The Newfoundland and Labrador Heart Health Program Dissemination Story :
The Formation and Functioning of Effective Coalitions
Peggy Holmes, Doreen Neville, Catherine Donovan, Carol Ann MacDonald

The Newfoundland and Labrador Heart Health Program Dissemination Story: The Formation and Functioning of Effective Coalitions.

Newfoundland and Labrador is the most easterly province of Canada (O'Loughlin et al., Figure 1) with a population of 537 000. Rural in nature, 50% of the population resides in widely-dispersed communities of less than 2500 people. The economy traditionally relied on the fishing industry, but with the closure of the once lucrative cod fishery in 1991, the poorest province in Canada faced a difficult economic climate with up to 20% unemployment rates. With little funding available to supplement or sustain expensive initiatives, the Demonstration Phase of the Newfoundland and Labrador Heart Health Program (1990-1996) focused on how community-based programs are developed and sustained, with a view to diffusion throughout the province. The whole province was defined as the demonstration site for the project, and a community mobilization strategy was used with extensive reliance on community health professionals and volunteer contributions.

Peggy Holmes MSc., Doreen Neville, ScD., Catherine Donovan, MD, Carol Ann MacDonald, Med.
Newfoundland and Labrador Heart Health Program Corresponding author: Peggy Holmes
Newfoundland and Labrador Heart Health Program
Department of Health and Community Services
Confederation Building, West Block
P.O. Box 8700
St. John's, NL, Canada A1B 4J6
Email: PHolmes@mail.gov.nl.ca

During the Demonstration Phase, six Regional Heart Health Coalitions were established, one in each health region of the province. For the purposes of this study, coalition is defined as a multipurpose, long-term partnership within which members are issue-oriented and collaborate on behalf of the organizations, groups of communities they represent. Regional community health personnel spearheaded the formation of the heart health coalitions and committed their support. Coalition membership generally included representation from community agencies, health organizations, local government, service groups, local businesses, and other non- affiliated lay volunteers.

When the Demonstration Phase ended in 1996, seven of the nine community projects were successfully sustained post-funding, factors most closely associated with project sustainability were identified, and Regional Coalitions continued to come together, identify needs, and train members (Neville, Donovan, Laing, and Swanson, 1997). Informal diffusion of heart health activities had been occurring spontaneously since the inception of the Demonstration phase with more active diffusion occurring through the Coalitions. When the formal Dissemination Phase began in July 1998, the NLHHP had already demonstrated that with relatively little investment, volunteer-based community action for heart health can be both generated and sustained. Infrastructure and resources have already been developed to support dissemination of successful initiatives throughout the province. For example, the Heart Smart Restaurant Program, a health promotion program implemented in one health region as part of the Demonstration Phase, has since become a province wide initiative due to the positive response from the other five Heart Health Coalitions.

Research Focus

In the Dissemination Phase (July 1998 - March 2003) the six Regional Heart Health Coalitions have confirmed their commitment to the dissemination process. The research focus of the NLHHP in the phase is to document the formation and evolution of these coalitions and track their development over a five-year span. This will allow for the identification of those factors that contribute to these coalitions' successes, and those which impede their progress in the dissemination of heart health activity in Newfoundland and Labrador. (Refer to Table 1 for the goals and objectives of the Dissemination Phase). In this research, dissemination is defined as the communication of an innovation, (including information or ideas), through a planned, systematic process or a passive, unplanned diffusion process (Crosswaite & Curtice, 1994). Dissemination, particularly planned, systematic activity, is believed to occur through channels, (mediums for health interventions). In this research, the Regional Heart Health Coalitions are the primary channels for the dissemination of innovations, including successful activities, effective tools and messages, and lessons learned.

Coalitions have become an important vehicle for health promotion and primary prevention programs. The frequent utilization of coalitions for these purposes increases the need to study them in a systematic manner (Butterfoss, Goodman & Wandersman, 1996). Still, little is known about the factors that contribute to a well-functioning and stable coalition (Kumpfer, Turner, Hopkins, & Librett, 1993: Cook, Roehl, Oros & Trudeau, 1994). Within the Newfoundland and Labrador Heart Health Program, the Regional Coalitions have been established and sustained for 3-4 years in the 6 community health regions. Therefore, the Newfoundland and Labrador Heart Health Program is in an excellent position to study the factors that influence the stability and effectiveness of these coalitions and contribute to this area of research.

Four key variables related to the development and functioning of effective coalitions, hence dissemination of heart health activities in Newfoundland and Labrador, emerged through a consultation process with the Regional Coalitions and a review of the relevant literature: leadership, composition, capacity, and evaluation. The heart health coalition members identified stability and strong leadership skills as important in the formation of their coalitions and in their future functioning. The leaders' membership in other organizations, as well as his/her level of education, commitment, and competence are all thought to be factors that contribute to his/her effectiveness (Butterfoss et al, 1993). This research explores the approaches adopted and the personal styles of coalition members that are identified as leaders to examine how leadership relates to functioning.

