Chapter 8

Partnerships to Improve the Public's Health

Learning Objectives

• Describe the ecological model of health
• List partners based on the ecological model of health
• Discuss strategies for sustaining partnerships
• Define the key elements for assessing partnerships

Public Health Partners

Health is created at the intersection of multiple factors that contribute to or hinder the healthiness of populations. Health depends not just on access to medical care but also on such factors as individual makeup, social settings, and environmental conditions (Institute of Medicine [IOM], 1997). The Institute of Medicine defines health as the “state of well-being and the capability to function in the face of changing circumstances” (IOM, 1997, p. 41). The factors contributing to a healthy state, the determinants of health, occur across many parts of life and include individuals' lifestyle and genetic makeup, the communities in which we live, the local economy and employment options, opportunities for recreation, social support, the built environment, government and policy, the natural environment, and the global ecosystem. Collaboratives, coalitions, and partnerships have long played important roles in the history of public health. For our readers, we will make some distinctions among these commonly used terms. Collaboratives are formed by groups and individuals working toward a common purpose and sharing power. Coalitions primarily involve groups working together to reach an agreed-upon goal. Partnerships embody efforts to include the representation of individuals and groups from a wide array of organizations and sectors found in a given community (Padgett, Bekemeier, and Berkowitz, 2004).

The role of partners from the array of sectors of society affecting health is an essential area for exploration and development in achieving good health outcomes, broadening participation in policymaking, planning for public health interventions, and ensuring accountability to the communities that are served. Public health partnerships include community-based, grassroots groups and stakeholders from major sectors of society, such as business, the media, government, schools and academia, and the health care system (IOM, 2002). As opposed to coalitions, which are generally viewed as time- and resource-intensive and occasionally experience conflicts around coalition goals, processes, and areas of work, most partnerships are organized at the community level and are often characterized as having face-to-face connections that reach across traditional boundaries found in community-wide organizations (Padgett et al., 2004). Coalitions typically involve groups, rather than individuals, working together. In Florida during the past twenty years, Healthy Start Coalitions were mandated by law to convene an array of health organizations that shared a mission to provide quality maternal and child health (MCH) services. A major function of this coalition was the awarding and accounting of public revenues for MCH services. The engagement of representative community members—for instance, mothers who were or would one day be recipients of public health MCH services—has been difficult to achieve across the thirty-plus Healthy Start Coalitions organized to oversee funding and services by contracted public health organizations around the state of Florida. Alternately, public health community-wide partnerships are formed by individual stakeholders and community groups; are organized locally; and tend to focus on health promotion, community health assessment, and disease prevention. Building capacity to improve community health and empowering community members are also goals of community-wide partnerships. Mobilizing for Action through Planning and Partnerships (MAPP), a comprehensive process for improving community health, is an example of a community-wide partnership initiative (National Association of County and City Health Officials, 2011). Community partnerships, with their diverse makeup and shared responsibilities, might be especially useful as we work toward significant system changes to address the complex health problems of modernity.

The term collaborative partnerships was coined during the Turning Point initiative, a joint venture of the Robert Wood Johnson Foundation (RWJF) and the W. K. Kellogg Foundation from 1996 to 2006 to support the work of partnerships in creating more effective, community-based, and collaborating public health systems (Padgett et al., 2004). Collaborative partnerships are practices that include cooperative work across multiple private, public, and community partners at the state and local levels, and as such combine elements of two traditions in public health—collaborative decision making and community partnerships. An evaluation of the Turning Point project found that collaborative partnerships at the state level demonstrated an ability to transform the public health infrastructure and foster change (Padgett et al., 2004). The study was unique in that partnerships involving local, state, and national partners in pursuit of effective local public health systems rarely appear in the literature, an unfortunate gap when you consider that many important and far-reaching policy and program decisions are made at the state and national levels.

