Over the past few decades, collaborative groups have become essential to achieving systems change in the public health arena.1 , 2 Collaborative groups provide an opportunity to bring the strengths, experience, and knowledge of multiple disciplines to bear on particular issues or problems. Such groups can work together to share information and resources to address social problems touched by multiple systems and disciplines. Depending on their members and their goals and purpose, collaborations can take many forms. Generally, parties agree upon long-term goals that can be reached through systemic changes and that involve a variety of systems and stakeholders, often aimed at improving population-level health outcomes. Many public-private and multiagency collaborations are underway to address public health issues at the community, state, and national levels.3 , 4 Many of these collaborations are specific to a particular health topic, such as asthma5 , 6 or childhood obesity7 , 8; however, some collaborations address health from a broader perspective.8
The Partners in Program Planning for Adolescent Health (PIPPAH) initiative was established in 1996 by the Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau, Office of Adolescent Health. The primary purpose of PIPPAH was to promote an adolescent health focus among the key professional disciplines that were likely to encounter adolescents in their work while fostering interdisciplinary collaboration. The National Association of County and City Health Officials (NACCHO) was 1 of 8 PIPPAH grantees during the initiative's last funding cycle (2006–2011), all of which serve a national membership body or workforce of professionals who could positively impact adolescent health.
PIPPAH's Structure and Activities
PIPPAH is a collaborative comprising 8 national organizations focused on developing infrastructure and capacity to enable their members to better serve adolescents and their families. Each organization (1) develops and conducts its own adolescent health–related activities specific to their members or constituencies; (2) contributes to a single, overarching collaborative project; and (3) meets regularly to share information, network, and discuss opportunities for collaboration beyond the larger collaborative project.
PIPPAH grantees reported a total of 117 key activities aimed at communication and information sharing on adolescent health topics, education and training, leadership, expertise, and infrastructure building, and adolescent health promotion. Through these activities, PIPPAH grantees reached hundreds of thousands of individuals through their membership bodies and, internally, through building capacity within their own organizations.
NACCHO is engaged in a number of activities aimed at improving the capacity of local health departments (LHDs) to address adolescent health issues in communities, including developing and disseminating policy statements, publications, and online communications; providing technical and financial assistance to LHD youth engagement projects; developing a strategic plan for maternal, child, and adolescent health (MCAH) at NACCHO; and gathering LHD input for a local-level adaptation of the state-level Adolescent Health System Capacity Assessment Tool (SCAT).
NACCHO's policy statements represent shared priorities among NACCHO's members and board. Each policy statement requires the board's approval and must be updated for its relevancy every 3 years. During the PIPPAH funding cycle, NACCHO updated the following policy statements related to adolescent health—Support for Coordinated School Health Programs, Support for Comprehensive Sexual Health Promotion and Education, and Support for Minors' Access to Confidential Health Services—and developed a new policy statement in support of an Adolescent Health Platform. In addition to the collaborative PIPPAH publication (described later), NACCHO published a series of articles to inform LHDs, decision makers, and funders about a variety of adolescent health topics. The article “Bringing Adolescent Health to the Forefront” was published in the January/February 2007 edition of the Journal of Public Health Management and Practice to provide an overview of the 21 Critical Health Objectives for Adolescents and Young Adults and to highlight the importance of using positive youth development approaches in local-level adolescent health efforts.9 NACCHO also published the issue brief YouTube, Facebook, MySpace, blogs, and More: Innovative Ways Local Health Departments Are Reaching Adolescents, which highlighted the efforts of 3 LHDs to reach adolescents through information technology. Finally, NACCHO produced Local Health Department Approaches to Meeting the Needs of Pregnant and Parenting Teens, a report highlighting the efforts of 4 LHDs, discussing the issue of teen parenting, and providing recommendations for future LHD action. NACCHO's publications are available at www.naccho.org.
