Building and Sustaining Community Partnerships for Teen Pregnancy Prevention
A Working Paper
Sharon Lovick Edwards Renee Freedman Stern Cornerstone Consulting Group, Inc.
B. Organizing the Partnership 1. Administrative Structure & Governance Processes 2. Relationship between Residents & Professionals 3. Communication 4. Defining the Mission, Goals & Objectives 5. Building Consensus 6. Managing Conflict 7. Creation of an Action Plan
The National Strategy to Prevent Teen Pregnancy, begun in January 1997, was formulated in response to a call from the Congress for a strategy to reduce teen pregnancies and to a directive to assure that at least 25 percent of U. S. communities have teen pregnancy prevention programs in place. Toward that end, HHS initiated a multi-year partnership-building process to solicit a nationwide commitment to the goal of preventing teen pregnancies.
In the fall of 1997, The Cornerstone Consulting Group, Inc., began a year-long inquiry in partnership with the Urban Institute, to examine the potential benefits that community partnerships might hold for communities attempting to effectively reduce unintended teenage childbearing.
For this working paper, Cornerstone completed an extensive literature review of various partnership relationships designed to produce change in a range of topical areas. Many of the problems addressed were associated with teenage risk-taking behaviors. Our examination considered research in the fields of violence prevention, substance abuse prevention, teenage pregnancy prevention, youth development, community development, environmental protection, and general business enterprises. The discussion that follows is intended to provide the reader with an overview of the literature on partnerships and to help inform the development of future community partnerships to prevent teen pregnancy.
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II. Community Partnerships: A Promising Strategy for Teen Pregnancy Prevention?
Before approaching the question of the advantages of community partnerships as a strategy for adolescent pregnancy prevention, it is useful to review what is known about the causes of teen pregnancy and approaches to preventing it.
A large body of research has identified a number of factors that underlie adolescent sexual and contraceptive behavior, pregnancy, and childbearing. Several recent reports summarize these studies.(1) Moore and colleagues consider five types of influences that contribute to these behaviors: biological; family, peer, partner and sibling; community; policy; and media. Among the many factors in each of these categories, they identify four that are most predictive of early pregnancy and childbearing: poverty, early school failure, early behavior problems, and family problems.(2)
Kirby provides a three-part framework for organizing factors underlying teen pregnancy and childbearing. There are biological antecedents, including gender, age, testosterone level, and timing of puberty. Research has shown that these factors are causally related to adolescent sexual and contraceptive behavior and pregnancy, and they have moderate effects. A second group of antecedents can be viewed as manifestations of social disorganization or disadvantage. These include factors in the community and the family: violent crime, poverty, unemployment, family marital disruption, parents' lack of education, mother's and/or sister's being an adolescent mother, poor child rearing practice, lack of parental support and/or supervision, and inappropriate sexual pressure or abuse. The second group also includes factors in the individual teen: lack of religious affiliation, drug and alcohol use, aggressiveness, engaging in other problem behaviors and deviance, delinquency, poor educational performance, low educational expectations, low expectations for the future, and external locus of control. Research has shown that these factors are associated with adolescent sexual behavior and pregnancy-some strongly, some weakly, some in varying degree depending on the study. A third group of antecedents are attitudes and beliefs about sexual behavior, pregnancy and childbearing; these include beliefs, personal values, and perceived norms and intentions. Research has shown that most of these factors are weakly or moderately associated with sexual behavior and pregnancy, with some variation from study to study.
This large, complicated, and interrelated accumulation of factors suggests that the course that leads to adolescent sexual activity, contraceptive use, pregnancy, and childbearing is complex. Kirby concludes that "not merely one or two, but a multitude of antecedents are related to one or more sexual or contraceptive behaviors, pregnancy and childbearing, including characteristics of the teens themselves, their peers and sexual partners, their families and their communities and states. No single one of these antecedents is highly related to behavior; rather, each of many antecedents is weakly (or, in some instances, moderately) related to behavior."(3)
A vast array of programs have been launched over the past 30 years in an effort to affect one or another of the factors underlying teen pregnancy and thus reduce the problem. These have included educational programs, programs that improve access to contraception, and multi-component programs. Educational programs include those that teach only abstinence and those that teach abstinence plus effective contraceptive practice. Among them are those that include skill development, such as Postponing Sexual Involvement and Reducing the Risk. Programs designed to improve access to contraception include the development of school-based or school-linked clinics and adaptations of family planning services to increase their accessibility and appeal to youth. Multi-component programs may include some combination of job readiness training, academic tutoring, recreation, mentoring, sexuality education, life skills training, and health and mental health care. Most emphasize one aspect of this array. For example, Summer Training and Education Program and Youth Incentive Entitlement Employment Program focus on job training and employment opportunities, and the Teen Outreach Program utilizes mentoring and service learning. A few programs have included a community component-for example, Project ACTION and the School/Community Program for Sexual Risk Reduction. A few programs, among them the Children's Aid Society's Teen Pregnancy Prevention Program, have offered a comprehensive array of services and activities.
Recent reviews of the literature(4) find serious shortcomings in most of the studies of teen pregnancy prevention programs. Many studies lacked sufficient sample size. Few included long-term follow up. Many programs were conducted as demonstration projects, with a maximum of resources and support; very few have been replicated in less ideal circumstances. A number of studies lacked an experimental design or independent evaluators, or they utilized improper statistical analysis. In addition, difficulty measuring behaviors and a publishing bias toward positive outcomes limited what was known. The accumulation of limitations makes conclusions about programs difficult.
However, a few cautions judgments can be mentioned. None of the programs have been shown to have large, sustained effects on adolescent sexual behavior, contraceptive use, pregnancy, and childbearing rates. Only a few have been shown to have moderate effects. Some educational programs have shown modest positive effects on delay of sexual initiation and less effect on contraceptive use or pregnancy rates. State level data indicate that funding for family planning services can reduce adolescent pregnancies; however, it is not clear how the use of clinic services by adolescents is best encouraged or sustained. Among the multi-component programs, some have shown an effect in reducing sexual risk taking, some have not. The most intensive programs were usually the most effective. Effects tended to disappear when programs were stopped.
Most investigators concerned with adolescent pregnancy have concluded that broad-based, comprehensive prevention efforts are the best approach to intervention in this complex problem.(5) Kirby notes that because the factors underlying adolescent sexual and contraceptive behavior, pregnancy, and childbearing are numerous and complex, each with a small effect, it will be difficult to reduce adolescent pregnancy a great deal. Biological antecedents cannot be changed. Many other factors are related to social conditions that will be difficult to affect. Thus, he concludes that effective programs must focus on multiple factors, including beliefs, perceived norms, skills and intentions, and environmental factors that interfere with intentions to be abstinent or use contraception. However, to have a greater effect programs must address antecedents related to poverty and social disorganization.(6) Many current programs have serious shortcomings: they do not address many of the risk factors, they focus on a single aspect of prevention, they are brief and superficial, and they are often too late to have a large effect, especially on high-risk groups.
While more research and evaluation is certainly needed, some programs have shown promise. Increasingly, programs serving youth recognize that meaningful strategies require community- wide, coherent, and comprehensive intervention strategies in order to be effective.
Partnerships are most appropriate
- when they address social problems that have multi-faceted causes, and
- when the most promising strategies require influence and resources beyond the scope of any single organization or sector.
Teen pregnancy prevention, it has often been suggested, is such a complex phenomenon, with so many, varied factors underlying it and an array of risky behaviors associated with it, that only a concerted effort on behalf of entire communities is likely to have a significant impact. Because the problem is so complex and no one intervention or sector can "solve" this problem alone, strategic alliances and/or partnerships among multiple sectors are seen by many as essential.
Beyond teen pregnancy prevention, those working on other complex social problems with multiple, interrelated causes - violence, alcohol and other drug use, youth development - have also come to the conclusion that individual, single shot solutions are inadequate.(7) As a result, efforts to address all of these problems have increasingly focused on the need to involve a variety of community institutions and mobilize resources community-wide through creative partnerships.
Partnerships, coalitions, and collaborations (see Appendix A for definitions) have been a strategy for promoting health and for delivering social services since the early decades of this century. It wasn't until 1990, however, that "Inter-organizational and Interdisciplinary Collaboration" was given an entry in the Encyclopedia of Social Work. Professional interest in cooperative approaches increased in the 1960s because of decentralization, specialization, and categorization of services and growing acknowledgment of the complexity of the social and economic conditions that these services attempt to ameliorate. Shrinking resources, increasing competition, and administrative and technical innovations also contributed to interest in collaboration.
