Gustat, Jeanette PhD, MPH; Healy, Isobel MPH; Litt, Jill PhD; Reed, Hannah BS; Tabak, Rachel G. PhD; Goins, Karen Valentine MPH; Bornstein, Daniel BS; Carnoske, Cheryl MPH, RD; Lyn, Rodney PhD; Eyler, Amy A. PhD
Multidisciplinary coalitions and community networks have become integral in health promotion and disease prevention.1 The advantages of partnership approaches are widely accepted by government agencies and foundations, and as a result, the majority of recent prevention initiatives have required the formation of community coalitions.2 Networks with multidisciplinary partnerships have the potential to address complex health conditions through an ecological approach.3 By working within multidisciplinary teams, community organizations not only approach issues on multiple levels but also draw on a broad range of resources and expertise provided by other organizations within an expanding network.4
Multidisciplinary collaboratives have the potential to improve community health by marshaling the connections and skills of their diverse memberships. These varied partnerships have potential to advance policy and environmental change agendas for healthier communities.5 Supportive environments can be all-encompassing, including the physical, social, and policy environments. Policy and environmental changes are key components to successful and sustainable interventions and are particularly relevant for obesity prevention initiatives.6–10 There has been much examination of multidisciplinary collaboratives' effectiveness in facilitating these types of changes for health issues such as asthma, tobacco use, underage drinking, and type II diabetes, and knowledge about the effectiveness of these collaboratives for promoting policy and environmental change for advancement of physical activity and active living is just starting to emerge, beginning with examination of popular walk to school initiatives.4,11–17 Given the increase in interdisciplinary community collaboratives with a focus on facilitating more active-living friendly communities, information on barriers and enablers to achieving these changes can help identify best practices and can improve the efficiency and effectiveness of such collaborative groups.10
The findings presented here are part of a larger study called “Coalitions and Networks for Active Living (CANAL)” that examined composition, operations, and activities of multidisciplinary collaboratives that promote active living.16 The CANAL study was conducted by the Physical Activity Policy Research Network (PAPRN), a research network funded by the Centers for Disease Control and Prevention to study the effectiveness of policies on population physical activity. The purpose of the current analysis is to explore successes and challenges that collaborative groups experience in promoting and implementing policies in support of active living and/or physical activity in their respective communities. This analysis can provide information useful to groups in planning and prioritizing strategies for improving population physical activity.
This study was designed by the CANAL research team, a subgroup of the PAPRN and is part of a larger study of composition, operations, and activities of collaborative groups that promote active living.16 The term “collaborative” refers to any type of multidisciplinary group, coalition, or network. Structured telephone interviews with each collaborative's lead coordinator(s) were conducted by trained staff (from the Colorado School of Public Health and Washington University in St Louis) between May and August of 2011, with detailed notes taken on all interviews. Prior to data collection, both sites received institutional review board approval of study protocols in compliance with human participants protection guidelines set by the Office for Human Research Protections with the US Department of Health and Human Services.
Collaborative groups were referred to the study by members of the PAPRN, the National Society for Physical Activity Practitioners in Public Health, and the Physical Activity and Public Health Practitioners Course alumni.18 Additional recruitment strategies included advertisements on Web sites and Prevention Research Center newsletters. Online searches for active living collaboratives were also conducted using the following key words: coalition, collaborative, network, physical activity, active living, policy, and/or environmental change. Criteria developed by the research team for collaboratives to be eligible for interviews included having physical activity and/or active living as a primary or secondary goal, having work focused on policy and/or environmental change, being comprised at least 3 partners from various sectors, and having been in existence for at least 1 year. Lead coordinators or the lead person on physical activity from each eligible collaborative served as interview respondents. Detailed information regarding the structure and composition of participating collaboratives can be found in the study of Litt et al.16
The complete interview assessed collaborative composition, community and policy engagement activities, and levels of success in achieving environmental and policy change across 8 strategy areas: (a) parks, open spaces, and recreation facilities; (b) transit and parking; (c) children's play areas; (d) public plazas; (e) streetscaping; (f) street improvements; (g) infill and redevelopment; and (h) Safe Routes to School. Interview questions were developed by the CANAL team on the basis of previously validated instruments when possible. The instrument has been described in a previous publication.16 This current analysis focuses on 2 open-ended questions that asked respondents to describe (a) their collaboratives' most successful project and (b) any challenges or barriers that affected the ability of the collaborative to do its work. Probes were used to elicit descriptive responses for each question. Probes for the successful project question included (a) approach type, (b) partner involvement, (c) funding status, (d) project goals, (e) collaborative proponents, (f) collaborative opponents, (g) current project status, (h) project sustainability, and (i) project evaluation and replication. Coordinators were encouraged to describe what they perceived as their most successful project. Definitions or parameters of success were not used so that each coordinator could describe what his or her collaborative considered as successful.