Value of Partnerships for Public Health Organizations

In the United States, private foundations and government entities have invested hundreds of millions of dollars to promote coalitions and partnerships around health issues (Lasker, Weiss, and Miller, 2001). As a result, thousands of coalitions, alliances, collaboratives, and other health partnerships have been formed. The common, underlying theme in this massive effort to foster partnerships is the belief that the complex problems of today are just too monumental for any one group or sector to address alone. The socioeconomic and environmental components of many health issues have not responded to top-down or single-solution programs (for example, abstinence-only adolescent pregnancy prevention programs). Partnerships offer great potential to engage other people and their organizations or community groups to work together in a supportive atmosphere in which strengths and resources are maximized (Lasker et al.). Partnerships can also be very frustrating, in part due to their formal procedures and structure—and in a number of cases because some organizations providing health and human services are required to work together in “forced partnerships” in order to qualify for funding. Coalitions or partnerships have become common requirements in many federal, state, and private foundation grants and may be partnerships on paper only. Some estimates indicate that half of all partnerships fail within the first year—although the reasons are not well established (Lasker et al.). Telltale signs of a partnership on the brink of failure include a history of conflict, manipulation, or domination by one partner; the absence of a clear purpose; a lack of communication; an imbalance of power; hidden agendas; and philosophical differences. One striking characteristic of weak partnerships is their noticeable lack of group efforts to incorporate community voices into their plans and actions (Shortell et al., 2002). Conversely, a successful partnership experiences trust, a shared interest in maintaining the partnership and building a vision together, collaborative decision making, and shared mandates and agendas (Wilcox, 2000).

Effective public health programs engage individuals and organizations knowledgeable about or active in every level of the public health system to create and sustain conditions that produce health. The practice of partnering with groups or organizations that operate within a specific area of the ecological model of health (environmental protection agencies promoting ecosystem health, county building and zoning offices affecting the built environment, and so on) is a recognized strategy for achieving health outcomes. Although public health experts are fairly united in their beliefs about engaging community partners in improving public health system and agency performance, local public health agencies typically involve their community partners when community support is needed for priorities that have already been identified by officials for targeted community populations (Lewin Group, 2002). Without a system-wide understanding of the components of effective partnerships, agencies are often defining and developing partnerships according to their own standards. Such variation in the use of the term partnerships complicates the process of establishing an evidence base concerning partnerships. A systematic review of available research on the effect of partnerships on public health outcomes in England from 1997 to 2008 reveals limited evidence about the impact of partnerships on health outcomes (Smith et al., 2009). The primary explanation for the lack of evidence is the absence of rigorous evaluation research on the connection between partnerships and improvements in population health. In the absence of evidence, the benefits of partnerships in public health are primarily presumed (Smith et al., 2009). The lack of evidence has not diminished the strong belief that partnerships and community engagement are important public health activities endorsed by national public health groups, including the National Association of County and City Health Officials (NACCHO), the Public Health Leadership Society, the U.S. Department of Health and Human Services, and the American Public Health Association.

Two examples illustrate some of the evidence that is building in support of the value of partnerships. First, an evaluation of community substance abuse programs and the active presence of community partnerships showed a weak but statistically significant difference in substance abuse prevalence rates between programs with partnerships and those with none (Yin, Kaftarian, Yu, and Jansen, 1997). Second, the Mectizan Donation Program (MDP) has been instrumental in controlling onchocerciasis, or river blindness, in Africa and Latin America, and has been described as one of the greatest miracles of the twentieth century (Peters and Phillips, 2004). The success of the program is attributed, in great part, to MDP partnerships involving twenty-five different international organizations. In a self-assessment survey of the partners, members rated highly the partnership's governance and management, identifying few problems. An analysis of results determined that members gave high ratings based on the perceptions of the program by external organizations. Partners believed that their opinions mattered and resulted in action. The program was also ranked highly in the area of performance evaluation and accountability. As the relatively new field of research into public health systems evolves, it will be important to study the degree of partnership involvement in public health efforts along with the effect of such involvement on process and outcomes.

Many different models of partnerships have emerged over the past decades, including strategic alliances and partnerships of a few stakeholders; coalitions of ten or more organizations; and community-wide initiatives that engage many people, groups, and organizations. This chapter explores the logic behind community-wide partnerships as a strategy for public health practitioners, presents the ecological model of health to guide the formation of valuable public health partnerships, and suggests methods for assessing the role of partnerships in achieving the mission of public health.

Building Community-Wide Partnerships Using an Ecological Model of Health

Creating conditions for people to be healthy and contributing to the well-being of family, friends, neighbors, and people across a region, state, and nation—and the world—are shared responsibilities. Health is a primary public good because so much of what humans are able to accomplish in the areas of employment, social relationships, and participation in civic activities depends on health status. Because health is important for employers, government entities, communities, and society, maintaining and improving conditions in which people can be healthy are shared tasks that are best achieved through strong and broadly based partnerships.

