Best Practice Approaches
State Oral Health Coalitions and Collaborative Partnerships
A Best Practice Approach Report describes a public health strategy, assesses the strength of evidence on the effectiveness of the strategy, and uses practice examples to illustrate successful/innovative implementation.
Report last updated: May 17, 2011
II. Guidelines & Recommendations
III. Research Evidence
IV. Best Practice Criteria
V. State Practice Examples
A. Coalitions and Collaborative Partnerships Improving Oral Health
|In public health, collaborative partnerships (used in a broad term) take many forms, including coalitions at the state, regional and community levels, alliances among service agencies, consortia of health care providers, grassroots efforts, and broader advocacy initiatives. The structure of partnerships varies and may include formal organizations with a financial interest or individuals that have formed around a concern or event.1
Two definitions of a coalition include: "an organization of individuals representing diverse organizations, factions or constituencies who agree to work together in or to achieve a common goal"2 and "an organization of diverse interest groups that combine their human and materials resources to effect a specific change the members are unable to bring about independently."3 Coalitions are inter-organizational, cooperative and synergistic working alliances, united in a shared purpose. More contemporary standards refer to coalitions as more formal working partnerships and the alliance is considered more long-term and durable.4 Coalitions should be issue oriented, structured, focused to act on specific goals external to the coalition, and committed to recruit member organizations with diverse talents and resources.5 Coalition members collaborate on behalf of the organization they represent and also for the coalition itself.2 Coalitions exchange mutually beneficial resources and direct their interventions at multiple levels (i.e., policy change, resource development and environmental changes).
Coalitions may be comprised of organizations, combinations of individuals and organizations, and of other coalitions.4 Coalitions often form in response to an opportunity or threat. Coalitions can vary in size from a few to hundreds of persons. The literature has describe three types of coalitions based on membership: 1) Grassroots coalitions are organized by volunteers in times of crises to pressure policy makers to act, 2) Professional coalitions are formed by professional organizations either in time of crisis or as a long-term approach to increasing their power and influence, and 3) Community-based coalitions of professionals and grassroots leaders are formed to influence more long-term health and welfare practices for their communities, usually initiated by one or more agencies. Coalitions for health promotion tend to be long-term. They can be community-based or agency-dominated, bringing agencies, interest groups and individuals together in an alliance to plan and implement prevention strategies to accomplish a purpose. These coalitions provide planning, coordinating and advocacy functions.
Oral health problems usually involve significant social and cultural factors and require many resources and partners to implement prevention and treatment services. Building linkages with partners can provide more public recognition and visibility, leverage resources to expand the scope and range of services, provide a more comprehensive approach to programming, enhance clout in advocacy and resource development, enhance competence, avoid duplication of services and fill gaps in service delivery, and accomplish what single members cannot.6 New providers of public health services, such as managed care organizations, hospitals, nonprofit corporations, churches, and businesses are promising partners to improve oral health.7
A state oral health coalition or other forms of collaborative partnerships can provide guidance and recommend directions for the state oral health program. A coalition can identify needs and problems, support priority setting, and help develop a state oral health improvement plan. Collaborative partnerships can establish and foster relations needed to implement solutions.8,9 A state oral health coalition should have input from broad-based constituency groups so that oral health becomes a compelling issue beyond the borders of traditional oral health providers and becomes integrated into general health. Coalition members could include representatives from health agencies, the state public health association, the state dental and dental hygienists societies, health care professional groups, the primary care association, safety net clinics, consumer advocacy groups, communities, businesses, schools, universities, faith-based organizations, hospitals, third party payers, foundations, the media, and the legislature.
The literature points to the importance of coalitions in several ways:2,3,4,10
An American Public Health Association publication, The Spirit of the Coalition, by Bill Berkowitz, Ph.D., Associate Professor of Psychology, University of Massachusetts, Lowell, and Tom Wolff, Ph.D., Associate Professor of Psychology, University of Massachusetts Medical School, provides public health practitioners and other public health community workers with down-to-earth details of how coalitions work most effectively in everyday practice.11 The introduction states that the document "is about community coalitions, as a way to create change in local community life. What these coalitions do is join people from different parts of the community to deal with community problems." The authors state that coalitions do not always succeed, solve the problem or heal the wounds. They are not magical cures for all community issues. But they are a structure that can be used to facilitate change in almost every community in one form or another and are a highly utilized vehicle in public health.