In 2009, NACCHO selected 2 LHDs to serve as demonstration sites for using youth engagement strategies to strengthen their existing adolescent health efforts. As a result of this 2-year planning and implementation project, Denver (Colorado) Public Health established a youth internship position and experimented with using social media to incorporate youth input into project decision making; Harris County (Texas) Public Health and Environmental Services conducted focus groups with youth and used Photo Voice as a participatory data-gathering method. More information on these youth engagement projects is available on NACCHO's MCAH Web page (www.naccho.org/topics/hpdp/mcah/overview.cfm).
The MCAH strategic plan guides NACCHO's MCAH-related activities conducted on behalf of LHDs. The first 5-year MCAH strategic plan was drafted in 2009 through facilitated discussions with members of NACCHO's MCAH workgroup and representatives of partner organizations. In light of a substantial turnover in the MCAH workgroup membership and significant changes in the public health field, including passage of the Patient Protection and Affordable Care Act, NACCHO revisited the strategic plan with the 2011–2012 workgroup and facilitated a discussion to reestablish the MCAH vision and strategic directions for the next 3 years. The MCAH strategic plan is available at www.naccho.org.
In June 2011, NACCHO collaborated with the Association of Maternal and Child Health Programs to host a strategy meeting with 13 adolescent health staff members from 7 geographically diverse LHDs. During this meeting, participants reviewed the SCAT, assessed its application for the local level, and produced recommendations for use in LHDs. After reviewing the tool, participants expressed an enthusiasm for modifying the SCAT for use at the local level and provided extensive feedback on necessary modifications, including a new name: Ask How Your Community Can Improve Adolescent Health: Adolescent System Capacity Tool (ASC).
In addition, NACCHO and the other grantees participated in the development of the PIPPAH Collaborative Project—a common project that would be relevant and engaging for all grantees and their constituents. The PIPPAH collaborative project, which was developed by consensus, involved a series of interviews with key adolescent health experts, each of whom could offer a unique and multidisciplinary perspective to addressing the health of adolescents. These interviews were disseminated as (1) a monograph containing each of the interviews, Creating Healthy Opportunities: Conversations With Adolescent Health Experts; and (2) a series of podcasts, with highlights from each of the interviews. Each of the grantees used these products in at least one PIPPAH-funded activity, and many planned to continue to disseminate and use the resources after the end of the PIPPAH funding cycle.
PIPPAH's structure allowed NACCHO to develop strong relationships with other grantee organizations that, in turn, enhanced the resources and capacity of NACCHO in responding to adolescent health issues.
Benefits of Collaboration
A comprehensive evaluation was undertaken during the last PIPPAH funding cycle to determine the extent to which grantees benefited from participation in PIPPAH. The results of the evaluation identified a number of benefits beyond the funding of adolescent health projects and the development of the collaborative project. All grantees reported benefiting from PIPPAH's networking opportunities because of the collaborative relationships that enabled them to remain informed of and gain support for key issues.
Over the course of the study, grantee organizations were able to support one another's individual key activities through various methods of collaboration, from sharing ideas to sharing decision making and jointly developing content. Evaluation findings indicated that the types of collaboration on key activities increased and grew more intense over time, pointing to greater involvement and more advanced collaboration among grantees as a result of participating in PIPPAH. Grantees reported that their levels of collaboration increased substantially over the course of the PIPPAH funding cycle, suggesting that PIPPAH enabled grantees to develop mutually beneficial relationships that were considerably stronger than when the initiative began.
PIPPAH grantees also demonstrated increased commitment to and understanding of adolescent health. Those organizations that began the funding cycle with reportedly low or average levels of understanding of multidisciplinary strategies to address adolescent health reported an increase in their understanding at the close of the evaluation. Similarly, those organizations that reported lower awareness of adolescent health saw great improvement. However, there was little change in reported commitment of organizational leaders with regard to adolescent health as a priority, even among those reporting low or average commitment to start. Despite this challenge, PIPPAH grantees were able to increase their focus on adolescent health both by infusing issues related to adolescents into organizational workgroups and annual meetings and by adopting organizational policies specific to adolescent health.
