As a result of the inability of researchers to systematically evaluate the impacts of community coalitions to date, the literature does not provide a full accounting of the issues, populations, or intervention methods addressed by community coalitions. However, broad searches for community coalition activities in public health reveal a range of issues being addressed (from safe streets initiatives to access for the uninsured and underinsured to diabetes management), using a range of intervention methods designed to affect change at multiple levels (e.g., individual, systems, and policy). This section discusses the impact of coalitions in three areas: individual impacts, systems impacts, and policy impacts—to convey the range of outcomes that community coalitions can demonstrate given appropriate evaluation designs and resources.
Individual impacts are changes in health or behavior at the person level. One example of a coalition program that was able to demonstrate individual-level impacts is the Appalachian Cancer Coalition. The Community Coalition Action Theory was used to evaluate 1,369 initiatives conducted by 11 different community coalitions with a focus on cancer prevention. The evaluation provided assessments for organization change/capacity outcomes, process outcomes, and long-term impacts. Intervention methods included outreach, education, and screening. An example of an individual-level outcome associated with the coalition activities is increased screening rates (Kluhsman, Bencivenga, Ward, Lehman, & Lengerich, 2006).
Another study that demonstrated individual-level impacts was the California Healthy Cities Project. More than 70 coalitions participated in the project, with the aim of raising health as a priority in decision-making processes for local government. Selected interventions and outcomes, representing processes and impacts at various levels, included: 1) reduced youth tobacco use through counter-messaging pro-tobacco influences, 2) increased average GPA for teens in an intergenerational tutoring program from below 2.0 to above 2.5, 3) decreased violent crime arrests by 47 percent during the reporting period following forums to promote public safety awareness by local merchants and citizens, 4) established policies to allow interim use of public and private land for community gardens and recreation, 5) developed a “Quality of Life Index” to monitor livability indicators and guide policy development and resource allocation, and 6) incorporated a health element into the General Plan of a city (California Healthy Cities and Communities Program, 2008; Kegler, Twiss, & Look, 2000).
Systems impacts are changes in infrastructure or capacity in the community. Evaluations of the HCAP program have identified numerous systems impacts directly attributable to the participating community coalitions ( National Opinion Research Center [NORC], 2007; West, de Libero, & Shelton, 2005). While some consortia failed to achieve all of their original goals, the information is largely positive overall. Grantees used the flexibility of the HCAP program to develop over 75 different types of program activities. The national evaluation of HCAP found substantial evidence that coalitions were able to improve the efficiency of service delivery in their communities (NORC, 2007). The following list of systems impacts abstracted from the national evaluation of HCAP demonstrates the diversity of issues and approaches that community coalitions utilize to generate results for systems-level health improvements:
- Several grantees employed case management systems and were able to secure provider support of the system by documenting cost savings.
- Seventy-five percent of grantees successfully implemented a system for patient tracking and for managing use of services.
- Across all grantees reporting, primary care and specialty referral systems supported referrals for over 483,000 and 438,000 patients, respectively.
- Grantees reported assigning over 560,000 individuals to medical homes over the course of their projects and assigning over 1.2 million individuals to primary care providers.
- Enrolling the uninsured in health insurance plans also improved the financial stability of safety net providers, offering them an additional source of funding for care they might have otherwise provided for no reimbursement.
Community coalitions have also achieved policy impacts at the local, state and federal levels. One example of a community coalition that was pursuing county policy changes was the Los Angeles County Alcohol, Tobacco, and Drug Policy Coalition. This coalition was formed to change the county’s policies surrounding alcohol and tobacco billboards and storefront advertising. Specifically, the goal of the coalition was to pass an ordinance at the city level and establish a multi-sector movement to protect youth from the dangers of alcohol and tobacco use. The 60-member coalition mobilized to persuade the Los Angeles City Council to pass an ordinance restricting alcohol and tobacco advertising in 1998 (Butterfoss, 2007), demonstrating that community coalitions have also been successful in creating broader policy changes.
This chapter summarized the current issues in the literature surrounding the evaluation of community coalitions’ influences on health outcomes and community capacity, provided evaluation frameworks with the potential to be widely applied to overcome evaluation challenges, and supplied an illustrative selection of community coalition impacts. Evaluations of community coalitions must be linked to a solid logic model or theory in order to assess coalitions’ impacts at multiple levels within the community and their sustainability. Chapter Four provides an in-depth examination of community coalition sustainability and the role that evaluation plays in fostering sustainability.