levels. The ICOH conceptual model has broad application for public health nurses who are frequently called on to serve as evaluators for community coalitions engaged in health programing. The model has implications for evaluators to use in teaching coalition members and leaders about their internal strengths and areas for improvement, so that coalitions can develop more effective internal structures and thereby promote long-term sustainability.
The cost of chronic disease in the United States is increasingly understood as being related to systemic community problems such as lack of physical exercise, tobacco abuse, and teenage pregnancy (Mitchell & Shortell, 2000). Solving these social issues will require more than government alone can achieve (Hasnain-Wynia, Margolin, & Bazzoli, 2001; Kurland & Zeder, 2001), and thus, a growing number of private foundations have funded collaborative community partnerships, or coalitions, between public and private agencies to address the social determinants of health at a local level (El Ansari & Phillips, 2001; Hallfors, Hyunsan, Livert, & Kadushin, 2002). The pooling of public and private resources has helped to reduce service redundancy and maximize an ecological approach to community health programing, wherein health problems are viewed as existing in the larger social, political, and economic environment that either positively or negatively influences individual health behaviors (Butterfoss & Francisco, 2004; Lantz, Viruell-Fuentes, Israel, Softley, & Guzman, 2001; McLeroy, Bibeau, Steckler, & Glanz, 1998).
Most partnerships and coalitions require significant community participation to identify local health problems and design program interventions that address the social determinants of health (Chalmers et al., 2003; El Ansari & Phillips, 2001; Lantz et al. 2001; Syme, 2004). Thus, coalitions have great potential for community capacity building, because they serve as learning organizations for developing members' knowledge, aptitude, and skills in leadership, consensus building, and advocacy (Butterfoss, 2004; Francisco, Paine, & Fawcett, 1993; Wallerstein, Polascek, & Maltrud, 2002). Such internal benefits reflect the effectiveness of a coalition's organizational infrastructure, and members' gains are thought to be transferable to other public health goals for lasting community change (Goodman et al., 1998; Provan, Veazie, Teufel-Shone, & Huddleston, 2004).
Increasingly, public health nurses and public health nursing faculty are called upon to serve as evaluators for community coalitions because of their expertise in community programing and because evaluation is integral to the core functions of public health. Yet, to date, there has been no conceptual model to explain effective coalition infrastructure as means of facilitating a learning environment in which members and leaders receive ongoing training and technical assistance for performing competent community assessment, planning, implementation, and evaluation (Armbruster, Gale, Brady, & Thompson, 1999; Kreuter, Lezin, & Young, 2000; Spitz & Ritter, 2002). Conceptualization is an essential part of the evaluation process, and public health nurses serving in the role of evaluator require a framework for understanding the essential constructs of effective coalition infrastructure and for identifying achievable internal outcomes that may result from effective organizational structures. The purpose of this article is to present the conceptual model, Internal Coalition Outcome Hierarchy (ICOH), and its seven levels of internal outcomes that promote long-term sustainability by building capacity and improving the internal benefits of coalition membership. The model has broad application for use by public health nurse evaluators in terms of teaching and providing formative feedback to coalitions that are engaged in health promotion programing.
Community coalitions are voluntary collaborations between public and private agencies and community stakeholders who are focused on a shared interest involving community health promotion (Mitchell & Shortell, 2000). Like other organizations, coalitions can experience governance and infrastructure difficulties; however, such issues become far more challenging because of the voluntary networks established by coalitions (Alexander, Zuckerman, & Pointer, 1995).
Group theory asserts that members must be satisfied and feel that the benefits of participation outweigh the costs in terms of time, commitment, level of involvement, and relationships (Armbruster et al., 1999; Bracht & Tsouros, 1990; Provan et al. 2004). When coalitions are not able to deliver on their promises to members in terms of increased networking, information sharing, access to resources, participation in decision making, receiving recognition, or experiencing a sense of accomplishment, then members can become dissatisfied, and conflicts arise (El Ansari & Phillips, 2001). Indeed, coalition members' satisfaction and participation have been shown to be related to perceptions of a positive organizational climate and strong ties with other community organizations (Butterfoss, Goodman, & Wandersman, 1996). If coalition leadership becomes so focused on goal attainment that members feel a sense of burnout, lack of direction and lack of benefit in terms of new knowledge and skills, then it can lead to disintegration of the coalition's collaborative network (Provan & Milward, 2001). Coalition leadership can promote a positive organizational climate, in which members experience satisfying relationships by clearly defining members' responsibilities and the derived benefits thereof (Doz & Hamel, 1998).