B. Coalition Development
Coalitions move through three stages of development: 1) formation, 2) implementation or maintenance, and 3) outcomes or institutionalization. Coalition cycle and recycle through these stages as new members are recruited, plans are renewed and/or new issues are added.12
Coalitions are heavily influence by contextual factors in the state throughout all stages of development. A Community Coalition Action Theory provides a model of development and maintenance of coalitions based on observed practices of coalition building.13 Attachment B provides the theoretical model. Attachment C is a set of practice proven propositions (rules) for effective coalition development.
C. Factors to Enhance Coalitions and Collaborative Partnerships to Improve Health Outcomes
|Roussos and Fawcett reviewed published studies on coalitions and collaborative partnerships and reported seven factors that potentially enhance partnerships' ability to improved behavioral and population-level health outcomes:14
1. Having a clear vision and mission - Developing a clear vision and mission is essential for collaborative partnerships. A clear vision and mission may help generate support and awareness for the partnership, reduce conflicting agendas and opposition, help identify allies, and minimize time costs and distractions from appropriate action. Providing stakeholders opportunities to participate in the planning may sustain their participation in the partnership. Periodic review and renewal of the vision and mission allow a partnership to adapt and address emerging issues.
2. Action planning for community and systems change - Planning is common to all collaborative partnerships. Action planning is the process of identifying what community and systems changes to facilitate, who will produce them and by when, and how to gain support and minimize opposition in bringing about changes. Planning should include accountability.
3. Developing and supporting leadership - Leadership is most often reported as a key factor for effective collaborative partnerships. An individual or core group of members can provide leadership for a collaborative partnership. By using democratic and consensus decision-making methods, leaders may increase members' satisfaction, broaden community participation, and improve overall coalition effectiveness. Different leadership skills may be useful during different stages of partnership development. The early stages of coalition development may require greater facilitation and listening skills to help engage a diverse membership. Later, when a partnership has developed a strong identity and presence, negotiation and advocacy skills may be more helpful in bringing about changes. Partnership may benefit from a leadership team that includes various people with a variety of experiences and skills. Also, developing champions who work within a specific sector or for a specific objective can disperse leadership among all members of a partnership. Successful leadership inspires commitment and action, builds broad-based involvement, and sustains hope and participation. (Collaborative leadership training for the coalition members, written job descriptions for the leaders, and elected and rotating leadership will help build coalition leadership.)
4. Documentation and ongoing feedback on progress - Although community health partnerships aim to improve population-level outcomes, a long period of time is usually needed to observe the distant outcomes. Documentation and evaluation of intermediate outcomes is also important for a partnership by providing feedback on what is and is not working and guiding day-to-day activities. Tracking intermediate outcomes can help document progress, celebrate accomplishments, identify barriers, and redirect efforts to more effective activities.
5. Technical assistance and support - Technical assistance and support enhance the partnership's competencies for community assessment, member recruitment, leadership development, meeting facilitation, action planning, program development and implementation, evaluation, social marketing, and fundraising. Such assistance is often provided by professionals outside a partnership or by the partnership's members with the expertise. Written materials, manuals, tip sheets, and other resources have been developed for coalition builders, such as the Community Tool Box (http://ctb.ku.edu/) addressing needs of community health and the development of coalitions and Coalition Building Tip Sheets (http://www.tomwolff.com/healthy-communities-tools-and-resources.html#free) which are summaries of key points on many critical issues in seeking collaborative solution.
6. Securing financial resources for work - The sustainability of a partnership and its capacity to do work will depend on its ability to secure financial resources. Resources are often used to hire community organizers and mobilizers who can facilitate community and systems changes and implement interventions. Several studies found an increased rate of community changes (such as new programs and policies) when staff and community organizers were hired by collaborative partnerships. The financial security of a partnership may depend on its ability to demonstrate its value to the community and its contribution to making community changes.
