Food & Fitness: Lessons Learned for Funders.

Communities face issues that are complex, affect diverse stakeholders who hold conflicting perspectives, involve historical systems, and have long delays between the time action is taken and results of the actions become obvious. In order to improve outcomes some funders have begun to shift their priorities to support systems change, rather than activities or programs that address discrete short-term needs and problems. In 2007, W.K. Kellogg Foundation funded Food & Fitness, a 9-year initiative designed to address the then-emerging concerns about childhood obesity and health inequities from a system perspective. Funded partnerships in communities with inequities across the United States created community-based approaches to increase access to locally grown food and healthy places for physical activity. This 9-year systems change initiative provided a unique opportunity to document lessons that can inform funders and communities seeking to create places that will support the health of children and families, as well as those leading other systems change initiatives.

Policy and system change and community coalitions: outcomes from allies against asthma.

Objectives. We assessed policy and system changes and health outcomes produced by the Allies Against Asthma program, a 5-year collaborative effort by 7 community coalitions to address childhood asthma. We also explored associations between community engagement and outcomes. Methods. We interviewed a sample of 1,477 parents of children with asthma in coalition target areas and comparison areas at baseline and 1 year to assess quality-of-life and symptom changes. An extensive tracking and documentation procedure and a survey of 284 participating individuals and organizations were used to ascertain policy and system changes and community engagement levels. Results. A total of 89 policy and system changes were achieved, ranging from changes in interinstitutional and intrainstitutional practices to statewide legislation. Allies children experienced fewer daytime (P = .008) and nighttime (P = .004) asthma symptoms than comparison children. In addition, Allies parents felt less helpless, frightened, and angry (P = .01) about their child's asthma. Type of community engagement was associated with number of policy and system changes. Conclusions. Community coalitions can successfully achieve asthma policy and system changes and improve health outcomes. Increased core and ongoing community stakeholder participation rather than a higher overall number of participants was associated with more change.

Asthma coalition effects on vulnerable sub groups of children: the most frequent users of health care and the youngest.

OBJECTIVE: To examine the impact of Allies Against Asthma, community-based coalitions working to improve asthma outcomes, on vulnerable children: those with the most urgent health care use and those of youngest age. METHODS: Allies zip codes were matched with comparison communities on demographic factors. Five years of Medicaid data (n = 26,836) for significant health care events: hospitalizations, ED and urgent care facility visits, were analyzed. Longitudinal analyses using generalized estimating equations and proportional hazards models compared Allies and comparison group children. RESULTS: In the two start-up years of Allies, odds of having a significant event were greater for Allies children than for comparison children (p < 0.05). During the third and fourth years when Allies activities were fully implemented, for frequent health care users at baseline, odds of an asthma event were the same for both Allies and comparison children, yet in the less frequent users, odds of an event were lower in Allies children (p < 0.0001). In the initial year of Allies efforts, among the youngest, the Allies children had greater odds than comparison children of an event (p < 0.01), but by the fourth year the Allies group had lower odds (p = 0.02) of an event. Hazard ratios over all years of the study for the youngest Allies children and most frequent baseline users of urgent care were lower than for comparison children (p = 0.01 and p = 0.0004). CONCLUSION: Mobilizing a coalition of diverse stakeholders focused on policy and system change generated community-wide reductions over the long-term in health care use for vulnerable children.

Improvements in health care use associated with community coalitions: long-term results of the allies against asthma initiative.

OBJECTIVES: We assessed changes in asthma-related health care use by low-income children in communities across the country where 6 Allies Against Asthma coalitions (Hampton Roads, VA; Washington, DC; Milwaukee, WI; King County/Seattle, WA; Long Beach, CA; and Philadelphia, PA) mobilized stakeholders to bring about policy changes conducive to asthma control. METHODS: Allies intervention zip codes were matched with comparison communities by median household income, asthma prevalence, total population size, and race/ethnicity. Five years of data provided by the Center for Medicare and Medicaid Services on hospitalizations, emergency department (ED) use, and physician urgent care visits for children were analyzed. Intervention and comparison sites were compared with a stratified recurrent event analysis using a Cox proportional hazard model. RESULTS: In most of the assessment years, children in Allies communities were significantly less likely (P < .04) to have an asthma-related hospitalization, ED visit, or urgent care visit than children in comparison communities. During the entire period, children in Allies communities were significantly less likely (P < .02) to have such health care use. CONCLUSIONS: Mobilizing a diverse group of stakeholders, and focusing on policy and system changes generated significant reductions in health care use for asthma in vulnerable communities.