Many government and private funders-interested in eliminating duplication, increasing cooperation and leveraging resources-have mandated collaborative approaches to programs in health and human services, housing, justice, and the environment. Somewhat later the for-profit sector moved in this direction, as well. The forces favoring partnerships intensified in the 1980s, spurred by federal policies that reduced traditional sources of funding for local programs. Approaches have included comprehensive community planning, functional specialization among organizations, joint programs and collocation, and task integration. Since the 1980s, inter-organizational collaborations "are rapidly becoming a common method of producing goods and services."(8)
If broad-based, comprehensive prevention efforts are a beneficial method of addressing the issue of high rates of adolescent pregnancy, are community partnerships a meaningful approach for delivering these interventions? Reviews of literature on partnerships suggest that these associations do have some significant advantages over individual organizations or agencies.(9)
In partnerships the expertise of different individuals, professions, and groups can be pooled, allowing a more complete understanding of issues, needs, and resources, improving the capacity to plan and evaluate, and allowing for the development of more comprehensive strategies. Further, division of responsibility allows each partner to specialize, doing what it does best. Because partners share responsibility and risk, they are more willing and likely to be creative, becoming involved in new and broader issues. Partnerships, through efficiencies of scale and elimination of duplication, allow maximum use of resources. They also provide access to and permit development of more talents, resources, and approaches than any single organization could. Partnerships bring together larger and more diverse constituencies than single organizations. By including diverse perspectives, partnerships can develop a more comprehensive vision, increase accountability, and achieve a wider base of support for their efforts. By demonstrating widespread support and taking joint action, partnerships can maximize their members' power and increase access to policy makers, the media and the public.
Another rationale for the preference for partnerships comes from the perspective of service integration and coordination. The proliferation of categorical services, often motivated by federal and state funding directives, created complex and fragmented systems that were frequently difficult to access, as well as inflexible and redundant. By coordinating service providers, partnerships can develop comprehensive plans, eliminate duplication, allow members to specialize in their functions, link and integrate partners' activities, and ensure consistency. These benefits improve efficiency, making better use of more limited resources, increase flexibility, and enhance the ability to leverage resources.
Partnerships thus have various advantages over independently operating organizations. However, the notion of community partnerships requires its own justification. This rationale comes in part from an emerging public health promotion model(10) that claims a strong relationship among health, life style and social norms: while individuals are still considered to have a role and some responsibility, environmental factors are viewed as crucial in supporting or preventing individual health promoting behavior. Organized community support programs and environmental changes can reinforce individual life style changes. In other words, many chronic health conditions, such as violence, alcohol and other drug use, heart disease, and adolescent pregnancy, "are rooted in a larger social, cultural, political and economic fabric."(11) The social ecological approach to health promotion maintains that prevention efforts must affect both personal and environmental factors because of the "interactive and transactional nature of behavior-environment relationships."(12)
By strengthening the environment, community partnerships can affect these chronic health conditions. Without changes in the social and cultural environment, however, interventions that affect individuals are likely to have little success. In the late 1970s the World Health Organization endorsed community development, with emphasis on self-help, citizen participation, and community control, as an approach to health promotion.(13)
Those who study the factors that underlie adolescent sexual behavior, pregnancy and childbearing have noted the relationship between these health concerns and a variety of factors in the family and the community. Some have concluded that "to reduce pregnancy markedly, [programs] must have multiple effective components that address both the more proximal antecedents of adolescent sexual behavior as well as the more distal antecedents involving one or more aspects of poverty, lack of opportunity, and family dysfunction, as well as social disorganization more generally."(14)
Those who study other complex social problems have reached similar conclusions. Examining the issue of violence prevention, Cohen and Lang conclude that there is no single or simple solution to violence because the behavior is the result of a complex of environmental, political, cultural, educational, and behavioral factors. They find that effective community-based strategies must be coordinated, including a variety of interventions to reach specific risk groups in multiple settings and provide social support for individual behavior change.(15) Various branches of the Department of Health and Human Services recommend community-based, multi-strategy approaches to a variety of problems. The National Center for Injury Prevention and Control of the Centers for Disease Control and Prevention (CDC) makes this recommendation: "no single action in isolation is likely to solve the problem of youth violence. There are too many types and too many causes to be solved by one strategy. The most effective programs include several types of activities."(16)
Similarly, the Office of Substance Abuse Prevention (OSAP) of the Substance Abuse and Mental Health Services Administration notes the complexity of the problem of substance abuse, its multiple, interrelated causes, and the interaction of the individual, drugs and the environment. OSAP establishes a framework guided by the principle "that no one system, agency, or organization can prevent alcohol and other drug problems in communities."(17) The Family and Youth Services Bureau of the Administration for Children and Families advises communities interested in creating youth development programs that "the complexity and interrelatedness of factors contributing to crime, violence, and other social problems...require a commitment to looking beyond superficial solutions."(18)
Community partnership is referred to in journals of education, public health, and social work, in the fields of housing, substance abuse, and violence prevention, and it is becoming part of a new type of public-private business approach. It is mentioned in conjunction with collaboration, empowerment, and initiatives. And yet, in spite of its prevalence in the literature and in practice, there is no single, clear definition, framework, or application. Community partnerships seem, instead, to reflect the motivations and purposes of those who are involved, and they are greatly affected by the availability of financial resources, commitment of the members, and the host of macro social, economic, political, and cultural factors that influence change. In spite of this ambiguity, there does seem to be some agreement that community partnerships, although difficult, can be invaluable components of a community's attempt to effect change.
While the advantages noted above to community partnerships can be considerable, so too is the difficulty in forming and sustaining such arrangements.(19) Individuals and organizations with experience in complex, multi-year partnership enterprises frequently note that:
- partnerships take a long time to establish and considerable energy to maintain,
- skilled staffing and support are frequently needed to manage a successful partnership,
- it is difficult, and takes time, to establish true community consensus on controversial issues,
- collaboration is particularly challenging when the partners come from different racial, ethnic, linguistic, class and/or educational backgrounds-yet it is exactly this cross-sector involvement that is seen as most desirable.
Given the sheer organizational issues involved, projects built on complex partnership structure will rarely have a short term impact on the problems they seek to address. Instead, most energy in the early stages of the partnership will be devoted to building the partnership itself. Consequently, many would suggest that strategies employing partnerships be reserved for projects and initiatives with the intention and the resources to exist over an extended period of time.
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Many researchers have noted the "lack of empirical research to guide the development and maintenance of coalitions."(20) Some have concluded that "the literature on coalitions is mainly 'wisdom literature,'" anecdotal and based on experiences and impressions.(21) Nevertheless, various typologies have been proposed on the basis of descriptive evidence.
The term "partnership" (as well as related terms such as "collaboration," "coalition," and others) can be used to describe a wide variety of relationships and structures. Coalitions have been categorized by membership characteristics-grassroots volunteers or professionals or community-based combinations of professionals and grassroots leaders. Coalitions have also been typed according to their reason for formation, their functions, their stage of development, and their organizational structures.(22) Others have categorized partnerships according to their products: planning products, services, community actions, and community changes.(23) In terms of organizational structure, there are organization-set coalitions, which are groups of cooperating organizations that provide resources or services under an umbrella organization, for example, the United Way. There are network coalitions, which are loosely coupled groups of organizations that provide services to a particular client population and come together for a specific purpose. There are action-set coalitions, which bring together agencies and individuals that may not have been in the same network to achieve a particular purpose, planning, implementing, coordinating, and advocating for their communities.(24) Appendix C contains a review of several theoretical models of partnerships.
The relationship of differences in partnership type to their success has hardly been studied in a systematic way. One study that compared a partnership initiated within the community with one developed in response to an external funder's mandate found little difference.(25) Another examined state level adolescent pregnancy prevention coalitions that varied widely in their environments, structures, activities, and underlying philosophies and found no systematic differences in their effectiveness.(26) Some suggest that there are probably different combinations that are best in various circumstances and to achieve particular outcomes.(27)
One of the most common ways of looking at partnerships is by identifying their stages of development and the main activities associated with each phase. (One such framework is presented in Appendix B, the representation of a community coalition organized to prevent alcohol and other substance abuse.) The most complete descriptions of partnership formation, implementation and maintenance are found in implementation manuals designed to guide communities and organizations as they create and manage partnerships.(28) By combining the advice presented in these manuals, we have identified a series of steps that are important to partnership-building efforts. We have used these steps to organize factors that were observed to contribute to or obstruct the development of partnerships in the literature on the functioning of actual partnerships in teen pregnancy prevention and other fields. The processes involved in forming and sustaining partnerships frequently do not occur in sequence but occur simultaneously and repeatedly over the lifespan of the partnership.(29) However, for the purposes of exposition, we present them as a series of sequential steps.