This research also explores the influence of the coalitions' composition in terms of demographics, recruitment processes, relationships between members, and coalition member classification and roles. Heart Health Coalition members are classified as community health professionals; people who represent organizations, groups or agencies; and lay volunteers (any coalition member who may or may not be involved in other groups or organizations). Members with different backgrounds play different roles on coalitions. For example, professionals help develop capacity by providing information, technical assistance, and training (Elder, Schmid, Dower, & Hedlund, 1993) while volunteers are in an ideal position to deliver health promotion programs being accessible to peers and familiar with the community's cultural climate (Wells, DePue, Buehler, Lasater, & Carleton, 1990).

Having the capacity required to meet their mandates was also identified by the coalitions as key in their functioning. For the purposes of this study, capacity is defined as the extent to which a community has local access to the knowledge, skills and resources needed to conduct effective health promotion programs (Jackson, Fortmann, Flora, Melton, Snider & Littlefield. 1994). Training and support of all coalition members, awareness and support of the community health boards and the provincial government for the NLHHP, and communication and information sharing are some elements of capacity that are being studied.

The key variable of evaluation was also identified during consultations with the Coalitions. They indicated if would be beneficial if they worked in conjunction with the Research Team to devise an evaluation mechanism for their programs and activities that was acceptable to all of its potential users. Including those affected by research outcomes in all stages of the evaluation process improves usefulness of results (Potvin, 1996; Tenove, 1999). This process is referred to in the literature as a participatory evaluation method (Francisco, Paine, & Fawcett, 1993). Consultations helped determine the evaluation process and what information needed to be collected for the purposes of evaluating heart health activity at the community level, in addition to what would meet the research needs of NLHHP.

Dissemination model

A large model for dissemination (Figure 1) was developed describing key partners, their roles, and how they all work together to promote community action for heart health (i.e., heart health activity initiated at the local level), which is the ultimate focus of the dissemination strategy. The major players were determined to be the community, Regional Heart Health Coalitions, and the NLHHP (with its links to the Provincial Government and the Canadian Heart Health Initiative). The model also recognizes the influence of other organizations and social and economic factors.

Volunteers and local community health staff are the main partners at the community level. They are responsible for assessing their environment and developing activities that are most suitable for their community with support of the regional partners. The two key players at the regional level are the Heart Health Coalitions and the Regional Community Health structures. The Regional Coalitions take a lead role in stimulating heart health action in communities and help to mobilize communities, recruiting and training volunteers, maintaining active communication of knowledge and experiences between communities, and maintaining their own knowledge and skills. The community health structures provide volunteer training, professional guidance, administrative support, and oversee the distribution of heart health materials and resources.

At the provincial level, the Coordinating Committee and the Research Team provide advice and direction for the overall project, ensuring the continued support and active participation of its member organizations, supplying training resources and promotional materials, maintaining the communication infrastructure, and overseeing the collection, analysis and reporting of all data. The Provincial Department of Health and Community Services provides the project manager, health promotion resources and the integration of heart health into policy and program development. At the national level, NLHHP will continue as an active partner in the Canadian Heart Health Initiative with other provinces, the federal government, and the Heart & Stroke Foundation.

Following the development of the Dissemination Model, the specific components of the dissemination strategy related to capacity building, including knowledge and skill development and infrastructure support, were implemented. The Heart Health Coalitions were consulted to identify the specific training and resource needs anticipated as required to support community based action; training materials were then developed (e.g., Mobilizing Communities to Take Action; Recruiting, Training and Supporting Community Volunteers; and Making Healthy Public Policy). Training used a stepped approach, with the NLHHP providing training for community health professionals, who in turn, support the Regional Heart Health Coalitions. The Coalitions and local community health professionals provide training and assistance to community volunteers. In terms of infrastructure support, the major support for volunteers and community action is through existing Regional Community Health structures, which have committed their professional and physical resources (e.g., staff time, meeting space, printing). NLHHP supports the community health structures and coalitions by facilitating information sharing and communication between the regions using a provincial website, teleconferences, newsletters, and workshops.

Research methods

The bulk of the data collection will proceed via the use of a series of standardized key informant interviews with community health professionals, coalition members who represent organizations and lay volunteers, provincial government representatives and senior community health administration. Interviews occur at three time periods; baseline (completed March 1999), interim (completed December 2000), and final data collection (anticipated completion November 2002). Other data collection includes ongoing review of records and activities related to heart health activities (recording, for example, the number of participants, the initiator of the activity, topics covered) and minutes and outcomes of meetings. A provincial telephone survey dealing with awareness of, attendance at, and perceptions of heart health activities in the community will be used during baseline and final data collection.