The task force on community preventive services that developed the Guide to Community Preventive Services recommended evidence-based interventions for improving the public's health, to be implemented through public and private partnerships (Community Guide Branch, n.d.). The Community Guide includes interventions in which community-wide partners are essential participants in decision making and capacity building, such as in the development and promotion of walking trails to increase physical activity. Further, the Institute of Medicine, an independent organization that provides unbiased, expert advice on health to decision makers and the public, recommends far-reaching, population-centered health strategies to address the behavioral and lifestyle interventions needed to reduce hypertension rates across the nation (IOM, 2010b). The IOM identified community-wide public and private partnerships that include businesses and community health workers as essential actors in the efforts to increase adherence to medications. Hypertension is one of the leading causes of death in the United States—one in six people who die each year do so as a result of this disease. The scope of the interventions the IOM has identified to significantly reduce and control hypertension in the population reflects the broad range of factors influencing an entire nation's health and indicates the need for action and partnerships across many sectors of society, involving both private and public resources and efforts.

In Chapter One we presented an expanded ecological model of health showing the major domains of the determinants of health and well-being and including the additional domains of the global ecosystem and the built and natural environments. The areas of the model highlight the many factors that affect a community's health and help us consider the different types of partners that could work together toward improving health outcomes for community populations. Because health is a product of factors and interrelationships between and across the multiple domains that contribute to health status, organized efforts to improve community health outcomes require the participation of representatives from multiple domains of the ecological model of health. Engaging partners from all areas affecting health ensures a consideration of relevant risk and protective factors when assessing, planning, and implementing community health improvement initiatives.

A recent study on the risk of injection drug use (IDU) conducted by faculty in the Department of Epidemiology at the University of Michigan School of Public Health provides an example of the interactive effects of different domains of the ecological model of health (Roberts et al., 2010). Researchers found that the risk of IDU was greater for metropolitan statistical areas in the study with worse local environmental conditions and economic circumstances. This finding underscores the importance of sociopolitical and economic factors as determinants of IDU for the metropolitan areas in the study and supports the concept of partnering with groups and individuals experienced in environmental and economic research and services.

Table 8.1 describes each component of the ecological model of health and offers examples of likely partners. The contributions of some organizations occur in multiple domains of the model, and it would be important to monitor overrepresentation of such organizations during community health improvement initiatives. Diversity in partnerships is a valuable asset, especially when addressing the great health disparities present in communities, and encourages a broader input of advice and expertise. By directly involving members of communities experiencing excessive health disparities, the likelihood of creating and maintaining sustainable and culturally appropriate strategies increases significantly (Mensah, 2005).

Table 8.1 Examples of Partners for Each Domain of the Ecological Model of Health

Community organizations, such as hospitals and other health care provider groups, are knowledgeable about the patient populations they serve and provide valuable information on a variety of factors influencing health. Health care providers are represented in the community domain as well as in the local economy area of the ecological model of health. For many private health care providers, improving the bottom line of profit for the business is the primary force behind the types of services they offer and the charges they bill to the consumers of those services. Another group of private health care providers is classified as nonprofit, including organizations that do not share their profits with shareholders or owners and instead reinvest the surplus in pursuit of organizational goals. Recent changes in tax law require health care providers who are classified as being not for profit to report the costs of the activities in which they engaged during a tax year to protect or improve the community's health or safety, the community benefit requirement. Recently, the group for Advancing the State of the Art in Community Benefit (ASACB) developed uniform standards that focus on better alignment of nonprofit hospitals' governance, management, and operations as well as the strategic allocation of resources at the program level. Nonprofit hospitals are now exploring a range of primary care and community-based prevention programs to meet new tax requirements. The development of these programs involves engaging a wide array of stakeholders as ongoing partners in promoting healthy behaviors and building healthy environments (Association for Community Health Improvement, 2006). Historically, nonprofit hospitals have written off the debt of unpaid charges to meet the monetary obligations of a not for profit organization.

These changes in tax law increase opportunities for strategic partnerships between the local public health sector and nonprofit health care providers, potentially adding notable capacity to the efforts for improving community health. Strategic partnerships involve partners' working together and planning to achieve specific objectives by maximizing the efficient and effective use of their resources. Local public health agencies have engaged in strategic partnerships with community organizations that share the public health mission. For example, federally qualified health centers receive federal funding to promote health in the community by providing primary care services, outreach programs, and health education for vulnerable populations. Strategic partnerships between local public health agencies and federally qualified health centers are common in many parts of the nation. LPHAs have also partnered with not-for-profit hospitals to provide services that benefit the community.