Community partnerships usually begin when factors in the environment bring together a group that identifies and describes the community, the issue(s), and the community's needs and resources related to the issue(s); involves the community; recruits members; and prepares for resistance. These activities together comprise the community mobilization or engagement stage of partnership development.
Several characteristics of the environment in which the partnership takes shape help bring together partners. Some number of these factors are necessary for the formation of a partnership, but they might not be sufficient.(30) The most frequently noted factors include:
- the history of collaboration within the community,(31)
- the recognition of mutual need or purpose and shared responsibility for the problem as well as the solution,(32)
- scarcity of resources, economic insecurity among members, and competition for clients,(33)
- external mandates,(34) for example, the opportunity to compete for public or private funding and/or the need to comply with applicable statutes, regulations, or funding guidelines, although these were not sufficient where other conditions were absent,(35)
- problem complexity and the need to reduce costs and increase profits in for-profit partnerships, (36)
- the failure of existing efforts to address the problem-in other words, the need for innovation,(37)
- viewing the prospect of collaboration as compelling(38) and attaching positive attitudes, expectations and value to collaboration,(39)
- the level of power and security of members(40) and the legitimacy of the group to address the issue.(41)
The issue of teen pregnancy in many communities presents a powerful convergence of several of these environmental factors. This may explain why efforts to address the issue have tended to increasingly rely on mobilizing partnerships at the community or state level.
Community mapping(42) or needs assessment(43) or social reconnaissance(44) is identified in many studies as a crucial step in the process of forming community partnerships.(45) One element of community mapping is defining the community in terms of its location, general characteristics, and relevant demographic features of residents.(46) Several studies noted the value of starting within a relatively small area or an area that contained a small number of residents in order to create more breadth of action, a more manageable scale of relationships, and increased motivation, flexibility, and adaptiveness.(47)
Gathering data on the incidence and prevalence of health concerns and risk factors is another element of community mapping. There are three components of this information: epidemiology-the extent, distribution, and nature of the problem; etiology-the origins of the problem; and assessment-the effectiveness of various solutions.(48) Surveying the attitudes, beliefs, and behaviors of various sectors of the community and partnership members relevant to the group's mission is a third element of community mapping. Awareness of community politics is also important.(49) This process also includes documenting community resources and services currently available; inventorying assets and resources that might be useful; and documenting needs, barriers and alternatives. The perspective of community residents on service delivery, barriers to service, community resources and needs is important. Once all of this information is gathered, it is essential to disseminate it to community residents and leaders.
Community mapping has obvious value in establishing a base of information for creating and adjusting implementation strategies and for measuring success. In addition, the process has other important effects: it can facilitate recruiting and involving residents actively in planning; provide information that mobilizes residents and agencies; and provide a place to test and refine delivery strategies.(50) Several sources noted the difficulty and complexity of this information-gathering effort and recommended technical assistance to achieve the best results.(51)
Community involvement is another essential, and particularly challenging, part of the mobilization process. Several studies of partnerships noted that skills in community organizing and development are essential,(52) especially among the conveners of the partnership.(53) Most emphasize inclusion of those most affected by the problem, including youth-at-risk, parents, and traditionally disenfranchised groups.(54) Yet involving youth and males and sustaining residents' involvement are among the greatest challenges, requiring expertise, resources, time and energy.(55) In the Annie E. Casey Foundation supported Plain Talk partnerships, community members were involved through their participation, often paid, in the community assessment process.(56) Stipends, home health meetings, door-to-door canvassing, and addressing other needs identified by residents as more pressing are useful in recruitment.(57) Grassroots organizations are also helpful in this regard.(58) A number of studies of partnerships found that technical assistance(59) or the hiring of a community organizer(60) is important in successfully involving the community.
Beyond involving community residents, membership recruitment includes attracting a broadly representative group of individuals and organizations both within and outside the community with a role to play in the issue. Diversity of membership is considered essential in partnership success.(61) The evaluators of the Community Partnership Demonstration Program funded by the Center for Substance Abuse Prevention (in the Substance Abuse and Mental Health Services Administration) hypothesize that "successful partnerships will reflect their target community characteristics."(62)
Most studies found benefits to including prominent citizens and political leaders, and representatives of business, education, and health and human services sectors, faith communities, youth serving organizations, the media, professional organizations and service organizations.(63) Less expected partners include sectors such as housing, transportation, justice, welfare, child welfare and foster care, sports and recreation, managed care, shelters, drug companies, and organizations that are concerned with birth defects and disabilities.(64) Some suggest a balance between public and private sectors.(65) In general, involving various sectors from the beginning is an advantage. In the Plain Talk partnerships, this was particularly true of health care providers.(66)
Partnerships tend to grow as they develop, often beginning with a small group with common needs and interests and broadening to include diverse constituents.(67) Some partnerships have found it useful to limit new members based on geography, on programmatic novelty, philosophical approach, and interpersonal style.(68) While diversity is considered important, large, diverse partnerships are more difficult to manage.(69) Because of the variety of partnership types and structures, no absolute or even approximate number of partners can be identified as optimal.(70)
Preparing for potential resistance is another important step in community mobilization. Studies of partnerships found resistance in community politics(71) and in community distrust and suspicion of outsiders, especially official bodies and their representatives(72) and especially when the partnership mission is imposed from outside.(73) There were also unexpected barriers to partnerships from those who might be adversely affected by the effort(74) and in well organized opposition groups without popular, local support.(75) Including potential opponents in planning is advocated by some.(76) Several studies noted that the climate continues to change over the life of the partnership, so monitoring the environment and adjusting to new conditions is an on-going part of maintaining the association.(77)
Once the community is mobilized, the partnership creates itself in a formal sense, developing a structure for governance; establishing processes for decision-making, conflict resolution, and communication; establishing its mission, goals and objectives; and creating an action plan.