Probes for the question on challenges included (a) challenge(s) or barrier(s) experienced, including whether there were financial, personnel, political, procedural, data, time, infrastructure, or coordination issues; (b) length of time collaborative had been together when the challenge or barrier occurred; and (c) limitations the collaborative experienced as a result of the challenge(s) or barrier(s). Interviews were conducted over the telephone and the data set was derived from detailed notes taken by the interviewers.
We used a grounded theory approach to develop a coding guide based on the probes used by the interviewers.19 As concepts emerged from the data, additional codes were included. Each response set was coded independently by 2 members of our research team and then verified by a third. Coding discrepancies were resolved through discussion among members of the CANAL research team. Consensus was reached and all discrepancies were resolved. Frequencies were then determined for each code and overarching themes were identified. Relevant quotes for each code were abstracted from each interview. The statements represented as quotes below denote both actual quotes and paraphrases from respondents.
Of 96 groups invited, coordinators from 59 collaboratives from across the nation participated in the interview and represented a response rate of 61%. Respondents represented all areas of the United States, with 22% from the Midwest, 17% from the Northeast, 32% from the South, and 29% from the West. Six groups declined, 3 cancelled scheduled interviews, and 28 groups never responded. Of the nonrespondents, 19% were from the Midwest, 14% from the Northeast, 19% from the South, and 40% from the West. The majority of responding groups worked at the local level (78%) whereas the remaining groups focused on statewide issues. More than half the groups had been together 4 years or more and most had paid staff (85%).
When asked to describe the approach used for the most successful initiative (ie, policy, program, or project) undertaken by their collaborative, coordinators provided a number of responses categorized as relating to the built environment, policy, capacity building, and programmatic or awareness building (Figure 1). Of all respondents, 41% named environmental approaches (eg, trail building, park enhancement, gardens), 31% identified policy-related approaches (eg, Complete Streets), 25% sought to build capacity (eg, build partnerships, develop tools/reports, conduct assessments), 24% were focused on program approaches (eg, Federal Safe Routes to School program), and 17% employed approaches around raising awareness (eg, 1-time event, community mapping activities). Respondents were encouraged to identify more than 1 approach if applicable. The majority (71%) of collaboratives reported just 1 strategy, 19% reported 2, 8% reported 3, and 1 collaborative (2%) reported 4 strategies.
Funding emerged as a common element of collaborative groups' most successful initiatives, with 47 of the 59 groups reporting that their most successful initiative was funded (80%). Eight collaborative groups (14%) reported no funding for their most successful initiative, and 4 groups (7%) did not speak to funding in their description of their most successful initiative.
The collaboratives reported between 1 and 4 goals for each of their successful projects, with 39% reporting 1 goal, 34% reporting 2, and 27% reporting 3 or 4 goals. Goals included making changes or improvements to the built environment (eg, building community gardens, constructing walking paths) (47%); activism or advocacy to promote active living and physical activity (eg, leadership development, written advocacy, testimony in a policy, legal or judicial hearing) (41%); making changes to existing policy or the creation of new policy (32%); engaging or partnering with elected or appointed officials, community leaders, school district, or school board officials (29%); programmatic outcomes (eg, Safe Routes to School initiatives, professional development for school teachers to integrate physical activity) (14%); identifying community health needs (12%); and expanding the group's network of partners (eg, recruiting new partners with policy expertise, partnering with practitioners with planning and design expertise) (10%) (Table 1). Other goals included working on media advocacy and increasing participation in wellness plans.
