The PPH was a large, complex Initiative with over 50 separate grantee organizations and ambitious goals for community change promoting long-term improvements in population health. In general, the PPH Initiative was able to manage the complexity effectively and produce a number of substantial achievements. In particular, of the 37 partnerships funded continuously throughout the initiative, in each of the five goal areas, between 25% and 40% were able to make a high level of progress.
Other efforts have been made to promote collaboration between health departments and community groups, including Mobilizing for Action through Planning and Partnerships (MAPP)14
and Turning Point. MAPP is a community assessment process developed collaboratively by the National Association of City and County Health Officials and the Centers for Disease Control and Prevention. It was designed using principles similar to PPH but is strictly an assessment process with no funding attached for the implementation of joint HD/community projects. PPH funded the use of MAPP in PPH sites as one tool of many that health departments could use to get the community and other stakeholders in the broader health system engaged. As noted in the introduction, Turning Point13
created coalitions that included community representation but focused more on systems change in state and local public health, vs. PPH which focused on more community improvement that was also programmatic.
As with many multi-site community initiatives,2,15,16
some partnerships were more successful than others. Understanding the factors associated with partnership success may help in designing future initiatives, and for this reason, a systematic attempt was made to identify success factors in each goal area. The following expands briefly on the results presented earlier for two of the five PPH goal areas: partnership development and HD capacity building.
Partnership development was a key goal area because a strong, long-term relationship between HDs and community groups was viewed by PPH as the primary pathway to sustainable community-level programs and policy and systems changes. Many of the important factors identified in this study have been found elsewhere in the extensive literature on partnership development and sustainability.17–24
Trust among members and effective methods of communication have been shown to be key elements in partnership success factors in a number of studies.24
Devising effective means of gathering input from community members is another key element in successful coalitions.17,22
The other factors we identified—working in a small or well-defined community and having a stable group of core members—have not been identified explicitly in the literature. However, many of the structural and process factors that have been identified as important for success, e.g., setting up workable decision-making processes and finding a match between community priorities and partnership activities,20,21
are made easier in smaller communities with a stable partnership membership.
A second goal area was building HD capacity to work more effectively with communities. Only two factors were identified consistently by the local evaluators as associated with HD capacity building: strong leadership committed to working with the community and working collaboratively with the community on data collection and dissemination. A number of factors worked against HD capacity building, including the bureaucratic nature of HDs, lack of leadership, and communication challenges, related to differences in institutional culture between HDs and community groups.
We conducted a more in-depth investigation using the Partnership Summaries and other data in an attempt to understand the factors that led some HDs to be more successful in working with communities. The most critical ingredient was leadership—health department leaders with a strong commitment to a community-based approach to public health (CBPH). Strong leadership was needed to overcome the bureaucratic and HD cultural factors that are barriers to working flexibly and creatively with community groups. All the health departments we examined that were effectively implementing the CBPH had dynamic executive leadership (i.e., health director and/or health officer) that was strongly committed to changing the way public health approached its mission. These leaders took risks to work with community (e.g., agreeing to approach other agencies on the community’s behalf) and were flexible in the consideration and approval of the types and/or scope of projects the health department worked on with the community.
Successful HD leaders used financing of CBPH, planning, organizational change, and communication to promote effective collaboration with community groups. Regarding financing, “model” health departments (i.e., those making high progress in their building capacity to do CBPH) were able to find innovative ways around categorical funding constraints to support CBPH efforts. Model HDs built the capacity of community partners to apply for grants, designated a portion of categorical funding toward work in CBPH, and used their limited flexible funds to support their work with communities. Model HDs demonstrated a strong commitment to including community members in their planning processes, including planning related to revising mission statements, making major organizational changes, and promoting changes in background and deployment of their workforce. Organizational changes made by model HDs included increasing organizational flexibility, increasing the workforce resources dedicated to working with community, creating units or offices designed to work with community partners, and developing mechanisms for community input into health department planning and practice. Finally, model health departments communicated with the community rather than to the community. Communication strategies for these health departments were consistently designed to build capacity or support community needs for policy and systems change.
A significant limitation in our evaluation was our inability to track long-term changes in population-level health outcomes. This was a deliberate decision based on the relatively short 5-year time frame of the initiative, and it resulted in ratings of significance of the community change outcomes that were largely subjective. Other limitations of the evaluation included difficulties in gathering comprehensive data given the large number of partnerships, the open-ended nature of partnership activities, and the limited data tailored specifically to the geographic areas designated as PPH communities.
A significant strength of the evaluation design was the role of the local evaluators. The local evaluators in many cases became integral partnership members, attending meetings regularly and participating in discussions and decision making. This enabled them to gather better data on partnership structure, processes, activities, and outcomes, and also helped them feed back the data they were collecting more effectively to the partnerships. The relationships they developed with the partnerships assisted in the progress rating process, which required trust that being candid about shortcomings would not affect future partnership funding.
In conclusion, PPH showed that, given the right circumstances and support, health departments can be effective partners with community groups in broader health improvement efforts. These HD–community partnerships led to substantial programmatic, policy and systems changes that, if sustained, can be expected to lead to long-term improvements in community health outcomes.