Establishing internal administrative structures and governance processes is essential in partnership development(78) and typically occurs in the first three to six months,(79) although in some cases these efforts take up to two years to accomplish.(80) Some have noted that community partnerships are often in a constant state of development, even years after formation.(81) The forms the organization takes are variable; the crucial element is that there are formally defined structures and processes.(82) Where public and private organizations or diverse organizations come together, structures and processes should reflect all participants.(83) Members' rights, roles and responsibilities should be clearly defined.(84) Contracts,(85) memoranda of understanding,(86) or letters of agreement(87) are suggested as methods of formalizing relationships. Failure to clearly establish these can lead to conflict.(88) Further, the degree of members' participation is related to their sense of satisfaction; formalizing members' commitments and assessing their compliance with these partnership obligations increases their commitment.(89)
Other clearly defined structures are also essential in partnership development; yet the structure should be flexible and adaptable to changing conditions.(90) Many partnerships utilize a committee or task force structure organized around community sectors identified for change-for example, schools, criminal justice system, health care providers.(91) However, committees should include members from a variety of disciplines and perspectives, and committee leadership should reflect partnership diversity.(92) There should be regular and frequent meetings of all participants.(93) Meetings should be orderly and clearly directed, with minutes, agendas, and the like.(94)
In many partnerships, one or more of the members assume the role of "lead agency" or project manager, with responsibility for monitoring and coordinating group activities and maintaining accountability.(95) This centralized authority contributes to the successful development of some partnerships.(96)
Organizational processes must also be formally developed and clearly defined. Decision-making procedures are vitally important. Decisions should be made in a nonhierarchical and participatory manner, in which no one group or member dominates.(97) Non-hierarchical decision-making and problem solving are a defining element of inter-organizational networks.(98) Smaller and single issue coalitions tend to have more consensual decision-making; larger, multi-issue groups tend to use a working consensus method-for example, two-thirds of members.(99) By distributing decision-making equally among members, "members develop ownership of the process and its outcomes."(100) Member-led decision-making reduces obstacles and facilitates agreement in some partnerships.(101)
Because partnerships involve members from different disciplines, of different races, genders, and cultures, and with different levels of status or position within their own organizational hierarchy, creating equality and satisfactory working relationships among them is often difficult. "Managing people (or in our case, organizations) with different views of the world is the major inter-organizational problem of our day."(102) Partners need to develop mutual respect, understanding, and trust in order for the association to develop.(103) Allowing time at the start for members to learn about each other, including cultural and communication differences and agendas, to test boundaries, to evaluate others, to develop relationships, and to forge new alliances is helpful.(104) Cultivating patience and a willingness to learn and compromise are also important.(105) In partnerships involving schools, which are frequently the site of interventions suggested by researchers or funding sources, it is particularly important for school staff at all levels to support the program. This is facilitated by involving all of the school community, from the beginning, in developing the program and training those who will deliver the intervention.(106) In partnerships involving governmental and non-governmental agencies, differences in the complexity of organizational structure and the timing of decision-making can create problems in collaboration.(107)
Creating relationships of equality between residents and professionals is particularly challenging. Residents' inexperience may make them reluctant to assume leadership roles.(108) In other cases, the disparity between individuals members of partnerships and those who are representatives of organizations creates problems.(109) Establishing separate resident groups, conducting training workshops, and providing on-going mentoring and support to residents are helpful in building their capacity to plan and govern.(110) Involving all participants from the beginning in creation of the partnership is also noted as important.(111) Residents need opportunities for authentic input.(112) Over time in many partnerships, professionals shift from a leadership to a support role in relation to residents.(113) This shift is seldom fully realized and appears to be facilitated by extensive community development efforts in the neighborhood.(114) However, this shift-viewing residents as potential partners with assets and expertise rather than as clients with problems to be solved-is the essence of community empowerment and a goal in many partnerships.(115)
Established procedures for communication among members and between members and staff are also essential. Communication has to be open and frequent and both formal-through established protocols and well-developed systems-and informal or personal.(116) As the frequency and intensity of communication increases, the level of cooperation tends to increase.(117) Evaluators of the Community Partnership Demonstration Program of the Centers for Disease Control and Prevention found that frequency of interaction between members is related to members' satisfaction with the partnership.(118) Open lines of communication and feedback to and from the community are also a key component in the success of partnerships.(119) Information often needs to be presented in different ways, at different levels of complexity, and more than once, with time for processing to accommodate different cultural and individual styles and capacities.(120) Direct communication among all participants, including leaders is important.(121) Butterfoss and colleagues conclude that communication might be the most important ingredient in creating a positive climate within the partnership.(122)
There appears to be unanimity in the literature on the need to create a formal statement of the partnership's mission and its goals and objectives.(123) Butterfoss and colleagues see this as the most important element in organizing a partnership.(124) Failure to clearly define the mission, goals and objectives is among the most commonly reported obstacles to partnership development among substance abuse prevention groups.(125) These formal documents not only clarify the purpose of the partnership and provide guidelines against which to measure success, they also provide a mechanism for the individual members to come to a common mission and shared view of the group's role.(126) The importance of citizen participation in defining the problem, establishing priorities, and shaping the mission, as well as implementing activities and retaining control over what happens in the community is emphasized by many.(127)
Some studies suggest that the mission be unique to the partnership, not identical with the mission of any of the member organizations.(128) Some find that more targeted missions rather than more global ones lead to higher levels of action and change in the community.(129) Goals and objectives need to be understood by all partners;(130) they have to be realistic.(131) Several studies suggest defining some short-term goals to allow for early successes that will lend credibility to the partnership and help sustain effort.(132) Others caution against tackling goals that are too large.(133) The partnership's sense of purpose needs to be reestablished periodically to revitalize and refocus the group.(134)
In many cases, the mission, goals, and objectives are, to some extent at least, imposed on the community and the partnership from outside. In the case of the Public/Private Ventures-led Community Change for Youth Development partnerships, the evaluator felt that the "focused but flexible" framework established by the funder expedited the move toward consensus and reduced conflict; however, the effect on community ownership of the issue and its solution are not yet known.(135) In another case, in which a model developed elsewhere was replicated in new communities, the process of shaping and adapting the intervention to the needs, resources, and constraints in the local context helped establish local ownership.(136)
Crucial to the adoption of a shared mission and common goals and objectives is the process of building consensus, an "on-going challenge" in developing and sustaining partnerships.(137) The more diverse the group, the greater the challenge.(138) In the literature on partnerships, several techniques are identified as useful in building consensus. In the early stages, focusing on the importance of the problem rather than specific solutions increases consensus.(139) Respecting differences and building on similarities are also important in consensus building.(140) Having staff who reflect the diversity of the community and extensive early outreach to all sectors and to "values' shapers," for example, media, clergy, and community leaders, help in building consensus.(141)
On-going discussions, in which all points of view are heard and respected, allow those whose personal values conflict with the initiative's approach to support the group's position.(142) Sometimes members have to agree to disagree. This is particularly true for "single issue" members and for those who represent organizations strongly opposed to the group's position. Acknowledging differences in writing sometimes allows partners to move beyond their differences; in other cases, dissenting partners must leave the group.(143) Partners need to fully explore alternatives and avoid agreeing simply to maintain harmony.(144)
Conflict is seen as inherent in partnerships: in the tension between members' individual agendas and their shared mission; in members' divided loyalties to their own organization and to the group; between the coalition and the targets of change; and among members and staff.(145) Conflict and cooperation are simultaneous processes within inter-organizational relationships.(146) Conflict is likely to develop when "(1) participants have a history of adversarial relations; (2) the collaboration includes ideologically diverse participants or those with different professional or organizational cultures; (3) the outcome has the potential to shift dominance from those in power; (4) the parties hold differing interests regarding desired outcome; or (5) new issues or players emerge."(147) In many partnerships, conflicts tend to diminish over time.(148)
The best advice for managing these inevitable differences is to acknowledge that they will occur, address them openly, and apply techniques of consensus building-open communication and expression of misgivings, agreeing to disagree, respect for others' point of view, and a willingness to work together and make compromises.(149) Training in conflict resolution can help partnerships manage their differences.(150) Conflict can present opportunities to develop new options and ways of working together. By resolving conflicts positively, partnerships can improve the climate, facilitate future interaction, and increase cooperation among members.(151) Abramson and Rosenthal cite the inability to deal directly with conflict as one of the most serious obstacles to coalition success.(152) Alter and Hage find excessive conflict to be an indicator of partnership imbalance.(153)
In managing the tensions between members' loyalties to their own organizations and to the partnership, the literature provides some specific suggestions. Representatives of organizations need authority and credibility within their own group(154) and latitude to act within the partnership.(155) Representatives' responsibilities within their own organizations may need to be reduced to allow them time to devote to the partnership; stable representation from partner organizations is also important to partnership success.(156) Recognizing the complexity of the various roles of partnership members and discussing strategies for managing them are useful in assuring success.(157)
The creation of a satisfactory action plan (or strategic plan or implementation plan) is essential to effective partnership development.(158) In the model developed by the Work Group on Health Promotion and Community Development at the University of Kansas, such a plan includes specific objectives for community changes to be sought in achieving the group's mission, the action steps that will effect these changes, and evidence that members support the plan. Focusing on specific community changes in the action plan leads to greater success than identifying issues and clarifying the mission.(159) It is beneficial if funders require an action plan.(160) Priorities should be established by members with elected officials, funders and experts(161) and should fit the unique needs of the community.(162) Elements of plans originate in individual committees, but the whole membership reviews and approves the plan. This approach "maximized ownership at the committee level with buy in and coordination at the larger level."(163) In the Plain Talk partnerships, residents created messages and defined broad objectives and the general shape of the implementation plan; then staff took these ideas and organized them into a formal action plan.(164)
Once internal structures and processes are developed and an action plan completed, community partnerships begin to provide services and/or take action in the community. Related to the partnership's ability to implement its plan and sustain itself are the availability of resources and support. Evaluation also becomes an important concern.
As partnerships develop, their focus shifts from internal concerns-how to form and keep the organization going-to external concerns-how to affect the environment and achieve the mission.(165) Most partnerships provide services for members and for the larger community. These might include conferences, training workshops, newsletters, resource directories, reports on the nature and extent of identified problems, position papers, and draft legislation. Services can be distinguished from community actions, which are the activities undertaken by members of the partnership in the community in order to create changes in community programs, policies, and practices.(166) Community actions can be both universal, for example, for all adolescents, and targeted, for example, for high-risk youth.(167) Implementation of specific activities that derive from the action plan is a characteristic of a mature partnership.(168) Actions need to be of sufficient intensity, scope and duration to have an effect.(169) In at least one partnership, focus on production of services reduced the group's ability to take action in the community.(170) One type of community action that has a strong positive effect is a program of mini-grants, providing funds to small, new programs in the community.(171)
The need for sufficient resources and support is critical in partnership implementation and maintenance. Various types of resources have been identified as important. Several studies find that paid staff is important because staff insure consistency in organizing, communication, and follow-through.(172) A full-time project director can be key to building external support and developing internal programs.(173) Partnerships with a project manager who assumes a central leadership and coordination role tend to be the most effective.(174) The value of a community organizer was noted previously.(175) Having staff who are from and accepted by the community(176) and have appropriate training and experience(177) are important to success.