While more than half of the collaborative groups (51%) reported no opposition to the successful project, more than one-third (36%) of groups described varying degrees of opposition. Respondents cited general skepticism, public opposition related to changing land use, safety issues, and concerns about financial costs. With regard to land use changes, 1 collaborative working to develop a community garden in a residential neighborhood encountered resident resistance to converting open space “into anything else.” Another collaborative faced skepticism around whether community members would have the time and interest to participate:
because in this part of town getting volunteers and recruiting parents, and anyone for that matter is difficult.... The skeptics didn't think we could get volunteers to care for the gardens, but we had a waiting list for community garden plots.
Safety was a concern for some community members who thought of their “county as being a dangerous place for walking and cycling,” and 1 respondent reported opposition from a traffic engineer who told the collaborative that “bicyclists should not be on the road, for safety reasons.” Groups also reported opposition originating from elected officials, public agencies, and private industry, with cost being a chief concern. Regarding elected officials, 1 respondent stated, “There was some resistance some think we're using tax dollars.” Another reported, “The biggest opposition was dealing with the state legislators' lackadaisical attitude toward the measure.” In terms of public agency opposition, it was reported that the director of the Department of Transportation “was for it, but the staff.... had to be pushed kicking and screaming toward this.”
Most collaborative groups (75%) stated that their most successful policy, program, or project was still in effect and 73% reported plans to continue it. Only 24% of respondents reported that their work had been replicated, and 39% indicated that their project had been evaluated or that evaluation activities (eg, data collection) were underway.
The number of challenges reported by collaboratives varied, with 7% reporting no challenges, 12% reporting 1, 31% reporting 2, 29% reporting 3, and the remaining 22% reporting between 4 and 6 challenges to their work. Financial issues were identified as the primary challenge by 71% of the 59 collaborative groups (Table 2). Personnel changes were the next most common challenge (54%). One respondent shared:
We are all volunteer(s), and have never been able to get capacity building grants to hire someone to have paid staff function. This has led to burn out and lack of effectiveness, because we're all doing this in our spare time. We've had people, core people, move away or say I can't do this anymore and take expertise with them, and that's a challenge too.
The political environment was cited by 34% of respondents as a challenge. Another respondent noted:
We probably would move faster if everyone was engaged. We had some elected officials on our city council that were supportive, but with the change in political leadership we went from a progressive environment to a more conservative environment...there has been a philosophical debate about whether government should be involved in health.
Culture and composition of the collaborative (including issues of how the individual organizations worked together in the collaborative) were described as challenges by 22% of the groups. One respondent shared:
We all work really well together, but we're all from such different facets of government. The good news is that we get to reach out to very different groups, but the bad news is that we all come from such different backgrounds that we approach things differently.
Another respondent discussed the difficulties of varying levels of engagement of members within the collaborative:
We have some people that are very involved and follow through with what they've indicated they want to do and others that volunteer and then don't follow through. We also have some that just come to meetings then don't volunteer or do anything. That's a barrier, and we probably would move faster if everyone was engaged.
Twelve percent of the groups reported other challenges focused on community-specific issues, such as public safety, poverty, and issues related to the geographical size of the community.
Four groups indicated that they did not encounter challenges to their work and instead focused on their successes. Three additional collaborative groups quickly acknowledged challenges before moving on to a discussion of overcoming their challenges and identifying the strengths of their respective groups. Phrases, such as “we do the best we can,” “it's a good working relationship,” and “we all came around the table around a vision and mission,” dominated the responses from these 7 collaboratives.
A few of the collaboratives reported that the challenges they experienced prevented them from accomplishing their goals. Ten percent of respondents stated that their collaborative failed to engage their target communities, and 7% were not able to implement a specific policy related to active living. Program implementation was hampered for 7% of respondents. Two goals were identified as unreachable—the establishment of partnerships as one group and funding as another group. While fiscal challenges were experienced by 42 of 59 groups, only 1 collaborative reported funding as a specific goal in and of itself.
