Bornstein, Daniel B. BS; Carnoske, Cheryl MPH, RD; Tabak, Rachel PhD; Maddock, Jay PhD; Hooker, Steven P. PhD; Evenson, Kelly R. PhD
Lack of physical activity (PA) is a threat to health nationally and globally1–3 and was recently labeled a global pandemic, with economic, social, environmental, and health consequences.3 Attempts to increase population levels of PA through individual-level interventions have proven to be insufficient.4,5 Therefore, altering the social and physical environments in which people live, work, learn, commute, and play, so that they all support PA, is required to positively impact population levels of PA.6 Such broad social and environmental change requires collaborative efforts among stakeholders from a wide range of societal sectors (eg, health care, education, public health, transportation, industry, media, and sport) to influence policy and practice at community, state, and national levels.1,7,8
Coalitions, formal or informal, provide a structure through which diverse stakeholders can convene to solve critical public health problems.9–11 Models for understanding the complex nature of community level public health coalitions have been proposed and are helpful in identifying the myriad of factors that may explain their successful formation and maintenance.10,12–14 The factors proposed in existing models of public health coalitions can be encapsulated within 3 broad categories: the social and political environment surrounding the coalition, the membership and management of the coalition, and the characteristics of each individual coalition partner.11,15 Of these 3 broad categories, the characteristics of each coalition partner may be the least understood and most poorly measured, despite a coalition's success being inextricably linked to these factors.10,15,16
Evidence from the for-profit sector also recognizes the importance of more fully understanding partner-level factors. The field of business administration suggests that factors specific to each partner organization are critical to understanding why and when partnerships succeed or fail in the for-profit sector.17,18 For-profit entities are motivated to engage in partnerships that serve their own self-interest (eg, competitive advantage in the marketplace) versus more altruistic interests (eg, improving population health).18 Cost/benefit ratio of participation in a public health coalition has been suggested as a potentially important partner characteristic16,19,20 and may be related to self-interest. However, the extent to which partners in a public health coalition are motivated to participate for self-serving reasons versus altruistic reasons has not been previously considered.
Given that lack of PA is now considered pandemic,3 and that proposed methods to address this call for coalitions comprised of diverse partners, understanding the factors related to why a partner would choose to join and remain committed to a PA coalition is needed.
Brief History of the National Physical Activity Plan
As the 2008 Physical Activity Guidelines were being developed,21 an informal coalition began forming in October 2006 to develop the National Physical Activity Plan (NPAP). This coalition included government agencies, nonprofit entities, academics, and for-profit corporations. The 2008 guidelines focused on the types and amounts of PA that individuals should accumulate to achieve the health benefits of regular PA. However, there was recognition of the need to develop a national plan that would provide evidence-based recommendations for policies and practices to address environmental changes that would support a more physically active lifestyle. The stated mission of the NPAP coalition was to “develop a National Plan for Physical Activity that produces a marked and progressive increase in the percentage of Americans who meet PA guidelines throughout life.”22
Initial NPAP funding came from the US Centers for Disease Control and Prevention, which allowed for subsequent recruitment of organizations interested in joining the coalition as an “organizational partner” (Supplemental Digital Content Table 1 available at: http://links.lww.com/JPHMP/A25). Each organizational partner (OP) contributed monetary and in-kind support for the NPAP including, but not limited to, a 1-time contribution of $10 000 and in-kind support of an individual representative from its organization to serve on the NPAP coalition's Coordinating Committee (http://physicalactivityplan.org/committee.php). The Coordinating Committee, which also included academic researchers with noted expertise in PA and public health, oversaw all aspects of development and launch of the NPAP. In addition, the Coordinating Committee collaborated openly with approximately 300 additional individuals (http://physicalactivityplan.org/history/working_groups.php) and organizations (http://physicalactivityplan.org/partners_affiliates.php) who assisted in developing and revising the NPAP's content but who were not involved in key strategic decisions related to the NPAP.