Both quantitative and qualitative data are being collected and analyses will be completed using SPSS and NUD*IST. A series of within-case analyses, using data from all the key informants in a region to describe what has happened in the coalition (and the region) relative to the project objectives will be conducted. Data from the within-case analyses will be used in a case-oriented strategy for cross-case analysis. Each case will be compared with the other five, in order to enhance the external validity of the findings. Data from the surveys and abstraction from existing records will be utilized in the regional case studies and also combined to provide a province-wide perspective on dissemination patterns. For each wave of data collection, regional cases will be validated in a workshop organized with a sample of the regional key informants and regional coalitions. Baseline data were validated in May 1999 at the Provincial Exchange Workshop while interim data validation is planned for June 2001. It is important to note that only baseline and interim data have been collected at this time and only baseline data have been validated. However, at the end of the third and final wave of data collection, six cases representing the regions will be fully documented and analyzed. This will enable us to identify the features of the variables under investigation that acted as barriers and facilitators to the functioning of the Regional Coalitions and therefore the dissemination process.

Key learnings to date

The results to date focus on the descriptive analysis of the baseline data only. Strengths and weaknesses of different coalition composition, capacity, leadership, and evaluation are yet to be determined. More in-depth analysis and interpretation will be conducted post-interim data collection. Analysis of interim data is underway.

Heart health activities continue to disseminate across the province with over 300 activities initiated in the regions since 1998, reaching over 16,000 participants, involving 500 volunteers. Preliminary analysis of the baseline characteristics of the six Regional Coalitions reveals sufficient variation across the key dimensions of composition, capacity, leadership and evaluation to support the development of six regional case studies and the cross-case analysis. Differences were found in coalition membership composition (e.g., some were mainly composed of professionals, while others had a combination of volunteers, organizational representatives, and Community Health Staff). Effects of these and other differences in composition on the dynamics of the coalitions will be examined over time.

In terms of capacity, training opportunities varied across regions (specifically between the most urban and rural areas), while all coalitions identified a local link with the provincial NLHHP via the program manager as essential to sustainability. Regarding the leadership component, individuals identified as leaders by coalition members were commonly the Community Health professionals (e.g., regional Health Educator, regional Dietician, Public Health Nurse). The effect of this on community action and ownership of heart health activity will be examined.

In terms of evaluation, the coalitions had a vision of "heart health" but initially struggled with articulating clear goals and objectives. Community volunteers especially struggled with abstract concepts around goals and objectives and focused more on concrete activities. The effects of evaluation on coalition functioning, specifically roles of the different coalition members will continue to be examined.

Discussion

The dissemination Phase has revealed some challenges for the coalitions. The recruitment and motivation of community volunteers is an ongoing concern. This finding is not surprising however, given that prior to the Dissemination Phase, the Coalitions identified recruitment, training and retention of volunteers as one of their major resource needs. The NLHHP did respond to this issue by producing resource manuals: "Recruiting and Training Community Volunteers" and "Supporting Community Volunteers". Evaluation of these resources is the next step in meeting this challenge.

Some coalitions also expressed concern about the level of community ownership and ability to mobilize the community. The NLHHP did respond by producing a resource manual entitled "Mobilizing Communities to Take Action". The results of the cross-case analysis will help determine characteristics of coalitions with perceived high levels of community ownership and how these attributes can be fostered in the other coalitions.

The dissemination Phase has also provided other partnership opportunities. The NLHHP invited the Canadian Diabetes Association - Newfoundland and Labrador division to form a partnership in producing a Provincial Diabetes Prevention and Health Promotion Strategy funded by the Canadian Diabetes Strategy Prevention and Promotion Contribution Program. The lifestyle issues addressed by the Heart Health Initiative (i.e., obesity, inactivity and smoking) are also the major risk factors for Type 2 diabetes. This commonality, along with a strong foundation of community-based action, led to this partnership and coordination of mobilization efforts. Other partnerships include those between the Municipal Departments of Recreation and the Regional Coalitions on issues of active living and other heart health activities, and the role of the NLHHP as the Community Representative on the provincial Alliance for the Control of Tobacco (ACT).

The Dissemination Phase has also contributed to overall health promotion in the province with the Regional Coalition structure of the NLHHP being identified by other groups as a successful vehicle for health promotion strategies. For example the Provincial Interdepartmental Food and Nutrition Policy Committee, which has recently published a new Food Policy paper, have recognized the Regional Heart Health Coalitions as a successful vehicle for health promotion and see the potential for partnerships with the coalitions to disseminate their Food Policy. Also, the provincial Strategic Social Plan has incorporated elements of community-based implementation. This recognition is evidence that the Newfoundland and Labrador Heart Health Program is in an excellent position to study the factors that influence the stability and effectiveness of these coalitions and make a significant contribution to this area of research.

Once the Dissemination Phase of research is complete, future research for the NLHHP will be focused on more quantitative outcome measures assessing the sustainability and impact the different Regional Heart Health Coalitions have had on the dissemination of heart health activity in the province of Newfoundland and Labrador.

Acknowledgements

The NLHHP would like to thank the Regional Heart Health Coalitions for their cooperation in participating in the Dissemination research.

The authors would also like to thank the Canadian Institute of Health Research for their monetary support, the Department of Health and Community Services Newfoundland and Labrador for their in-kind contributions, and the Canadian Heart Health Dissemination Project for their monetary and scholarly support.

References

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Published in Promotion & Education, a journal published by The International Union for Health Promotion and Education (IUHPE).

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