Successful coalitions have a shared social vision and mission among members (Butterfoss, 2004; Fawcett et al., 1997; Shortell & Kaluzny, 1994; Weiner & Alexander, 1998). They have a strong infrastructure that empowers its leadership and provides effective management, encourages diverse member participation, and builds collaborative networks within and outside of the organization itself (El Ansari & Phillips, 2001). Coalitions undergo developmental phases similar to those identified in group process theory (Francisco et al. 1993; Lantz et al. 2001; Mitchell & Shortell, 2000). Forming and organizing the infrastructure occur during the first phase of the coalition formation when leaders are focused on process data for monitoring activities, members, volunteers, services, and finances. When the infrastructure is well developed, then the coalition moves onto later phases involving action and implementation and ultimately dissemination and policy impact (Lantz et al. 2001).
Effective infrastructures require that members give up some of their own individual autonomy and yield their own goals to those of the coalition (Provan et al. 2004). Members in turn expect to benefit from new connections and networks and to gain shared information and skills that are developed at multiple levels including individual, organizational, interorganizational, community, policy, and societal levels (McLeroy et al. 1998). Because coalition members are of varying levels of knowledge, skills, and talents, it becomes the job of a coalition to ensure the acquisition of new knowledge, skills, and aptitudes for its members. Indeed, it has been shown that effective coalitions operate like lifelong learning organizations for members to identify problems and develop interventions (Butterfoss, 2004; Kreuter et al. 2000).
Governance of a coalition empowers leaders for their role in creating a social vision and mission (Mitchell & Shortell, 2000; Weiner & Alexander, 1998). Coalition leaders facilitate such activities as recruiting and orienting new members, but an even more significant role is in resolving conflicts (often through social norms control) and maintaining member satisfaction, commitment, and participation (Butterfoss, 2004; Mitchell & Shortell, 2000). Coalition leadership is instrumental in securing community-wide support and resources through positive relationships; thereby, improving the coalition's opportunities for funding and long-term sustainability (Cheadle et al. 1997). Leaders are also expected to provide technical assistance to overcome resource deficiencies, decrease uncertainty in the environment, and gain influence in the community. Coalition leaders have a large time commitment, and it is important that future leaders be developed within the group so as to promote participatory governance and sustainability (Weiner & Alexander, 1998).
Much research has focused on selected characteristics of successful coalitions (Butterfoss, Morrow, Webster, & Crews, 2003; Butterfoss et al., 1996; Kegler, Steckler, Malek, & McLeroy, 1998; Mitchell & Shortell, 2000; Wallerstein et al. 2002), but there has not been any conceptual model for understanding how these various attributes contribute as a whole to the coalition's organization effectiveness, which is seen as requisite to ultimately achieving successful program outcomes in the community. Moreover, no conceptual models or instruments have considered the importance of leaders' and members' perspectives on organizational structures. This distinction between members' and leaders' perceptions is important because coalitions, like all groups, are influenced to varying degrees by an interactive and dynamic process between members and leaders (e.g., Hollander, 1985). Group process theory indicates that leaders and leadership structures must be adaptable and responsive to group members' needs and strengths, so that the group as a whole (i.e., coalition) can develop and progress over time (Vroom & Jago, 1978). If leaders are not aware of members' perspectives or if members' visions or needs are not in accord with those of their leaders, it will be difficult for the group (i.e., coalition) to unite and ultimately achieve their goals for community health programing (Wheelan, 1994). Therefore, the conceptual model considers both members' and leaders' perspectives, so that this information can be used for formative feedback and hopefully strengthen the coalition as a whole, thereby promoting sustainability, and attained program outcomes in public health (Francis, Margolin, Casey, & Hasnain-Wynia, 2002).
The Targeting Outcomes of Programs conceptual model for evaluating coalition outcomes and impacts (Cramer, Mueller, & Harrop, 2003a, 2003b) was adapted to evaluate the internal organization of the coalition itself using the same seven theoretical constructs: Shared Social Vision, Efficient Practices, Knowledge and Training, Relationships, Participation, Activities, and Resources. The adapted model for infrastructure evaluation, ICOH (Fig. 1), is also hierarchical and provides the comprehensive framework for evaluating the internal organization of coalitions for their ability to have members' work together to achieve coalition outcomes and for leaders' ability to facilitate a learning environment for coalition members to achieve their goals.
| [Help with image viewing] [Email Jumpstart To Image] | Figure 1. Internal Coalition Outcome Hierarchy (ICOH) |
The ICOH model considers that effective coalitions have two distinct features. First, they have a diverse community membership that works well together to achieve outcomes in each of the seven theoretical constructs. Secondly, effective coalitions have leaders that facilitate a learning environment whereby members can achieve agreed upon outcomes. Because of the important influence of both members and leaders, it is likely that they may each view the theoretical constructs of coalitions differently. While members may rate their own ability to work together as effective, the coalition leaders may view members' abilities as less than positive and vice versa. Research on coalition governance indicates that members and leaders contribute in unique ways to the effectiveness of the coalition and when members and leaders have conflicting interests or when they have disparate views regarding their inputs (i.e., essential theoretical constructs), then the coalition's vision for community change is negatively affected and threatens long-term sustainability of the organization (Butterfoss & Francisco, 2004; Mitchell & Shortell, 2000; Weiner & Alexander, 1998).