The necessity of adequate, consistent, and sustained resources is noted in many studies.(178) Existing resources are inventoried and additional ones identified in the first six months.(179) Some advocate diversity in funding for achieving broad goals and increasing chances of survival.(180) Using local resources and focusing on sustainability and institutionalization are also advised.(181) Firm commitments for continued in-kind support are important.(182) In the case of one partnership, a large grant tied to services development early in the life of the association reduced the ability of the coalition to develop a comprehensive plan and then take actions necessary for community change. The evaluators speculate that if early resources are focused on the development of the coalition they will not create so great a problem.(183)
"Environmental linkages," relationships between members of the partnership and organizations and individuals in the environment but outside the partnership, are also important. These links, especially those to elected officials, government agencies, religious and civic groups, and community development associations, are often a vital source of resources.(184) Such links vary in formalization, standardization, intensity, and reciprocity, but the more links there are the greater the satisfaction of members.(185) Such links can also contribute to conflict.(186) There is benefit to establishing environmental links early in the partnership.(187) Formal links with other coalitions, which tend to develop later, are also beneficial in achieving goals.(188)
Leadership is a critical resource, and several partnerships have foundered because of a loss of leaders.(189) Development and dispersion of leadership throughout the association are important to sustaining the coalition.(190) It is also important that the leader be recognized as such within the partnership(191) and be respected by key influentials and by disenfranchised groups and communities of color.(192) Having leadership who have immersed themselves in the neighborhood improves cooperation.(193) Effective leadership is assertive and responsive,(194) fair,(195) attentive to and supportive of individual member concerns, and skilled in negotiation, problem solving, conflict resolution, and garnering resources.(196)
Technical assistance is a vital resource, especially useful in community mapping,(197) in community mobilization and involving residents,(198) and in involving key influentials.(199) Technical assistance is also valuable in forming the mission, goals and objectives,(200) in creating an action plan, identifying changes to be sought, and strategies and tactics for achieving change,(201) in annual planning sessions,(202) and in developing financial sustainability.(203) Perhaps most frequently, technical assistance is mentioned in connection with designing and implementing program evaluation.(204) It is important that the intensity of the technical assistance match the complexity of the partnership.(205)
Technical assistance falls into a set number of categories: enhancing experience and competence; enhancing group structure and capacity; removing social and environmental barriers; and enhancing environmental support and resources.(206) To be most useful technical assistance needs to respond to the needs expressed and identified by the community.(207) Some propose establishing "enabling systems" for community partnerships that would provide training programs for skills development; telephone and on-site consultation on organizational development; information and referral services; mechanisms for creating linkages among key community institutions and individuals; incentive grants and methods of recognizing achievements; and publications to promote partnerships.(208)
Most studies noted the importance of monitoring and evaluation. These activities should begin early in the partnership.(209) The impartiality of independent, external evaluation is the standard for scientific study.(210) There is value as well in evaluation efforts that are integrated into the system and collaboratively developed with partnership members.(211) Members of the partnership should be involved in setting evaluation goals, identifying data needed, and collecting and interpreting data.(212) The monitoring system should be dynamic, changing with developments in the coalition.(213) Whether internally or externally conducted, evaluation results should be reported at regular intervals, more frequently in early stages of development, and should be openly communicated to coalition members, the community and funders.(214) These recommendations reflect the view that monitoring and evaluation should not be one-time, after-the-fact judgments of partnership effectiveness but rather on-going feedback that can be used for improving the association.(215) In other words, evaluation should encourage creativity and innovation, not penalize failure.(216) Several types of evaluation are important in community partnerships.
Process or formative evaluation measures whether the community has been mobilized to address the problem by assessing the number of members and volunteers recruited; by-laws, goals and objectives, mission statements, committees, and reports created; financial resources generated; member satisfaction; and other measures internal to the partnership. In a variety of partnerships, these measures appear as the group takes form, usually within the first three to six months. They continue to be produced over the life of the partnership and are produced in greater numbers than other types of measures.(217) In the Plain Talk initiative, those partnerships that successfully moved from planning into the implementation phase completed a number of process measures defined by the funder and identified as "milestones" in the planning process.(218) In the CSAP Community Partnership programs evaluated on the FORECAST model, "markers" were used to verify that the program was implemented according to plan. If markers were not achieved, the plan might need review or the program might need "mid-course correction."(219) Many noted the importance of frequent feedback on these measures to assess fidelity to plans, to detect and communicate early successes to coalition members, the community, and current and potential funders, and to assess and consider the partnership course and needed adjustments.(220) Where resources are not available to conduct extensive evaluator-administered surveys and the like, self-administered checklists have been found to be useful.(221)
Partnerships also conduct outcome evaluation to assess whether partnership actions resulted in changes in the community. Outcome evaluation measures immediate results, such as services provided, actions taken in the community, and changes in community programs, policies and practices. These measures, which appear regularly after eight to 12 months of partnership existence and continue at fairly high and steady rates in successful partnerships, help sustain momentum, focus efforts, and justify activities to members, the community, and funders.(222) Regular feedback on immediate outcomes prompts discussion among members of partnership activities, focuses attention on the mission and objectives, communicates progress, and indicates where adjustments are needed in partnership functioning.(223) Feedback also leads to an increased number of changes in the community.(224)
Services, community actions, and community changes tend to increase at about the same rate in partnerships that are functioning well.(225) Community changes appear after community actions, and increases in community actions tend to produce community changes.(226)
Finally, it is necessary to document the connection between various partnership activities and the achievement of the partnership's mission, in other words, whether the partnership has had community-level impact. As one review noted "a well formed and maintained coalition is not necessarily effective in accomplishing its mission, even if it is effective in generating programs and activities or member satisfaction and commitment."(227) Impact or summative evaluation measures the effect of the partnership on intermediate and ultimate outcomes. Intermediate outcomes are behavioral objectives, such as increased abstinence and use of contraception, connected by research and theory to the ultimate health concern; and ultimate outcomes are the partnership's mission, for example, a reduction in the rate of teen pregnancy.
Measuring long term effects and system change is difficult; thus, impact evaluation demands skill, time, and resources, often requiring technical assistance to implement successfully.(228) For these reasons, some suggest limiting impact evaluation to the most promising strategies.(229) Others hypothesize that the greater the number of important changes in the community, the greater the likelihood of achieving a positive impact. They propose tracking process and activity outcomes with relevant risk factors and health indicators to establish links.(230) In the evaluation of a partnership to prevent alcohol and other substance abuse among youth, preliminary results indicate such a link.(231)
The long delay between the implementation of partnerships and measurable impacts creates problems for groups that need to justify their expenses, if not their existence, to the community, to policy makers, and to funding organizations. Large scale initiatives have been abruptly ended because they failed to show impact.(232) This situation is not easy to remedy; however, educating others about these delays, building short term goals into program design, and measuring process and intermediate outcomes can help indicate progress on the way to impact.(233)
Although the creation of an action plan is typically accomplished within the first year, planning is an on-going part of partnership development, and its continuation appears necessary for partnership success.(234) Butterfoss and colleagues note the need for regular reorientation to the purposes, goals, roles and procedures of the partnership.(235) Plans need to be reevaluated and changed as community conditions change, new funding becomes available, new opportunities arise, and the partnership matures.(236) At the least, plans should be ratified annually by the whole membership.(237) Planning retreats(238) and annual planning meetings(239) are important for reflection and problem solving and have a large positive effect on coalition growth. These sessions are also an opportunity to celebrate accomplishments.(240) Technical assistance is useful in these sessions.(241)
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As we have seen, establishing "partnerships" is a widespread practice in addressing social problems and is commonly seen as a useful strategic tool to bring together the resources, expertise, and will of a community. Partnerships are most useful when the problem to be solved is complex and multi-faceted and rooted in both the individual and the environment and when the efforts of a single agency or institution, no matter how dedicated to the cause, are believed to be insufficient to produce significant, positive outcomes.