Community initiatives promoting physical activity or active living take a number of different forms. These findings show that approaches used by active-living collaborative groups exist at all levels of the ecological model, ranging from programs at the individual level to advocacy and policy change. The most common approach reported for successful projects involved modifications to the built environment, such as new parks, park enhancements, trail building, or gardens. Correspondingly, although each of the 59 collaboratives possessed a unique composition of goals and approaches, the most predominant goals cited by collaborative groups for their most successful project were (a) direct changes or improvements to the built environment and (b) effecting changes to the formation of policy. Emerging research suggests enhancements to the built environment and formation of policy may be a direct result of a growing trend for developing multidisciplinary partnerships, notably comprised of urban planning, transportation, public health and other sectors.20,21 Respondents' emphasis on physical changes is consistent with current research, suggesting that the built environment has the potential to influence both recreational and utilitarian physical activity, including biking and walking.22,23
Although varying degrees of opposition were discussed, the majority of collaboratives reported no opposition to their project. One study of advocates and policy makers regarding obesity prevention legislation found that advocates viewed opposition to obesity prevention efforts as manageable whereas policy makers viewed opposition as a potential political cost.23 Collaboratives with strong leadership may be more experienced in dealing with opposition and, as a result, may take an optimistic view for success of strategies. Many of the interview findings demonstrated that attitudes toward success may relate to how challenges are overcome.
Financial and human resources for physical activity and active living were cited by respondents as key barriers to success. While a majority (80%) reported that their most successful project was funded, financial issues were also the chief challenge experienced by respondents (71%). Most collaborative groups specified some financial hurdle, either in terms of insufficient funds or in funding cuts. Lack of monetary resources was not the only resource-related challenge identified by respondents. The second most commonly reported challenge was staffing changes, as it is difficult to maintain continuity in projects and relationships with high turnover of key personnel. In spite of these reported challenges, the majority of collaborative groups noted that their most successful policy, program, or project was still in effect and reported plans to continue their work.
Reported levels of replication and evaluation of projects were low. Collaboratives, especially younger groups, may not have had sufficient time or resources in which to replicate success. The extent of evaluation is low given the high percentage reporting funding for this work. Grant-making organizations are increasingly requiring evaluation activities to assess the value of their investment. Perhaps funds awarded for physical infrastructure projects have not required the degree of assessment expected of public health program funding, and this may be an area for improvement.
Six of the 7 groups that either reported no challenges or chose to discuss successes when asked about challenges also declined to mention any opposition to their project. More investigation is needed to evaluate whether attitudes toward success and/or perceptions of challenges may influence successful outcomes and achievement of goals among collaborative groups.
This study has some limitations. While we attempted to reach out to all collaborative groups working in physical activity and active living within the United States, the total eligible population is unknown. The sample was obtained through a nomination process; groups with greater visibility and more successful initiatives were likely included and may not be representative of all groups working in the area. In addition, our questions and probes may not have been sufficient to capture the activity and issues for each collaborative. However, several questions in the interview were open-ended, thus respondents had the freedom to provide answers across a wide range of approaches and related activities. Likely attributable to the open-ended nature of the questions, agreement in the initial coding of the responses varied. As was previously mentioned, coding discrepancies were resolved after group discussion and consensus was reached on final interpretation. Also, parameters of a successful project were not specified in the interview and few collaborative groups reported evaluation of their successful projects. So, group efforts have not been validated.
The study also has several strengths. This is the first analysis to describe in detail successes and challenges in increasing population physical activity by the promotion of policy and environmental change through the work of multidisciplinary collaboratives. Given the national focus on obesity prevention, this study can help researchers discover ways to enhance successful collaborative efforts for both physical activity and nutrition. The PAPRN group is a national group of investigators working in the area of physical activity and active living to support the same goals as the collaboratives studied. This common purpose may have motivated busy collaborative coordinators to participate in the interview. The open-ended questions with probes addressed both the successes and the challenges these collaboratives experience and allowed respondents to discuss their own unique situation. In addition, our findings describe many general processes of community change and may be generalizable to other community improvement strategies.
This study supports the growing body of literature on collaborative effectiveness spanning across discipline and may be useful to professionals and community advocates seeking physical activity policy change.1,24–26 In addition, lessons from the successes reported by these collaborative groups can be used to help other groups working in the area of physical activity and active living. Recognizing and understanding the common challenges allows for the development of tools and strategies to overcome these challenges. Future investigation could focus on exploring the ways in which groups have overcome challenges, as well as the role individual perception plays in identifying goal opposition and attitudes toward success. Thorough analysis of whether a collaborative's age has an effect on its success and/or resilience in the face of adversity is yet to be determined. Focusing on approaches such as changes or improvements to the built environment and advocacy to promote active living may be good starting points for collaboratives, as these activities are likely to produce successful projects. Collaborative groups will benefit from learning about the successes and challenges experienced by peer professionals who are working across disciplines to support both built and policy environments that encourage active living.