Policy and system change and community coalitions: outcomes from allies against asthma.

OBJECTIVES: We assessed policy and system changes and health outcomes produced by the Allies Against Asthma program, a 5-year collaborative effort by 7 community coalitions to address childhood asthma. We also explored associations between community engagement and outcomes. METHODS: We interviewed a sample of 1477 parents of children with asthma in coalition target areas and comparison areas at baseline and 1 year to assess quality-of-life and symptom changes. An extensive tracking and documentation procedure and a survey of 284 participating individuals and organizations were used to ascertain policy and system changes and community engagement levels. RESULTS: A total of 89 policy and system changes were achieved, ranging from changes in interinstitutional and intrainstitutional practices to statewide legislation. Allies children experienced fewer daytime (P = .008) and nighttime (P = .004) asthma symptoms than comparison children. In addition, Allies parents felt less helpless, frightened, and angry (P = .01) about their child's asthma. Type of community engagement was associated with number of policy and system changes. CONCLUSIONS: Community coalitions can successfully achieve asthma policy and system changes and improve health outcomes. Increased core and ongoing community stakeholder participation rather than a higher overall number of participants was associated with more change.

Community coalitions to control chronic disease: Allies against asthma as a model and case study.

There is a rich and extensive literature regarding coalitions as vehicles for amassing resources, influence, and energy in pursuit of a health goal. Despite insufficient empirical data regarding outcome, a number of observers have posited the aspects of coalition processes thought to lead to goal attainment. The supplement, which this article is part of, is devoted to an examination of how these elements fitted together (or did not) in the seven areas across the United States where Allies coalitions devoted themselves to achieving asthma control. The aim of this article is to present the theoretical bases for the work of the coalitions. It illustrates and emphasizes how the community context influenced coalition development, how membership was involved in and assessed coalition processes and structures, and the community-wide actions that were instituted and the capacities they were trying to strengthen.

Collaborative design and implementation of a multisite community coalition evaluation.

Evaluation designs assessing community coalitions must balance measures of how coalitions do their work and evidence that the coalitions are making a difference. The Allies cross-site evaluation attempts to determine the combined effects of the seven coalitions' work at the individual, organizational, and community levels. Principal components considered are (a) contextual factors of the coalition community, (b) coalition processes and structure, (c) planning and planning products, (d) implementation actions, (e) activities and collaborations, (f) anticipated intermediate outcomes, and (g) expected asthma related health outcomes. Measurements are quantitative and qualitative, and data generated by these methods are used as ends in themselves and as a way to confirm or inform other measures. Evaluation has been an integral part of the planning and implementation phases of the Allies coalition work, with a priority of involving all of the partners in conceiving of and deciding upon the elements of assessment.

The coalition process at work: Building care coordination models to control chronic disease.

Asthma is a highly prevalent and frequently misunderstood chronic disease with significant morbidity. Integrating client services at the patient-centered level and using coalitions to build coordinated, linked systems to affect care may improve outcomes. All seven Allies Against Asthma coalitions identified inefficient, inconsistent, and/or fragmented care as issues for their communities. In response, the coalitions employed a collaborative process to identify and address problems related to system fragmentation and to improve coordination of care. Each coalition developed a variety of interventions related to its specific needs and assets, stakeholders, stage of coalition formation, and the dynamic structure of its community. Despite common barriers in forming alliances with busy providers and their staff, organizing administrative structures among interinstitutional cultures, enhancing patient and/or family involvement, interacting with multiple insurers, and contending with health system inertia, the coalitions demonstrated the ability to produce coordinated improvements to existing systems of care.

Integrating asthma prevention and control: the roles of the coalition.

Activities addressing pediatric asthma are often fragmented. Allies coalitions promoted integration, the alignment of concurrent asthma control activities across and within sectors. Systems integration describes activities from an organizational perspective. Activities included developing a shared vision, promoting consistency in asthma education and self-management support, improving adherence to clinical guidelines, advocating jointly for policy change, and seeking funds collaboratively. Service integration describes activities focused on ensuring seamless, comprehensive services through coordination within and across organizations. Activities included use of community health workers (CHWs) and nurses for care coordination, program cross-referral, and clinical quality improvement. Integration is a sustainable role for coalitions as it requires fewer resources than service delivery and results in institutionalization of system changes. Organizations that seek integration of asthma control may benefit.