Partnerships come in a huge variety of forms and sizes. (Appendix D contains descriptions of several partnerships at both the state and local levels.) They range from informal, non-binding agreements that are not written or not written in detail. The continuation of such partnerships depends on the participants' continuing to see that the arrangement is producing results or shows promise. Other partnerships are highly structured, formal arrangements with written, legally-binding agreements among members. Often these partnerships continue as long as their funding lasts, with continued support determined by formal evaluation results or political considerations. In some instances, the creation of the partnership itself is seen as a valued product, by participants and funders alike. Smoother working relationships, increased trust, and reductions in tension can be potential by-products of working together in partnership, even if the effort fails to achieve its original ends.
Partnerships have a wide range of aspirations for their work. Some loosely structured coalitions, including coalitions to address teen pregnancy, are satisfied that their periodic meetings produce increased communication and coordination. Members learn what others are doing and on occasion can be helpful to one another. At the other end of the spectrum, some partnerships set their goals at the level of producing substantial social change-reducing teen pregnancy rates, the incidence of drug abuse or the school drop-out rate-and are supported by large public or private financial resources, formal third-party evaluations, and considerable public attention.
The challenge of preventing teen pregnancy is good candidate for a partnership intervention strategy. The literature suggests that teen pregnancy has a wide variety of antecedents that include factors related to teens' biology and personality, their families, partners, friends and communities. Most experts in the field suggest that there is a need for multi-pronged services, far beyond the authority and resources of any one institution to provide. Meaningful strategies need to be community-wide, coherent, and comprehensive. The services often suggested to create a "comprehensive" approach to reducing teen pregnancy include health education, contraception, educational supports, job training and employment counseling, self-esteem building activities, recreational activities, and a wide range of social supports. Partnerships are created out of a desire and need to pool resources, share risks, increase creativity, increase efficiency, integrate and coordinate services, maximize power, and build community. Supporting all of these motives is a strong commitment to the value of working together to achieve a common goal.
A large literature describes the work of partnerships in teen pregnancy prevention, substance abuse prevention, violence prevention, community and youth development, as well as other fields, such as business and environmental protection. Much of this is "wisdom literature," descriptions based on experience and impressions. A number of models have been used to describe partnerships, and a variety of studies have attempted to examine scientifically the relationship between aspects of partnership structure or composition or development and outcomes and impacts. These links are just beginning to emerge.
However, the literature contains a wealth of practical advice on creating and sustaining partnerships. From the environment that gives rise to partnership efforts to the development of group structures and processes, these documents provide useful guidance as they describe a number of challenges. Among them are:
- attracting members from among community adults and youth and a broad range of institutions and service sectors, including religious and political leaders, representatives of business, youth serving agencies and organizations, schools, and many others;
- fashioning this diverse mix of professions, races, classes, languages, and levels of education and experience into a working partnership that can set goals, make decisions, attract resources, develop and implement a plan of action;
- developing the skill to establish an environment of trust, build consensus, expand leadership capacity, resolve conflict, and communicate effectively; and
- documenting accomplishments to sustain support.
Consequently, while the establishment of partnerships to combat teen pregnancy is a wise strategic choice, it is not a choice that should be taken lightly. The most effective partnerships typically do not happen easily or overnight. Instead, they are most frequently long-term efforts that require unusually skilled and dedicated staff, sustained financial support, and clear and consistent goals. In the case examples, the partnership often took years to develop and even longer to become recognized as successful. As a result, those with limited resources or a short time frame for intervention should probably consider less complex, more direct strategies.
A promising option, however, rather than the creation of new partnerships, would be a strategy designed to enlist already existing partnerships-those established to work to improve housing or combat crime, for example-in efforts to combat teen pregnancy. While such groups would have to re-commit to working together on a new project and would have to learn together about new issues, their prior experience would in many cases shorten the time needed to get beyond partnership-building and on to addressing teen pregnancy.
Finally, while partnerships are, in general, a promising way to address community problems, it needs to be said that in some ways teen pregnancy prevention is a uniquely complex issue. Nearly everyone has an opinion about what should be done about teen pregnancy, and the range of opinions is unusually wide. Furthermore, feelings and beliefs about sexuality are strongly held and often deeply rooted in culture and religion. Strategies that value inclusiveness and that seek to bring everyone to the table will often face a difficult challenge in forging community consensus around these highly charged issues.
Nonetheless, utilizing a "partnership" strategy to undergird any long-term and ambitious effort to address teen pregnancy is extremely valuable. There is no practical way, without a partnership strategy, to pull together the forces needed to address this critical problem with the strength and power it takes to produce significant results.
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[ Go to Contents ]
1. Dryfoos, 1990; Kirby, 1997; Miller, 1995; Moore, Miller, et al., 1995.
2. Moore, Miller, et al., 1995.
3. 1997, p.12.
4. Kirby, 1997; Moore, Sugland, et al., 1995; Santelli and Beilenson, 1992; Brindis, 1991.
5. Brindis, 1991; Carnegie Corp., 1989; Dryfoos, 1990; Moore, Sugland, et al., 1995; Santelli and Beilenson, 1992.
6. Kirby, 1997.
7. Executive Office for Weed and Seed, n.d.; OSAP, 1991; National Clearinghouse on Families and Youth, 1996.
8. Alter and Hage, 1993, p. 259.
9. Abramson & Rosenthal, 1995; Butterfoss, et al., 1993; Alter and Hage, 1993; Chavis, 1995; Cornerstone Consulting Group, 1997; CSAP, 1995; Mattessich & Monsey, 1992; Nezlek & Galano, 1993; Rabin, 1992; U.S. Environmental Protection Agency, 1990; Weiss, 1987.
10. Bracht, 1995.
11. Butterfoss, et al., 1993, p. 315.
12. Paine-Andrews, et al., 1996, p. 16.
13. WHO, 1978.
14. Kirby, 1997, p. 46; see also Santelli & Beilenson, 1992; Brindis, 1991; Carnegie Corp., 1989; Dryfoos, 1990.
15. Cohen & Lang, 1990.
16. NCIPC, 1993, p. 4.
17. OSAP, 1991, p. 3.
18. National Clearinghouse on Families and Youth, 1996, p. 19.
19. Annie E. Casey Foundation, n.d.; Cornerstone Consulting Group, n.d.
20. Nezlek & Galano, 1993, p. 434; see also Francisco, et al., 1993; Chavis, 1995.
21. Butterfoss, et al., 1993, p. 318.
22. Butterfoss, et al., 1993.
23. Francisco, et al., 1996.
24. Butterfoss, et al., 1993.
25. Mansergh, et al., 1996.
26. Nezlek & Galano, 1993.
27. Alter & Hage, 1993.
28. Allensworth, 1994; Brindis, 1991; Annie E. Casey Foundation, 1993b; Colorado Dept. of Health, n.d.; Cornerstone & Philliber, 1997; The Community Toolbox, 1997; Executive Office for Weed and Seed, n.d.; Fawcett, et al., 1993; National Assembly of National Voluntary Health and Social Welfare Organizations, 1991; OSAP, 1991.
29. Bailey & McNally Koney, 1995a, 1995b.
30. Weiss, 1987; Alter & Hage, 1993.
31. Abramson & Rosenthal, 1995; Butterfoss, et al., 1993; Francisco, et al., 1996; Mattessich & Monsey, 1992; Fawcett, et al., 1993.
32. Carbine & Lee, 1988; CDC, 1995; CSAP, 1995; Fawcett, et al., 1995; Ferraro, 1994; Kracke, 1996; NCIPC, 1993; Scarlett et al., 1991; Williams, et al., 1991; Weiss, 1987.
33. Abramson & Rosenthal, 1995; Alter & Hage, 1993; Butterfoss, et al., 1993; Weiss, 1987.
34. Abramson & Rosenthal, 1995; Butterfoss, et al., 1993; Weiss, 1987; see also the section on the history of partnerships, above, which notes various government and foundation initiatives that contributed to the creation of partnerships.
35. Weiss, 1987.
36. American Leadership Forum, 1993; Anderson, 1996; Rabin, 1992.
37. American Leadership Forum, 1993; Alter & Hage, 1993; Anderson, 1996; Butterfoss, et al., 1993; Rabin, 1992; Weiss, 1987.