Over the course of the NPAP's development, multiple organizations were either identified by the Coordinating Committee or identified themselves through the “Get Involved” page of the NPAP's Web site for possible inclusion as an OP. The goal was to include organizations from the multiple societal sectors represented in the NPAP (eg, health, education, public health, business and industry, transportation, community design) as OPs or organizational affiliates. Some organizations chose to sign on as OPs, whereas others chose to become organizational affiliates or to have no formal affiliation. Exact records for the number and type of organizations contacted and the number choosing to join as OPs, organizational affiliates, or not at all, were not collected.
The purpose of this study was to use qualitative methods to understand factors related to OPs' decisions to join and remain a part of the NPAP coalition. Specifically, we wanted to learn (a) why OPs chose to become involved in the NPAP, (b) the process by which OPs made the decision to become an NPAP partner, (c) what each OP's expectations were for being involved in developing the NPAP, (d) why each OP stayed involved with the NPAP, and (e) what effect being an NPAP OP has had on each organization. Understanding the factors related to OPs' decisions to join and remain a part of the NPAP coalition may help inform development and maintenance of state and local-level PA coalitions within the United States and national-level PA coalitions in other nations.
Study population and sampling methods
The study sample included Coordinating Committee members representing OPs that joined the NPAP coalition prior to its launch in May 2010. The sample was limited to these individuals, given that OPs were the only “members” of the NPAP coalition representing a given organization's interests, and that the purpose of this study was to learn about why organizations chose to become partners in the NPAP coalition. Therefore, 2 Coordinating Committee members representing OPs that joined the coalition after the NPAP's launch were excluded, as were 5 academic members of the Coordinating Committee who did not represent an OP. Hence, 18 individuals, each representing a different OP, were invited to participate. Thirteen participants representing 13 OPs (72% response rate) were successfully recruited and completed the study. In addition, 1 OP suggested that another member of their organization should be interviewed, bringing the total number of participants to 14.
This study was conducted from January through September 2012 by the Prevention Research Centers at the University of South Carolina and Washington University in St Louis. All study procedures were approved by the institutional review boards from each university.
Qualitative semistructured interviews were used to elucidate the key factors explaining why and how OPs decided to become and stay involved in the NPAP coalition. Truth and Reality-Oriented Correspondence Theory guided this study as it is used to illuminate “what's going on in the real world.”23 Specifically, we employed analytic induction,23 where a priori assumptions about “what's going on” are generated on the basis of previous research and/or experience, and then a case study is subsequently conducted to determine whether or not the facts generated from that case study support the a priori assumptions. In this instance, our assumptions addressed OPs' rationale for joining the NPAP coalition and were informed by literature from the fields of community-level public health coalitions and business administration.13,15–18 The assumptions were that OPs' strategic objectives were closely aligned with the mission of the NPAP and joining the NPAP coalition would positively impact their organization. The interview guide included 6 main questions, with corresponding probes (Table).
TABLE Semistructure...Image Tools
In order to maintain consistency across interviews, each participant was interviewed over the phone by the same member of the research team trained in qualitative interviewing. Interviews were recorded only after verbal consent was obtained. The range of the length of interviews was approximately 15 to 33 minutes (median, 23 minutes). All interviews were transcribed verbatim and coded to remove personal identifiers. QSR NVivo924 qualitative data analysis software was used to manage data and assist with data analysis.
Once transcribed, the interviews were coded using an initial codebook developed a priori by the research team. Coding was conducted by only 2 members of the research team for consistency. Organizational codes, based on the interview guide questions, served as initial codes for the development of a master code list, with additional codes added throughout the process. The coders used this list to analyze an initial transcript and independently assign codes to sections of the interview text, modifying and adding codes as needed. The coders then discussed the code list, arriving at consensus on any differences on codes or code definitions. This same process was employed for an additional 2 interview transcripts, further refining and building the master code list. The remaining 11 interview transcripts followed a similar iterative process where codes were added to reflect emerging themes, and any differences in coding were addressed with the 2 coders arriving at consensus.