Future Collaborations/Continued Activities
As funding for PIPPAH ended, each grantee reported a desire to continue to focus on adolescent health, although the extent to which this would be accomplished would vary depending on the types of activities that were undertaken and the amount of resources that would be required. A number of the grantees were actively integrating PIPPAH activities, such as newsletters and Web site management, into other program operations and some were confident that they would be able to continue certain intensive activities, such as hosting adolescent health sessions at annual conferences and supporting adolescent health residency programs for medical students.
NACCHO recognizes that adolescents require an integrated and appropriate array of programs and services that meet their unique needs and that LHDs are well positioned to serve, promote, and protect adolescent health. Thus, NACCHO continues to engage in adolescent health activities when possible, despite the discontinuation of PIPPAH funding. Separate funding from GlaxoSmithKline supported NACCHO's development of an online repository of tools and resources LHDs can use to create integrated, coordinated, and appropriate adolescent health systems at the local level. This work was guided by a panel of adolescent health experts from the fields of public health, medicine, nursing, school-based health care, education, and public health law at the local, state, and national levels. In addition to guiding the development of this online repository, the expert panel produced recommendations for the ideal adolescent health system. Both the online repository and the report of recommendations are available at www.naccho.org.
NACCHO combined its separate maternal and child health and adolescent health Web pages into a single MCAH Web page in an effort to increase the extent to which adolescent health efforts were integrated into MCH efforts and better support to LHDs' engagement with the life course perspective. The MCAH Web page provides the latest research, funding, and training opportunities to local public health practitioners who routinely oversee activities related to women, children, adolescents, and families.
NACCHO is also conducting a 3-year project to build the capacity of LHD MCAH programs. Activities include the development of a needs assessment of local MCAH capacity and a demonstration site project to build the MCAH capacity of 5 LHDs. As is represented in NACCHO's MCAH strategic plan, the life course perspective frames how NACCHO and LHDs design and conduct their work. Through these additional activities funded by the Health Resources and Services Administration's Maternal and Child Health Bureau, NACCHO strives to support LHDs in addressing the social conditions that influence the health of women, children, adolescents, and families and ensuring the health and well-being of current and future generations.
Many grantees reported that they would continue to collaborate with the other PIPPAH grantee organizations on projects related to both adolescent health and other population groups. For instance, NACCHO is working with the Association of Maternal and Child Health Programs to finalize the ASC and facilitate pilot projects in 6 LHDs. Each LHD chosen for the ASC evaluation will be expected to gather the appropriate partners, assess adolescent health capacity, and produce a final report of recommended modifications that need to be made to ensure that the ASC is appropriate for the local level.
To assist local public health professionals and the communities they serve, CityMatCH has developed a new methodology that will help create a better understanding of the preconception health status of adolescents and the factors associated with their future reproductive health. Descriptive, bivariate and multivariable analyses of data from the National Survey of Children's Health will be used, in addition to local data, to identify risk areas in need of public health action. This methodology is called the Community Approach for Adolescent Preconception Health Investments (CAAPHI). NACCHO will participate in an expert working group to further refine and adapt the CAAPHI project methodology over the next year.
The PIPPAH collaborative demonstrated how a relatively small investment of funding and resources can not only accomplish immediate project goals but also result in long-lasting partnerships to address complex population health issues. By providing each of the 8 grantees autonomy in individual activities, while promoting multidisciplinary collaboration through in-person meetings and the development of a single collaborative project, the structure of PIPPAH fostered collaboration among organizations and incubated relationships among staff. These types of grant-making activities are critical in increasing the capacity of organizations to focus on populations or health issues that historically have not been a priority or a primary focus of an organization. By pairing organizations from multiple disciplines and with varying levels of experience with a specific issue, the grantees were able to draw upon each other's strengths and expertise beyond the initial collaborative project, and those collaborations are likely to continue into the future.
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