38. Abramson & Rosenthal, 1995; Butterfoss, et al., 1993; Francisco, et al., 1996.
39. Abramson & Rosenthal, 1995; Alter & Hage, 1993; Butterfoss, et al., 1993; Mattessich and Monsey, 1992; Weiss, 1987.
40. Abramson & Rosenthal, 1995.
41. Mattessich & Monsey, 1995; Weiss, 1987.
42. Annie E. Casey, 1993a.
43. Brindis, 1991; Executive Office for Weed and Seed, n.d.; Colorado Dept. of Health, n.d.
44. Fawcett, et al., 1993; Fawcett, Paine Andrews, et al., 1995; Fawcett, et al., 1994.
45. Center for the Study of Social Policy, 1995; Cohen & Lang, 1990; Copple, et al., n.d.; Mulroy, 1997; Nadel, et al., 1996; Nezlek & Galano, 1993; NIJ, 1995.
46. Annie E. Casey, 1993a, b.
47. Annie E. Casey, 1993b; ISA Associates, 1994; Mulroy, 1997.
48. Nezlek & Galano, 1993.
49. Nadel, et al., 1996.
50. Kotloff, et al., 1995.
51. Kotloff, et al., 1995; Nezlek & Galano, 1993; see Cornerstone & Philliber, 1997 and Annie E. Casey, 1993a for examples of manuals designed to guide communities through this process.
52. Nezlek & Galano, 1993; OSAP, 1991.
53. Abramson & Rosenthal, 1995; Mattessich & Monsey, 1992.
54. Cohen & Lange, 1990: Fawcett, Paine Andrews, et al., 1995; Harrison, 1996; Kotloff, et al., 1995; Mattessich & Monsey, 1992; Mulroy, 1997; NCIPC, 1993; Rabin, 1992; Wolff & Foster, 1993.
55. Copple, et al., n.d.; Gambone, 1997; Kotloff, et al., 1995; NIJ, 1995.
56. Kotloff, et al., 1995.
57. Gambone, 1997; Kotloff, et al., 1995; Mulroy, 1997; Mattessich & Monsey, 1992; U.S. Dept. of Health and Human Services, 1997b, Group 3..
58. Copple, et al., n.d..
59. Fawcett, Paine Andrews, et al., 1995; Kotloff, et al, 1995; NIJ, 1995; Paine-Andrews, et al., 1996.
60. Gambone, 1997.
61. Butterfoss, et al., 1993; CSAP, 1995; Center for the Study of Social Policy, 1995; Copple, et al., n.d.; Kotloff, et al., 1995; Mattessich & Monsey, 1992; Nezlek & Galano, 1993; OSAP, 1991; Willaims, et al., 1991.
62. Motter, et al., 1993, page 263.
63. Butterfoss, et al., 1993; Copple, et al., n.d.; Fawcett, Paine Andrews, et al., 1995; Mattessich & Monsey, 1992; Mulroy, 1997; Nezlek & Galano, 1993; U.S. Dept. of Health and Human Services, 1997b, Group 1 and 3; Wolff & Foster, 1993.
64. U.S. Dept. of Health and Human Services, 1997b, Group 3.
65. Nezlek & Galano, 1993.
66. Kotloff, et al., 1995.
67. Nezlek & Galano, 1993.
68. Mulroy, 1997.
69. Alter & Hage, 1993; ISA Associates, 1994.
70. Mattessich & Monsey, 1992.
71. Abramson & Rosenthal, 1995; Nadel, et al., 1996.
72. Mulroy, 1997; NIJ, 1995; Wiist, et al., 1996.
73. Bailey & McNally Koney, 1995a.
74. Copple, et al., n.d..
75. Nezlek & Galano, 1993.
76. Fawcett, Paine Andrews, 1995.
77. Chavis, 1993; Mattessich & Monsey, 1992; Nezlek & Galano, 1993.
78. Bailey & Koney, 1995a, 1995b; Kotloff, et al., 1995; Mulroy, 1997; Wolff & Foster, 1993.
79. Fawcett, Paine Andrews, et al., 1995; Francisco, et al., 1996.
80. Center for the Study of Social Policy, 1995; National Evaluation of the Community Partnership Program, 1994.
81. Butterfoss, et al., 1993.
82. CSAP, 1995; ISA Associates, 1994; Nezlek & Galano, 1993; OSAP, 1991b.
83. Harrison, 1996.
84. Mattessich & Monsey, 1992; National Evaluation of the Community Partnership Program, 1994; Rabin, 1992; Ringwalt, et al., 1996.
85. Abramson & Rosenthal, 1995.
86. Butterfoss, et al., 1993.
87. Mattessich & Monsey, 1992; Ringwalt, et al.,1996.
88. Abramson & Rosenthal, 1995; Ringwalt, et al., 1996.
89. Butterfoss, et al., 1993.
90. Mattessich & Monsey, 1992.
91. Copple, et al., n.d.; Kotloff, et al., 1995.
92. Copple, et al., n.d..
93. Wiist, et al., 1996.
94. Butterfoss, et al., 1993; Ringwalt, et al., 1996.
95. Bailey & McNally Koney, 1995a; Butterfoss, et al., 1993; Kotloff, et al., 1995.
96. Kotloff, et al., 1995.
97. Abramson & Rosenthal, 1995; Alter & Hage, 1993; Butterfoss, et al., 1993; Copple, et al., n.d.; Francisco, et al., 1996; ISA Associates, 1994; Mattessich & Monsey, 1992; Mulroy, 1997; Schatz, et al., 1993; Williams, et al. 1991; Wolff & Foster, 1993.
98. Alter & Hage, 1993.
99. Butterfoss, et al., 1993.
100. Mattessich & Monsey, 1992.
101. ISA Associates, 1992, 1994.
102. Alter & Hage, 1993, p. 242.
103. Abramson & Rosenthal, 1995; Alter & Hage, 1993; Mattessich & Monsey, 1992; Mulroy, 1997; Ringwalt, et al., 1996.
104. Butterfoss, et al., 1993; Gambone, 1997; Harrison, 1996; Mattessich & Monsey, 1992; Nadel, et al., 1996; Ringwalt, et al., 1996.
105. Bailey & Koney, 1995a, 1995b; Mattessich & Monsey, 1992; Ringwalt, et al., 1996.
106. Aber, et al., 1996; Farrell, et al., 1996; Nadel, et al., 1996.
107. U.S. Dept. of Health and Human Services, 1997b, Group 7.
108. Kotloff, et al., 1995.
109. Bailey & McNally Koney, 1995a.
110. Butterfoss, et al., 1993; Gambone, 1997; Kotloff, et al., 1995; see also CSAP, 1995; Motter, et al., 1993; National Evaluation of the Community Partnership program, 1994; and OSAP, 1991; for discussion of the community capacity-building efforts of the CSAP Community Partnership Program.
111. Aber, et al., 1996; Schatz, et al., 1996.
112. Nadel, et al., 1996.
113. Kotloff, et al., 1995; Mansergh, et al., 1996.
114. Kotloff, et al., 1995.
115. Fawcett, Paine Andrews, et al., 1995; Mulroy, 1997; OSAP, 1991; and see section IIB above.
116. Butterfoss, et al., 1993; Harrison, 1996; Mattessich & Monsey, 1992; Rabin, 1992.
117. Alter & Hage, 1993.
118. ISA Associates, 1994.
119. Center for the Study of Social Policy, 1995; Kleiner, 1994; Schneider, 1994; Schatz, et al., 1993.
120. Butterfoss, et al., 1993; Gambone, 1997; Mattessich & Monsey, 1992; U.S. Dept. of Health and Human Services, 1997b, Group 3.
121. Gambone, 1997; Mulroy, 1997.
122. Butterfoss, et al., 1993.
123. Butterfoss, et al., 1993; Cohen & Lang, 1990; Gambone, 1997; Harrison, 1996; Kotloff, et al. 1995; Mattessich & Monsey, 1992.
124. Butterfoss, et al., 1993.
125. National Evaluation of the Community Partnership Program, 1994.
126. Abramson & Rosenthal, 1995; Francisco, et al., 1996.
127. Bailey & McNally Koney, 1995a; Cohen & Lang, 1990; Copple, et al., n.d.; Fawcett, et al., 1993; Fawcett, Paine Andrews, et al., 1995; ISA Associates, 1994; Kotloff, et al., 1995; Schatz, et al., 1993; Williams, et al., 1991.
128. Mattessich & Monsey, 1992.
129. Francisco, et al., 1996.
130. Mattessich & Monsey, 1992.
131. Copple, et al., n.d.; Mattessich & Monsey, 1992.
132. Butterfoss, et al., 1993; Center for the Study of Social Policy, 1995; Fawcett, Paine Andrews, et al., 1995; Mattessich & Monsey, 1992.