Our data revealed a range of reasons why OPs joined and remain committed to the coalition that developed and launched the NPAP, with 5 primary themes emerging:
1. Strategic Alignment, meaning the strategic initiatives (eg, strategic plan, mission, vision, goals, objectives, projects, or plans) of the OP were congruent with the vision, mission, and goals of the NPAP coalition.
2. Organizational Alignment, meaning the OP recognized the importance of aligning with other organizations involved with the NPAP coalition.
3. Provide Input, meaning OPs expected to lend expertise in developing the NPAP and/or to ensure that their organization's viewpoints were represented in the NPAP.
4. Seminal Event, meaning development and launch of the NPAP was a significant event in which involvement was viewed important.
5. Cost/Benefit Ratio, meaning the OP realized more positive than negative effects from having been involved in the NPAP coalition.
See Supplemental Digital Content Table 1 available at: http://links.lww.com/JPHMP/A25
All 14 study participants mentioned that their organization's strategic initiatives were congruent with the mission, vision, or goals of the NPAP, evident in statements such as “this is near and dear to our mission” and “it aligned very well with our strategic plan.” Specifically, strategic alignment emerged from:
* Process to join, defined as information related to how and why organizations became involved, and who was involved in the process.
* Process to stay, defined as information related to how and why organizations chose to stay involved, and who was involved in the process.
* Effect of involvement, defined as the impact, positive or negative, that being involved with the NPAP has had on the organization.
Process to join
When discussing the processes their organization went through in deciding whether or not to join the coalition, 13 participants (93%) mentioned strategic alignment. Nonprofits, for-profits, and governmental agencies all mentioned strategic alignment as being related to their process to join, highlighting the potential importance of strategic alignment when looking to bring new partners into a coalition. When asked why her organization joined the NPAP coalition, 1 participant said,
It's definitely part of our mission and our strategic plan. So when we heard that plans were afoot to make a National Physical Activity Plan we felt like it was very important and something that (our organization) wanted to support.
Process to stay
OPs were never formally asked to recommit to the NPAP (eg, they were not asked to contribute an additional $10 000). Most organizations, 16 of the original 18, remained involved at the time data were collected for this study, by continuing to fund the participation of their representative to the NPAP's Coordinating Committee, and provide additional in-kind support (eg, hosting in-person committee meetings, promoting the NPAP at conferences and meetings). When asked about their organization's choice to stay involved, strategic alignment once again emerged as a common theme, present in responses from 11 participants (79%). “Actually, this fits into our current strategic plan because one component of our strategic plan is around supporting national initiatives that support physical education and physical activity. So this actually was a nice complement to our current strategic plan,” said 1 participant.
Effect of involvement
Participants were asked what effect their involvement in the NPAP has had on their organization and what positive or negative consequences have resulted from their involvement. As detailed later, participants indicated no negative consequences from involvement in the NPAP coalition. Twelve participants (86%) stated that involvement in the NPAP coalition had an effect on their current and/or future strategic initiatives. One participant reported that being involved in the NPAP has had the effect of elevating the importance of PA within the participant's organization:
I would say in fact physical activity has grown in prominence on our screen over the past couple of years.... We've spent probably the past five years really ramping up our positions and our available tools and resources on nutrition and weight loss, but until recently we haven't done the same with physical activity, and I think that perhaps through participation in the plan we have seen this gap and are focusing more on physical activity internally as well.
Organizational alignment, meaning the OP recognized the importance of aligning with other organizations involved with the NPAP coalition, was viewed as important for 10 of 14 participants (71%). Organizational alignment was present in conversations about OPs' process for joining, process for staying, and effect of being involved in the NPAP. Based upon participant responses, 4 subcategories for organizational alignment clearly emerged: (a) alignment as a strategic goal, (b) improved operating efficiency through aligning with others, (c) building new or strengthening existing relationships, and (d) wanting to be associated with other well-known organizations. What was less clear was whether “other organizations” referred only to the OPs, or whether they also included organizational affiliates and/or members of sector working groups, which were organizations that worked closely on developing the NPAP but which did not support the NPAP at the same level as OPs. For example, one participant said, “There were several groups in there that I got to know for the first time that weren't necessarily on the coordinating committee.”