Communication and collaboration across the wide array of community health organizations have the potential to increase coordinated efforts for providing the services and products with the highest likelihood of improving community health status—and may reduce costs associated with redundant and ineffective programs. The Centers for Disease Control and Prevention (CDC, 2010a) reported an example of a strategic partnership between private and public entities in 2010. A community-level partnership between the New York City Department of Health and Mental Hygiene, municipal hospitals, and the New York Business Group on Health resulted in increased depression screening and management as standard practice and secured coverage for this service in all primary care settings in New York City. Partners collaboratively managed resources to increase access to mental health services in primary care settings and minimize duplication of their efforts.

Employers are important and strategic partners in the interest of public health, as their business decisions have wide-ranging effects. For example, businesses can stimulate the local economy by creating jobs, increasing demand for housing and services, and improving the overall quality of life. If we consider the high correlation between poverty and poor health outcomes, working on bolstering the local economy by creating sustainable jobs is a logical part of improving community health status. Forging strong partnerships between public health and local businesses increases the potential of both partners to recognize and address the determinants of health, thereby improving community health status and increasing the benefits of this primary social good. Businesses are also major contributors to the pollution of the natural environment, endangering life in the community and disrupting the local ecosystem. Engaging business leaders and their employees in promoting health and protecting the local ecosystem seems to be a high-leverage strategic activity when we consider both the positive and the negative effects of industry on health. Galvanizing the participation and responsibility of public and institutional stakeholders (businesses and employers) is expected to increase the quality of information necessary for effective decision making (Committee on Public Health Strategies to Improve Health, 2010).

Health and quality of life information, obtained largely through surveillance systems, is a primary tool for public health agencies. This information must be translated into messages to influence policy and decisions made by local governments and individuals. Public health professionals, for the most part, are not skilled at using surveillance information to communicate, market, and advocate for sound public health policies (Teutsch and Churchill, 2000). Communication in the field of public health is an important strategy of informing the public about health in their communities and around the world; this strategy helps to keep vital health data in the public domain and involves mass and multimedia techniques (World Health Organization, 1998). Because relationships with the mass media can either help or hinder communication, a strong and ongoing partnership with local and regional newspapers, local marketing groups, and television and radio stations can help local public health agencies plan and select communication strategies, identify appropriate media and materials for presenting those strategies, evaluate communication efforts, and use feedback to continuously improve health policies and messages. An example of an effective partnership can be found in the global Public-Private Partnership for Hand Washing with Soap for developing nations (Curtis, Garbrah-Aidoo, and Scott, 2007). This public health organization learned from commercial marketers how to understand consumer motivation; employ a single, unifying idea; plan for efficient outreach; and ensure its message was effective on a national scale. After the organization's first marketing program, 71 percent of the target audience knew the television ad, and rates of reported hand washing increased.

Partnerships with academia create the interface for increasing awareness and communication around translating academic research into actionable strategies for public health agencies and others working to improve the quality of life for various community populations. At the national level, the Council on Linkages Between Academia and Public Health Practice, a coalition of representatives from seventeen national public health organizations, has worked since 1992 to further academic and practice collaboration in order to develop a well-trained, competent workforce and a strong, evidence-based public health infrastructure (http://www.phf.org/link/index.htm). Collaborators are well known for their win-win philosophies and a sharing or leveraging of resources. Partnerships between universities and colleges and the public health sector at the community level can also serve to increase local workforce competencies, creating pathways to promotion as well as ensuring the practice of evidence-based public health services. Public health agencies working with academic partners can foster continuous quality improvement as the different entities share skills and experience to achieve the common goal of improved community health. Over the last decade, in multiple states, state and local health departments have partnered with universities to plan and evaluate the tobacco settlement projects, demonstrating the effectiveness of tobacco use prevention programs. Finally, evaluating the interventions of public health organizations contributes to the evidence base for public health practice and increases the likelihood of services and products that will improve the public's health. Partnering with local or regional universities and colleges helps to ensure that the skills and knowledge of evaluation science and models of continuous quality improvement are embedded in the practice of public health.