7. Making outcomes matter - Collaborative partnerships often begin because community health outcomes matter to a core group of individuals and organizations. The more the outcomes are promoted by a partnership to community members, grant makers, and influential leaders, the more likely the partnership is successful in securing human and financial support. Documenting community-relevant indicators of success and providing regular reports to community stakeholders, funding organizations, the media, and state/local government can make outcomes matter. Ongoing and systematic evaluation of coalition activities is needed to report outcomes and demonstrate the coalition's value to the community.
Mattessich and Monsey also reviewed research literature and reported factors influencing successful collaboration.15 The authors' working definition of collaboration is "a mutually beneficial and well-defined relationship entered into by two or more organizations to achieve common goals." The relationship includes a commitment to a definition of mutual relationships and goals, a jointly developed structure and shared responsibility, mutual authority and accountability for success, and sharing of resources and rewards. Nineteen factors that influence the success of collaborations are reported. The factors are grouped into six categories:
1. Factors Related to Environment
A. History of collaboration or cooperation in the community
B. Collaboration group seen as a leader in the community
C. Political/social climate favorable
2. Factors Related to Membership Characteristics
A. Mutual respect, understanding, and trust
B. Appropriate cross-section of members
C. Members see collaboration as in their self-interest
D. Ability to compromise
3. Factors Related to Process/Structure
A. Members share a stake in both process and outcome
B. Multiple layers of decision-making
D. Development of clear roles and policy guidelines
4. Factors Related to Communication
A.Open and frequent communication
B. Established informal and formal communication links
5. Factors Related to Purpose
A. Concrete, attainable goals and objectives
B. Shared vision
C. Unique purpose
6. Factors Related to Resources
A. Sufficient funds
B. Skilled convener
Attachment D provides additional details of each factor including a brief description and identifying the number of studies which identified the factor as important to collaboration's success.
Other qualitative analyses of published articles also described core competencies and processes needed for collaborative partnerships to be successful.16-21 Attachment E describes information provided in a workbook on coalition building, From the Group Up! A Workbook on Coalition Building & Community Development, edited by Gillian Kaye and Tom Wolff, Ph.D. The Workbook offers ideas, frameworks, and exercises for coalition building.22
D. Oral Health Coalition Framework
|Centers for Disease Control and Prevention (CDC), Division of Oral Health has developed a framework for oral health coalition (see Attachment F). The resource tool is also available from: http://www.cdc.gov/.23 The framework provides a reference for recruiting coalition members to have a broad-based representation of stakeholders who will bring a range of knowledge and skills for improving oral health. In addition, the framework illustrates diverse areas of activities that a coalition's workgroups may address and various outputs that reflect an active coalition.
E. State Oral Health Coalitions Among the States
F. Evaluation of Coalitions
Evaluation of state oral health coalitions provides information to enable states to develop and maintain coalitions as effectively and efficiently as possible.26 Evaluation of coalitions, which should include their outcomes and impacts, will help states determine what works and what does not work. Reasons for conducting an evaluation of coalitions include:
There are many levels on which a coalition may be evaluated. Questions for an evaluation may ask about: 1) measures of coalition effectiveness in structure and function such as engaging members and implementing activities, 2) impacts from specific projects implemented by the coalition, 3) outcomes related to changes in community policies, practices and environment, and 4) outcomes related to health status indicators such as incidence of caries. Ideally, the evaluation of a coalition would respond to questions related to all these levels; however, the number of questions that can be addressed will depend on availability of resources and the feasibility of collecting specific type of information. The scope of the evaluation may also be guided by the maturity of the coalition (the development or formation stage, the implementation or maintenance stage, and the outcomes or institutionalization phase). An evaluation consultant is highly recommended to guide and support the evaluation process.
Indictors of coalition effectiveness reflect a coalition's attainment of its mission, goals and objectives.
G. Initiatives and Coordinated Efforts
|Many initiatives and coordinated efforts recognize that collaborative partnerships are essential for improving oral health. State dental summits illustrate one such effort. Oral Health America's coalition development represents another such effort.