Alignment as a strategic goal
Several participants stated that aligning with other organizations was part of their organization's strategy, making it difficult to disentangle organizational alignment from strategic alignment, and thus leading to the development of this subcategory. The statement was typical of participants discussing alignment with other organizations as a strategic interest for their organization.
I mean if we were to say three top reasons (for becoming involved), one would be it aligned very well with our strategic plan, which was to partner with other national entities that are promoting fitness, but not really an organization within ‘our' industry
Improved operating efficiency
Other participants commented on the efficiency offered through combining resources with other organizations. Two participants discussing the process behind their organization's choice to become involved said, “We have an opportunity to align our resources with other organizations who have a vested interest in the same thing that we do”; and “...by working together with other organizations who share that common interest, even though the rest of our agendas may be different, you were more likely to move that piece of it forward”.
Relationships with other organizations
When asked generally about the effect involvement in the NPAP has had on their organization, building new relationships was evident in statements such as, “...it was an opportunity to get to know a lot of organizations that are different than the ones that we normally interact with” and “I think it's given us access to a lot of experts and a lot of new groups.” Some participants mentioned strengthening existing relationships in addition to building new ones as an effect of involvement: “It also continues to strengthen relationships that we have with other works that have similar missions.”
When asked about their organizations' expectations for being involved in the coalition, 9 participants (69%) stated that they expected to lend their organization's expertise in developing the NPAP and/or expected that the viewpoints of their organization would be represented in the content of the NPAP. Among the different types of expectations that emerged, providing input was a much more prevalent theme than others (eg, advancement of policies; improving PA levels of the population). The expectation for providing input seemed to be by design, which might explain why it was more frequently stated than other expectations. As 1 participant stated,
Well we did have an expectation that we would be proactively engaged in the plan because that was one of the decisions that was made pretty early on about what the role of the Coordinating Committee would be. And so almost by definition as a member of the Coordinating Committee, you would be involved in all of the steps of plan development.
When speaking about the expectation that their organization would be able provide input on content of the NPAP, 1 participant stated, “I would say an expectation that we had for being involved in the development was to establish our position in this group of organizations that were developing a plan as the experts in (our field).”
In deciding whether or not to join the coalition, many OPs (50%) cited the remarkable nature of the project as a reason for joining, evident in this participant's response,
...this was just historic... why not be involved in this. This has never been done before. There's been a lot of good talk about it, but the convergence of trying to get number 1, the physical activity guidelines out there, and then number 2, to create a document that outlines the strategies to execute on those, or to make those a realistic, deliverable for the American public was just historic.
All 14 participants (100%) stated that their organization did not experience any negative consequences associated with involvement in the NPAP coalition. The following quote typifies responses across participants: “Well I don't think there are any negative consequences.” Although there was no specific question about positive consequences of involvement, all organizations realized positive consequences as the result of their involvement in the NPAP (Supplemental Digital Content Table 2 available at: http://links.lww.com/JPHMP/A26).
Coalitions are highly complex. Their often heterogeneous membership represents disparate interests working to bring forth change that is influenced by the social and political contexts in which the coalition operates. Therefore, understanding the myriad of factors responsible for coalition success is equally complex. It has been proposed that coalition effectiveness is influenced by partner characteristics (eg, level of involvement, motivations for participating, member expectations).11,14,15 In addition, for a coalition to survive, the payoffs to member organizations must outweigh or at least equal the costs of membership.16,19,20 This study used qualitative methods to “unpack” partner characteristics, which are not yet well understood or measured11,14 to better understand why organizations joined and remain committed to the NPAP coalition.
Five themes emerged from our data for partner characteristics, most of which may indicate more self-motivated rather than altruistic reasons for OPs' commitment to the NPAP coalition. Strategic alignment, organizational alignment, and providing input, all emerged as themes that served primarily, if not exclusively, the partner organization. Seminal event emerged as a theme that may have had motivations that were equal parts self-serving and altruistic (eg, of benefit to the field of PA and health, or the American population as a whole). Our data show that, whether guided by self-serving or altruistic motives, the NPAP OPs experienced benefits from their involvement while experiencing no drawbacks, leading to the fifth theme that emerged—cost/benefit ratio. This may help explain why this coalition was particularly successful in achieving its initial goal to develop and launch a national plan for PA.