133. Schneider, 1994; U.S. Dept. of Health and Human Services, 1997b, Group 3.
134. Bailey & McNally Koney, 1995a.
135. Gambone, 1997.
136. Paine-Andrews, et al., 1996.
137. Kotloff, et al., 1995; ISA Associates, 1994; Schatz, et al., 1993; Willaims, et al., 1991.
138. Alter & Hage, 1993; ISA Associates, 1994; Kotloff, et al., 1995; Nezlek & Galano, 1993.
139. Nezlek & Galano, 1993.
140. Andersen, 1996; Ferraro, 1994; Israel, 1995; Rabin, 1992.
141. Kotloff, et al., 1995.
142. Bailey & McNally Koney, 1995a; Kotloff, et al., 1995.
143. Kotloff, et al., 1995; Nezlek & Galano, 1993.
144. Bailey & McNally Koney, 1995a.
145. Mizrahi & Rosenthal, 1992.
146. Alter & Hage, 1993.
147. Abramson & Rosenthal, 1995, p. 1483; see also ISA Associates, 1994.
148. ISA Associates, 1992.
149. Alter & Hage, 1993; Butterfoss, et al., 1993; Kotloff, et al., 1995; Mattessich & Monsey, 1992; Nezlek & Galano, 1993.
150. Fawcett, Paine Andrews, et al., 1995.
151. Abramson & Rosenthal, 1995; Butterfoss, et al., 1993.
152. Abramson & Rosenthal, 1995.
153. Alter & Hage, 1993.
154. Bailey & Koney, 1995a.
155. Mattessich & Monsey, 1992.
157. Bailey & Koney, 1995a.
158. Copple, et al., n.d.; ISA Associates, 1992; Kotloff, et al., 1995.
159. Francisco, et al., 1996.
160. Copple, et al., n.d.; Kotloff, et al., 1995; Paine-Andrews, et al., 1996.
161. Copple, et al., n.d..
162. Cohen & Lang, 1990.
163. Copple, et al., n.d., p..
164. Kotloff, et al., 1995.
165. Nezlek & Galano, 1993.
166. Fawcett, et al., 1993; Fawcett, Paine Andrews, et al., 1995; Francisco, et al., 1993, 1996.
167. Paine-Andrews, et al., 1996.
168. ISA Associates, 1992.
169. Copple, et al., n.d.
170. Wolff & Foster, 1993.
171. Fawcett, Lewis, et al., 1995, Fawcett, Paine Andrews, et al., 1995.
172. Bardach, 1993; Center for the Study of Social Policy, 1995; Fawcett, Lewis, et al., 1995; Francisco, et al., 1996; NIJ, 1995.
173. Mulroy, 1997.
174. Butterfoss, et al., 1993; Kotloff, et. al., 1995.
175. Fawcett, Lewis, et al, 1995; Gambone, 1997.
176. Schatz, et al., 1993.
177. Cohen & Lang, 1990; NIJ, 1995.
178. Center for the Study of Social Policy, 1995; Cohen & Lang, 1990; Gambone, 1997; ISA Associates, 1992; Mattessich & Monsey, 1992; Nezlek & Galano, 1993; Weiss, 1987.
180. Copple, et al., n.d.
181. Copple, et al., n.d.
182. Nezlek & Galano, 1993.
183. Wolff & Foster, 1993.
184. Bailey & Koney, 1996; Butterfoss, et al., 1993; NCIPC, 1993; Schatz, et al., 1993.
185. Butterfoss, et al., 1993.
187. Mattessich & Monsey, 1992.
188. Fawcett, Paine Andrews, et al., 1995; Nezlek & Galano, 1993.
189. Bailey & Koney, 1995b; Copple, et al., n.d.; Fawcett, Lewis, et al., 1995; Francisco, et al., 1996; Gambone, 1997; Wolff & Foster, 1993.
190. Nezlek & Galano, 1993; Schneider, 1994; Wolff & Foster, 1993.
191. Gambone, 1997; Mattessich & Monsey, 1992.
192. Copple, et al., n.d.; U.S. Dept. of Health and Human Services, 1997b, Group 1.
193. Mulroy, 1997.
194. Bailey & McNally Koney, 1996.
195. Bailey & McNally Koney, 1995a, Mattessich & Monsey, 1992.
196. Butterfoss, et al., 1993.
197. Kotloff, et al., 1995.
198. Fawcett, Paine Andrews, et al., 1995; Gambone, 1997; NIJ, 1995.
199. Paine-Andrews, et al., 1996.
200. Fawcett, Paine Andrews, et al., 1995; Mattessich & Monsey, 1992.
201. Fawcett, Paine Andrews, et al., 1995; Paine-Andrews, et al., 1996.
202. Francisco, et al., 1996; Paine-Andrews, et al., 1996; Wolff & Foster, 1993.
203. Fawcett, Paine Andrews, et al., 1995.
204. Nezlek & Galano, 1993; Paine Andrews, et al., 1996.
205. Wolff & Foster, 1993.
206. Fawcett, Paine Andrews, et al., 1995.
207. Francisco, et al., 1996.
208. Florin, et al., 1992.
209. Copple, et al., n.d.
211. Bailey & McNally Koney, 1995b; Chavis, et al., 1993.
212. Copple, et al., n.d.; Fawcett, Lewis, et al., 1995; Wolff & Foster, 1993.
213. Bailey & McNally Koney, 1995b; Fawcett, Lewis, et al., 1995; Francisco, et al., 1993, 1996.
214. Bailey & McNally Koney, 1995b; Copple, et al., n.d.; Fawcett, Lewis, et al., 1995.
215. Bailey & McNally Koney, 1995b; Cook, et al., 1994; Fawcett, et al., 1993.
216. U.S. Dept. of Health and Human Services, 1997b, Group 1.
217. Fawcett, et al., 1993; Fawcett, Paine Andrews, et al., 1995; Francisco, et al., 1996; Wolff & Foster, 1993.
218. Kotloff, et al., 1995.
219. Goodman & Wandersman, 1994.
220. Cohen & Lange, 1990; Fawcett, Lewis, et al., 1995; Florin, et al., 1992; NIJ, 1995; Ringwalt, et al., 1996; Schatz, et al., 1993.
221. Florin, et al., 1992.
222. Francisco, et al., 1993, 1996; Fawcett, Paine, et al., 1993.
223. Copple, et al., n.d.; Wolff & Foster, 1993.
224. Fawcett, Lewis, et al. 1995.
225. Wolff & Foster, 1993.
226. Fawcett, Lewis, et al., 1995.
227. Butterfoss, et al., 1993, p. 327.
228. Chavis, 1995; Cohen & Lange, 1990; Francisco, et al., 1993; Wolff & Foster, 1993.
229. Copple, et al., n.d.; Fawcett, Lewis, et al., 1995.
230. Fawcett, et al., 1993; Cook, et al., 1994.
231. Fawcett, Lewis, et al., 1995.
232. Cagampang, et al., 1997.
233. Cagampang, et al., 1997; Cook, et al., 1994; Fawcett, Lewis, et al., 1995; Fawcett, Paine, et al., 1993.
234. Center for the Study of Social Policy, 1005; Francisco, et al., 1996.
235. Butterfoss, et al., 1993; see also Schneider, 1994.
236. Abramson & Rosenthal, 1995; Cohen & Lang, 1990; Copple, et al, n.d.; National Evaluation of the Community Partnership Program.
237. Copple, et al., n.d..
238. Bailey & McNally Koney, 1995a; Francisco, et al., 1996.
239. Wolff & Foster, 1993.
240. Bailey & McNally Koney, 1995a.
241. Paine-Andrews, et al., 1996.
242. Butterfoss, 1993, p. 316.
243. Ibid., p. 317.
244. Abramson & Rosenthal, 1995, p. 1479.
245. Chavis, 1995, p. 235.
246. Bailey & McNally Koney, 1995a, p.22.
247. Alter & Hage, 1993, p. 46.
248. Mattessich & Monsey, 1992, p. 4.
249. Gray & Wood, 1991.
250. Chavis, 1993; Chavis, et al., 1993; Florin, et al., 1992.
251. Fawcett, et al., 1993; Fawcett, Paine Andrews, et al., 1995; Francisco, et al., 1993, 1996; Wolff & Foster, 1993.
252. Bailey & McNally Koney, 1995a, 1995b, 1996.
253. Mizrahi & Rosenthal, 1992; Roberts-DeGennaro, 1986.
254. Alter & Hage, 1993.
255. Ibid., p. 265.
256. Ibid., p. 103.
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