1. State Dental/Oral Health Summits
The Health Resources and Services Administration (HRSA)/Maternal and Child Health Bureau (MCHB) and the Centers for Medicare and Medicaid Services (CMS), in cooperation with ASTDD, have sponsored nearly thirty state dental summits. The dental summits were intended to provide a platform to bring together stakeholders to share information, collaborate on statewide problem solving, and develop specific oral health strategic plans around oral health issues, especially for children's oral health. The expectation of dental summits was to develop partnerships between State policy makers, legislators, Medicaid, the Women Infants and Children (WIC) program, Head Start (HS), the dental profession, state health programs, safety-net providers, and consumers that would ultimately lead to long-term strategies and actions for improving oral health and dental access.
The period between 2001 and 2005 was particularly active in building state partnerships; 21 states held dental summits. Some the dental summits had more than 100 participants. The impact of these dental summits was evaluated in 2003 (an Executive Summary of the evaluation report is available). Among these states, the summit formats varied. However, common aspects to the summit format included:
In addition, the majority of the states reported that their summit outcomes have enhanced coalition development and/or broaden stakeholder partnerships, heightened visibility of oral health among policymakers, stimulated the development of oral health committees, workgroups and task forces, and strongly influenced the development of state oral health or strategic action plans. Other outcomes included increased visibility of oral health among the public, creation of community-based and school-based programs, expansion of preventive services, and effective use of oral health data.
States that have use the SOHCS funding to support development of coalitions/collaborative partnerships included: District of Columbia, Massachusetts, Missouri, Texas, Utah, Vermont and Wyoming.
A. The Surgeon General's Report on Oral Health
|The Surgeon General's Report on Oral Health states:27 All Americans can benefit from the development of a National Oral Health Plan to improve quality of life and eliminate health disparities by facilitating collaborations among individual, health care providers, communities, and policy makers at all levels of society and by taking advantage of existing initiatives. Everyone has a role in improving and promoting oral health. Together we can work to broaden public understanding of the importance of oral health and its relevance to general health and well-being, and to ensure that existing and future preventive, diagnostic, and treatment measures for oral diseases and disorders are made available to all Americans. The report further promotes building an effective health infrastructure that meets the oral health needs of all Americans and using public-private partnerships to improve the oral health of those who still suffer disproportionately from oral diseases.
B. A National Call to Action to Promote Oral Health
|A National Call to Action to Promote Oral Health, a report released by the Office of the Surgeon General in April 2003, proposed five actions in its call for a response to act. One of the actions is to "increase collaborations" by linking the private and public sectors to capitalize on the talent and resources of each partner. Proposed implementation strategies include building and nurturing broad-based coalitions as well as promoting state-based coalitions for others to use as models.28
C. State and Territorial Dental Directors
|State dental directors or state dental consultants from 43 states responded to an ASTDD survey and identified ten essential elements that would build infrastructure and capacity to achieve Healthy People 2010 Oral Health Objectives. These elements reflect the public health core functions of assessment, policy development and assurance. One of these top elements is building linkages with partners interested in reducing the burden of oral diseases by establishing a state oral health advisory committee, community coalitions, and governmental workgroups.7
D. Oral Health America
|Over the past decade, Oral Health America has recognized the vital role of launching and nurturing coalitions in fulfilling its mission and in improving Americans' oral and overall health status. The national organization's broad goal is to work with all oral health coalitions needing assistance to identify their communities' oral health needs and to develop programs aimed at improving oral health for all Americans.24
E. American Public Health Association
|A book published by the American Public Health Association, The Spirit of Coalitions, provides public health practitioners and other public health community workers details of how coalitions work most effectively. Step-by-step guidance is provided for practitioners involved in coalition building. Actual samples of materials that coalitions have used, such as planning documents, membership brochures and publicity flyers, are provided as models that can be adapted for use.11
In the public health field, Kreuter et al. and Roussos and Fawcett have reported reviews of the research literature on collaborative partnerships:29
Overall, the documented research evidence for positive coalition or partnership outcomes is weak. The lack of positive evidence points to more research needed.14,29
For the best practice approach of State Oral Health Coalitions and Collaborative Partnerships, the ASTDD Best Practices Committee has proposed the following initial review standards for five best practice criteria:21,32,33
During the first phase of the ASTDD Best Practices Project, states submitted descriptions of their successful practices to share their experiences and implementation strategies. The following practice examples illustrate various elements or dimensions of the best practice approach for State Oral Health Coalitions and Collaborative Partnerships. These reported success stories should be viewed in the context of the state's and program's environment, infrastructure and resources. End-users are encouraged to review the practice descriptions (click on the links of the practice names) and adapt ideas for a better fit to their states and programs.