All participants mentioned that their involvement in the NPAP coalition was driven by their organization's strategic interests that were aligned with the mission, vision, or goals of the NPAP. This finding is not surprising given the relatively homogeneous composition of this coalition, composed primarily of health, public health, and sports and recreation-based organizations that may conduct research on, advocate for, and/or develop products and services related to PA.
Increasing population levels of PA will come largely from developing, advocating for, and implementing policies aimed at environmental and systems change across multiple sectors. Therefore, PA coalitions at local, state, and national levels will likely benefit from a more heterogeneous composition. Based upon our findings, coalition success at the national level, and possibly state and local levels, may rely heavily on understanding how the strategic interests of prospective and current partners would be positively impacted by the mission, vision, and goals of the coalition. Particularly when considering organizations not typically concerned with PA and health (eg, departments of transportation, retailers, departments of education, or elected officials), a thorough understanding of each organization's specific strategic interests may be an important first step in attracting highly committed partners.
Organizational alignment and its 4 subcategories emerged as the second most common partner characteristic in understanding organizations' participation in the NPAP coalition. However, it was sometimes difficult to disentangle organizational alignment from strategic alignment, leading us to question whether or not organizational alignment may in some cases be a component of strategic alignment. Irrespective of the possible relationship between organizational and strategic alignment, the 4 subcategories of organizational alignment clearly related more to the self-serving interests of the partner organizations than altruistic motives, which has been previously described in the literature. For example, the concept of improved operating efficiency has been described as a benefit of joining a public health–related coalition.15,20 Therefore, understanding the extent to which organizational alignment is important to prospective and current coalition members, and if it is, demonstrating how their organization could be positively impacted by aligning with other coalition stakeholders, may help with recruitment and retention of committed partners.
OPs expected that their “seat at the table” would grant them the opportunity to provide input on the process that would be followed for developing the NPAP, as well as on the actual content in the NPAP. In both cases, the extent to which those expectations were more for the benefit of the coalition or the individual partner were not completely clear. Providing input on the process to develop the NPAP appeared more altruistic considering participants' comments about their organization's capacity and desire to help the coalition achieve its mission of developing and launching the NPAP. Although one could argue that considering how closely the NPAP's mission was connected to an organization's strategic interests, achieving the NPAP's mission did ultimately benefit each OP.
Development of the NPAP was a unique event, and for that reason, it attracted a number of partners, with half of our participants citing it as being an important aspect of their organization's rationale for joining the coalition. The concept of the NPAP as a seminal event may have limited application for PA coalitions at state and municipal levels but may apply if and when a state or municipality endeavors to develop its own PA plan. For example, West Virginia modeled development of its state PA plan after the NPAP and achieved a similar level of success.25 The importance of seminal events may be a significant indicator to track over time as a potential barrier to sustainability of membership as the novelty of the event decreases.
The relationship between the relative benefits and drawbacks of participation, or cost/benefit ratio, has been described previously as influencing partner commitment and, therefore, coalition success19,26 and emerged as a clear theme in this study. It is possible that the cost/benefit ratio of participation is the primary operating construct, with strategic alignment, organizational alignment, and seminal event being latent variables for that construct. However, our study was not designed to address this possibility. As stated earlier, our data revealed that all NPAP OPs perceived strategic alignment with the NPAP and organizational alignment with other NPAP stakeholders as beneficial, stating them as either reasons for joining and staying in the NPAP coalition or as an effect of involvement. Likewise, participants stated that their organizations' involvement in the NPAP coalition was of value to their own constituents, making that a distinct benefit to participation, since it was not mentioned within the context of either strategic or organizational alignment. Perhaps most importantly, when participants were specifically asked whether their organization experienced any negative consequences as the result of their involvement in the coalition, all participants responded by saying that they could not identify any. This resulted in weighting the cost/benefit scale completely to the benefit side.