Successful Partnerships

Successful partnership efforts are those that conform to a few basic principles. Effective partnerships are open, inclusive, and diverse (Johnson, Grossman, and Cassidy, 1996). Partnerships that work well empower stakeholders and promote the development of leadership at multiple stages of the process, allowing leadership to emerge from the ongoing interactions of different and multiple persons engaged in addressing and solving complex health issues. Successful partnerships develop key strategies to reach and engage members of the target group whose health requires some population-centered prevention initiative. Shortell et al. (2002) provide an example of a rural site that supported two special councils—an interagency council and a community health council—to successfully ensure the participation of community agencies and the broader community. The partnership's steering committee was made up of members from both councils, along with important members of the business and health sectors. An urban community partnership in the Southwest with an aim to improve children's access to health care through school-based services provides another example of a successful partnership. The partnership represented a community advisory committee with three subcommittees: (1) a group of corporate and community organization members; (2) a resident group comprising parents and family members; and (3) a clinical group made up of school nurses, dental staff, nurse practitioners, and a physician. The subcommittees met routinely to respond to stakeholders and address the needs and concerns of all (Shortell et al., 2002). A compelling and shared vision often evolves from this partnership process and forms the basis for selecting the strategies and tactics designed to achieve the overall aim of improving community health status.

Using the ecological model of health helps to expand the list of potential partners. Once possible partners, with their varying levels of resources and value, are identified by public health agencies, community leaders will need strategies for engaging them (IOM, 1997). The likelihood of sustaining these key community partnerships increases when partners measure progress and communicate successes to the community at large. To that end, partners need goals for monitoring performance to ensure that changes are being implemented, improvements are under way, and outcomes are getting better.

Assessing the Role of Partnerships in Improving Community Health

Forming partnerships between and among multiple groups and organizations appears to be a logical strategy to address public health challenges when we consider the variety of factors and different sectors in society and nature that affect health. However, relatively little evaluation research has been conducted to assess the effectiveness and performance of community-wide partnerships. People enter into partnerships with some basic assumptions about their power, including partnerships' ability to enhance outcomes at a rate that is greater than any individual partner's contribution (Brinkerhoff, 2002).

An assessment of community-wide partnerships has two aims: (1) ensuring good partnership practice, and (2) determining the effect of partnerships on the performance of activities to achieve a common good. Within the health field, the following criteria for effective partnerships have been identified: “willingness to share ideas and resolve conflicts, improved access to resources, shared responsibility for decisions and implementation, achievement of mutual and independent goals, shared accountability of outcomes, satisfaction with relationship between organizations, and cost effectiveness” (Leonard, 1998, p. 148). Further, a 2002 research project to evaluate partnerships for community health improvement programs found six components of partnership management that distinguished between successful and unsuccessful partnerships: managing partnership size and diversity, developing multiple approaches to leadership, maintaining focus, managing conflict, recognizing life cycles or the different stages of partnership development and knowing when to “hand off the baton,” and having the ability to redeploy and blend funds easily to focus on local community needs (Shortell et al., 2002). Also, extensive empirical research and the work to produce the World Health Organization's Verona Benchmark led to the identification of six dimensions of partnerships (Watson, Speller, Markwell, and Platt):

• Recognizing and accepting the need for partnership
• Developing clarity and realism of purpose
• Ensuring commitment and ownership
• Developing and maintaining trust
• Creating clear and robust partnership arrangements
• Monitoring, measuring, and learning

Incorporating many of these concepts into an assessment tool enables stakeholders to reflect on the effectiveness of their partnership, benchmark their current status, and focus on identified strengths and weaknesses and areas for improvement. The use of such a self-assessment tool and the analysis of data generated about partnerships have the potential to inform the partnership process and to significantly increase learning and development for partnership members (Halliday, Asthana, and Richardson, 2004). Finally, Web-based partnership assessment tools are proliferating and demonstrate the need for and value of benchmarking quickly and easily for the purpose of partnership development.

Summary

Partnerships between local public health systems and community members, groups, and organizations help engage communities in the work of improving their health outcomes. The effectiveness of public institutions, including local public health agencies, depends to a large degree on the public's trust. Building and keeping trust involve communication and reciprocity, which are enhanced by effective and efficient partnering skills. Collaboration is vital for the implementation of successful public health efforts, given the number and range of organizations that work to keep the public healthy. As the public health challenges grow, so will the need for new or evolving partnerships. Public health departments are called upon to achieve positive health outcomes in a way that respects the rights of the individuals and of the community as a whole. This principle is achievable only when people and organizations have an opportunity to participate or be represented as partners in decisions about public health priorities, programs, and policy. Challenges facing public health practitioners include developing processes for building and sustaining partnerships, and assessing the functioning of each partnership in terms of trust, mutual support, and the leveraging or combining of resources that results in expanded capacity and sustainability.

Key Terms

Discussion Questions