A. Summary Listing of Practice Examples
|See Figure 1. Each practice name is linked to a detailed description report.
B. Highlights of the Practice Examples
1. State Oral Health Coalitions
2. Collaborative Partnerships Developed through Commissions and Task Forces
3. Collaborative Partnerships with Focus on a Specific Aspect of Oral Health
This report is the result of efforts by the ASTDD Best Practices Committee to identify and provide information on developing successful practices that address state oral health coalitions and collaborative partnerships.
The ASTDD Best Practices Committee extends a special thank you to CDC, Division of Oral Health for sharing resource information and tools on building oral health coalitions for this report. Please visit the CDC Website at http://www.cdc.gov/oralhealth/ for more information.
This publication was supported by Cooperative Agreement U58DP001695 from CDC, Division of Oral Health and by Cooperative Agreement U44MC00177 from HRSA, Maternal and Child Health Bureau.
Suggested citation: Association of State and Territorial Dental Directors (ASTDD) Best Practices Committee. Best practice approach: state oral health coalitions and collaborative partnerships [monograph on the Internet]. Sparks, NV: Association of State and Territorial Dental Directors; 2011 May 17. 27 p. Available from: http://www.astdd.org.
Attachment A: Strength of Evidence Supporting Best Practice Approaches
Attachment B: Community Coalition Action Theory
Attachment C: Toward a Comprehensive Understanding of Community Coalitions
Attachment D: Factors Influencing the Success of Collaboration
Attachment E: A Workbook on Coalition Building & Community Development
Attachment F: Oral Health Coalition Framework
- Toussos ST, Fawcett SB. A review of collaborative partnerships as a strategy for improving community health. Annu Rev Public Health 2000;21:369-403.
- Feighery E, Rogers T. Building and Maintaining Effective Coalitions. Published as Guide No. 12 in the series How-To Guides on Community Health Promotion. Stanford Health Promotion Resource Center, Palo Alto CA, 1989)
- Brown C. Art of Coalition Building: A Guide for Community Leaders. The American Jewish Committee, New York, 1984
- Butterfoss FD, Goodman RM, Wandersman A. Community coalitions for prevention and health promotion. Health Educ Res. 1993 Sep;8(3):315-30.
- Allensworth D, Patton W. Promoting school health coalition building. The Era Sigma Gamma Monograph series, 1990.
- Association of State and Territorial Dental Directors. Building infrastructure and capacity in state and territorial oral health programs. April 2000. Available from: /.
- Hayes R, Goodman A, Wilt S. Developing injury prevention capacity in New York City: the role of a local health department in fostering collaborations. J Public Health Management Practice 1997;3(6):25-29.
- Brownson RC, Smith CA, Jorge NE, et al. The role of data-driven planning and coalition development in preventing cardiovascular disease. Public Health Reports 1982;107:32-36.
- Centers for Disease Control and Prevention. State coalitions for prevention and control of tobacco use: United States, 1989. MMWR 1990;29:476-84.
- Roberts-DeGennaro M. Building coalitions for political advocacy. Social Work, July/August 1986:308-311.
- Berkoweitz B, Wolff T. The spirit of the coalition. American Public Health Association, Washington, DC, 2000. Available from: http://www.apha.org/publications/bookstore/.
- CDC, DOH. ECB Services, Inc. Dental Public Health Program Infrastructure Development and Technical Assistance. Year 1 Report. June 30, 2004.