Very little is known about PA coalitions in the United States, and most national PA plans from around the world lack an evaluation component that could inform development and advancement of national PA plans in other countries.27 Hence, the primary strength of this study is the qualitative methods, which provide important insight into factors that may impact PA coalitions at state and local levels within the United States, and efforts to develop and advance national PA plans outside the United States. The qualitative methods employed here identify new insight into organizational motivations for committing to a national-level PA coalition, which leads to important questions about state- and local-level coalitions that need to be addressed in future research.
There are some limitations to this study. It is conceivable that the majority of NPAP OPs having been from the health care or public health, and sports and recreation sectors is a limitation. However, it is also conceivable that the relative homogeneity of the NPAP coalition may in fact be a strength. For example, because strategic alignment was a highly prevalent theme in this study, it may highlight the importance of the need to understand how the strategic interests of an organization not obviously or typically associated with PA and public health could be positively impacted through membership in a PA coalition.
The greatest limitation lies in the organizations that were not represented. Representatives from 5 of the 18 OPs did not respond to repeated attempts to schedule an interview. It is possible that the experiences of those not interviewed differed from those who were interviewed, although we are not able to discern any differences (eg, size of organization, type of organization, sector in which the organization operates, length of time as a coalition partner). In addition, during the process of recruiting OPs for the NPAP coalition, there were several organizations that chose not join at the level of an OP, choosing instead to become “organizational affiliates.” Organizational affiliates contributed to the development of the NPAP document but did not commit the monetary and in-kind resources required of OPs and thus were not represented on the Coordinating Committee and not recruited into this study. Understanding why these organizations chose not to join the coalition may be as important as understanding the choice to join, but that analysis fell outside the scope of this study. Finally, the uniqueness of the NPAP coalition may be a limitation. The fact that the NPAP coalition was so highly focused on a single product (ie, development of the NPAP) and that the NPAP OPs contributed $10 000 to join the coalition may be atypical compared with state and local PA coalitions.
Based on these limitations, the ability to make inferences from this study to state- and local-level coalitions may be limited. Investigation of coalition partners in state and local PA coalitions will be necessary before definitive conclusions can be drawn about the similarities and differences between partner characteristics of the NPAP coalition and those of state and local PA coalitions. It is possible, for example, that the NPAP being a “seminal event” may have little relevance at state and local levels. Conversely, states and municipalities are beginning to develop PA plans modeled after the NPAP, which may be perceived as a seminal event. In addition, if the relative homogeneity of the NPAP coalition is different from the composition of state and local coalitions, this too could limit the generalizability of our findings. However, it is possible that state and local PA coalitions have membership compositions similar to that of the NPAP coalition.
Future directions from this study are 3-fold. First, the results should be presented to the NPAP coalition to inform recruitment of future OPs. Second, because this study involved only 1 PA coalition operating at the national level, it will be important to determine whether or not the themes that emerged are relevant to state- and local-level PA coalitions throughout the United States. Third, this study focused primarily on the process for developing and launching the NPAP and not on implementation. Therefore, it may be important to reinterview NPAP OPs in the future to determine whether or not different themes for decisions to join and stay committed to the NPAP coalition differ during the implementation process.
In conclusion, OPs joined and remained committed to the NPAP coalition primarily because doing so provided numerous benefits without any reported negative consequences to their organization, possibly explaining why the coalition was successful in developing and launching the NPAP. To the best of our knowledge, this study provides the most in-depth look at organizations' motivations for joining and remaining committed to a national-level PA coalition. Based upon our findings, building and maintaining a coalition with highly committed partners may hinge upon the ability to fully understand how each current or prospective partner believes it could benefit from: strategic alignment with the coalition, alignment with other coalition stakeholders, providing input into the coalition's processes and products, and the importance of the coalition's mission. Future research needs to identify the extent to which the 5 themes that emerged from this study of a national-level PA coalition can be confirmed in a broader sample of state and local-level PA coalitions.