In the ICOH model, the first three construct levels (i.e., Resources, Activities, and Participation) are focused on process evaluation, the middle levels (Relationships, Knowledge and Training, and Efficient Practices) are focused on outcomes, and the uppermost level (Shared Social Vision) is focused on impact. The hierarchical ICOH model depicts that effective coalitions have an infrastructure whose foundation depends on management of Resources (i.e., finances and staffing). The Resource construct includes the notion that both members and leaders share in the responsible use of finances and staffing. Effective use of Resources is needed to implement the diverse program Activities (i.e., programs and interventions). The Activities construct includes the notion that coalition leadership provides necessary oversight to ensure that the work plan is completed according to the allocated resources and on a timely basis. Effective activity implementation requires Participation from a diverse membership and means that members must willingly cooperate and that leaders are expected to facilitate such an environment as befits broad-based participation.
The middle three levels of the model—Relationships, Knowledge and Training, and Efficient Practices—represent outcomes attributed to the internal organization of coalitions. At the Relationship level, members who find their involvement to be rewarding are more likely to be satisfied with the relationships and connections they have developed through the coalition infrastructure, as well as with the networks developed by coalition leadership with outside organizations, and thus, members are most likely to feel that the benefits of coalition membership outweigh the costs. Moreover, when members and leaders perceive positive reactions based on their coalition experiences, then it is more likely that learning will occur either formally such as in trainings or informally through observation and role modelling. The outcome of positive Relationships would be improved Knowledge and Training among members and leaders in such areas as advocacy or public relations training. This represents a basic principle of teaching, wherein learners who feel positive and supported about their experiences are also more likely to report having learned and thus to view the coalition as fostering a learning environment. Knowledge and Training is the result of coalition training activities and gives recognition to the important role that coalition leaders have had in facilitating the educational needs of the membership.
When members and leaders have improved knowledge and skills, because the coalition infrastructure has created such an environment, then it follows that Efficient Practices would also begin to improve in a positive direction. At the Efficient Practices level of the model, effective coalitions are measured by members' and leaders' perceptions of how well they are enacting new knowledge and skills in the arena where community change is to occur; and thus, effective coalitions are measured by the degree to which members and leaders generate and sustain collaborative interactions and Efficient Practices with the community. This level also includes the notion that coalition leaders have an effect on the members themselves by establishing an effective infrastructure in which collaboration can occur.
The top-most level of the model focuses on the ultimate impact of sound coalition infrastructure, which is a shared Social Vision and mission among coalition members. Social Vision refers to the optimal social, economic, and environmental conditions that coalition interventions hope to help bring about. Mission refers to how well coalition work plans are enacted to support their Social Vision. Both members and leaders must experience the same shared Social Vision and mission for what it is they are trying to achieve, or the coalition will not be able to move forward in effectively creating community change. Nor is it likely that the coalition will have any chance at sustainability without a sense of shared Social Vision and mission.
Coalitions are critically important venues for communities addressing health care needs that are best approached through changes in individual behavior and societal norms. The contribution of chronic conditions to health care utilization indicates a need for coordinated efforts across service providers, which can be accomplished by coalitions. Major contributors to ill health, such as obesity and primary and secondary smoke, could be addressed effectively by community coalitions. Given the pivotal role of coalitions and the role that public health nurses and public health nursing faculty now play as evaluators, the conceptual model presented in this article provides a useful framework for helping coalition members and leaders understand the importance of functioning effectively as an organized entity, to achieve public health programing goals. Moreover, when coalitions function effectively from an organizational point of view and when there is accord between members and leaders, then the likelihood for continued sustainability is improved, because the coalition has formative feedback to identify its strengths and areas of improvement.
Evaluation is one of the essential services in public health nursing and serves as the guiding strategy to community health programing. Unfortunately, evaluation is frequently the forgotten item and the last thing considered by community coalitions when they are considering their program goals (Turnock, 2004). Public health nurses can provide invaluable guidance and support to community coalitions using the ICOH conceptual model early in the program-planning process and throughout the coalition's existence to teach members and leaders about the importance of organizational effectiveness in achieving outcomes related to membership benefits such as rewarding relationships, acquisition of new knowledge and skills, and collaborative practices between a diverse membership. When both members and leaders feel that the coalition infrastructure supports a learning environment that yields positive results based on participation, then the chances for long-term sustainability are improved. Coalition sustainability is important because of the amount of money, time, and energy involved in putting together multiple agencies and diverse groups of individuals into a cohesive and functioning entity. The ICOH model provides an organizing vision for the coalition that serves as the basis for formative evaluation of internal structure and function and offers public health nurses a significant tool for their work in evaluation.
The authors wish to acknowledge the support of funding provided by the Nebraska Health and Human Services System/Tobacco Free Nebraska Program as a result of the Tobacco Master Settlement Agreement.
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Key words: community coalition; conceptual model; evaluation; organization
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