- Butterfoss FD, Kegler MC. Toward a Comprehensive Understanding of Community Coalitions: Moving from Practice to Theory. In DiClemente RJ, Crosby RA, Kelger MC. (Eds.) Emerging Theories in Health Promotion Practice and Research. San Francisco, CA: Jossey-Bass Publishers, 2002:157-193. (Community Coalition Action Theory)
- Roussos ST, Fawcett SB. A review of collaborative partnerships as a strategy for improving community health. Annu Rev Public Health 2000;21:369-402.
- Mattessich PW and Monsey BR. Collaboration: What Makes It Work – A Review of Research Literature on Factors Influencing Successful Collaboration. Amberst H. Wilder Foundation, St. Paul, Minnesota, 1992.
- Wolff T. Community coalition building--contemporary practice and research: introduction. Am J Community Psychol 2001 Apr;29(2):165-72.
- Wolff T. A practitioner's guide to successful coalitions. American J Community Psychol 2001 Apr;29(2):173-191.
- Foster-Fishman, PG, Berkowitz, SL, Lounsbury, DW, Jacobson, S and Allen NA. Building collaborative capacity in community coalitions: a review and integrative framework. American J Community Psychol 2001 Apr;29(2):241-261.
- Mizrahi T, Rosenthal BB. Complexities of coalition building: leaders' successes, strategies, struggles, and solutions. Soc Work 2001 Jan;46(1):63-78.
- Kegler MC, Steckler A, Malek SH, McLeroy K. A multiple case study of implementation in 10 local Project ASSIST coalitions in North Carolina. Health Educ Res 1998 Jun;13(2):225-38.
- Shortell SM, Zukoski AP, Alexander JA, Bazzoli GJ, Conrad DA, Hasnain-Wynia R, Sofaer S, Chan BY, Casey E, Margolin FS. Evaluating partnerships for community health improvement: tracking the footprints. J Health Polit Policy Law 2002 Feb;27(1):49-91.
- Kaye G and Wolff T (Eds.). From The Group Up! A Workbook on Coalition Building & Community Development. AHEC/Community Partners, Inc., Amherst, MA. United Book Press, 2002
- Centers for Disease Control and Prevention, Division of Oral Health, 2011. Website. Available from: http://www.cdc.gov/.
- Oral Health America. Website. Available from: http://www.oralhealthamerica.org/.
- Centers for Disease Control and Prevention, Division of Oral Health. Website. Available from: http://www.cdc.gov/. (R. Lavinghouze, Evaluation Scientist, CDC, Division of Oral Health, personal communication, May 2005.)
- Centers for Disease Control and Prevention, Division of Oral Health. ECB Services, Inc. Dental Public Health Program Infrastructure Development and Technical Assistance. Year 1 Report. June 30, 2004.
- U.S. Department of Health and Human Services. Oral health in America: a report of the Surgeon General. Rockville, MD: Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000. Available from: http://www.surgeongeneral.gov/library/oralhealth/.
- U.S. Department of Health and Human Services. A national call to action to promote oral health. Rockville, MD: U.S. Department of Health and Human services, Public Health Service, National Institutes of Health, National Institute of Dental and Craniofacial Research, NIH Publication No. 03-5303, Spring 2003. Available from: http://www.surgeongeneral.gov/.
- Berkowitz B. Studying the outcomes of community-based coalitions. American Journal of Community Psychology 2001;29(2):213-227.
- Kreuter MW, Lezin NA and Young LA. Evaluating community-based collaborative mechanisms: implications for practitioners. Health Promotion Practice 2000;1:49-63.
- Granner ML, Sharpe PA. Evaluating community coalition characteristics and functioning: a summary of measurement tools. Health Educ Res 2004 Oct;19(5):514-32.
- Francisco VT, Paine AL, Fawcett SB. A methodology for monitoring and evaluating community health coalitions. Health Educ Res 1993 Sep;8(3):403-16.
- Fawcett SB, Lewis RK, Paine-Andrews A, Francisco VT, Richter KP, Williams EL, Copple B. Evaluating community coalitions for prevention of substance abuse: the case of Project Freedom. Health Educ Behav 1997 Dec;24(6):812-28.