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Facilitators of Well-Functioning Consortia: National Healthy Start Program Lessons.

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Title: Facilitators of Well-Functioning Consortia: National Healthy Start Program Lessons.
Language: English
Authors: Thompson, Mildr, Minkler, Meredith, Bell, Judith, Rose, Kalima, Butler, Lisa
Source: Health & Social Work. Aug 2003 28(3):185-195.
Peer Reviewed: Y
Page Count: 11
Publication Date: 2003
Document Type: Information Analyses
Journal Articles
Reports - Research
Descriptors: Community Involvement, Consortia, Empowerment, Infant Mortality, Program Effectiveness, Social Work
ISSN: 0360-7283
Abstract: Presents findings from a multisite case study of consortia in the federal Healthy Start Initiative to reduce infant mortality in high-risk communities. Examines the facilitators of well- functioning consortia in a framework of empowerment theory and community organizing with women of color. Implications for social work practice and for policy are provided. (Contains 32 references and 2 tables.) (GCP)
Entry Date: 2004
Accession Number: EJ672687
Database: ERIC
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  Value: <anid>AN0011852076;hsw01aug.03;2004Jul09.11:21;v2.1</anid> <title id="AN0011852076-1">FACILITATORS OF WELL-FUNCTIONING CONSORTIA: National Healthy Start Program Lessons </title> <p>Social workers often are central to the work of community-based consortia to improve service delivery and enhance community participation in health initiatives. This article presents qualitative findings from a multisite case study of consortia in the federal Healthy Start Initiative to reduce infant mortality in high-risk communities. The authors examine the facilitators of well-functioning consortia in a framework of empowerment theory and community organizing with women of color. These facilitators include flexibility in the design of locally appropriate consortia structures; broad institutional support; diverse incentives for participation; adequate resources on multiple levels; and identification with the program and its mission. Implications for social work practice and for policy are provided.</p> <p>Key words: consortia; Healthy Start; infant mortality; community involvement</p> <p>Key words: consortia; Healthy Start; infant mortality; community involvement</p> <p>Since the earliest days of the profession, social workers have been leaders in facilitating interorganizational collaborations to improve service delivery. Charitable societies in England and the United States during the late 1800s, for example, were designed to coordinate the work of private agencies attempting to address the needs of poor people (Cox & Garvin, 1995). More than a century later, social workers are still major players in hospital-based consortia, coalitions of health and social service agencies, and other collaborative partnerships concerned with improving services while controlling costs. Furthermore, social workers have been instrumental in the work of a new form of partnership--community-based consortia. Unlike coalitions and hospital or health care consortia, whose members tend to be representatives of organizations (Caplan, Lefkowitz, & Spector, 1992; Mizrahi & Rosenthal, 1992), community-based consortia typically include individual consumers and community members as well as organizational representatives. The goal of such consortia often involves strengthening integrated service delivery systems in a manner that helps empower the people and communities who are working together for a common goal or mission (Bailey & McNally Koney, 1995; Fawcett et al., 1995; Kreuter, Lezin, & Young, 2000).</p> <p>For this article we used findings from a multisite case study (Thompson et al., 2000) to examine factors facilitating well-functioning community-based consortia in Healthy Start programs to reduce infant mortality. The study was conducted by PolicyLink, a national policy, research, communications, and capacity-building organization founded in 1999 with the goal of advancing a new generation of policies, guided by the wisdom and experience of local constituencies, to achieve social and economic equity and build strong, organized communities.</p> <hd id="AN0011852076-2"> THE NATIONAL HEALTHY START INITIATIVE </hd> <p>When the national Healthy Start Initiative was inaugurated in 1991, the United States ranked 22nd in the world in infant mortality (U.S. Department of Health and Human Services, 1996), and African American babies were dying at more than twice the rate of white infants (Kotch, Blakely, Brown, & Wong, 1992). Administered directly by the Health Resources and Services Administration (HRSA) and later its Maternal Health Bureau, the national Healthy Start Initiative was designed to cut infant mortality rates in half in five years at 15 demonstration sites. The infant death rates in the sites chosen were at least one-and-one-half times the national average. With the exception of the Northern Plains area, which had a high proportion of Native Americans, the original Healthy Start communities had populations that were at least 50 percent African American, and five had sizable Latino populations (Howell, Dulvaney, McCormick, & Raykovich, 1998). Demographic shifts and the addition of 74 new sites by the late 1990s increased racial and ethnic diversity, but African Americans remain the primary racial/ethnic group involved in the program.</p> <p>The Healthy Start Initiative was founded on the premise that "communities themselves could best develop the strategies necessary to attack the causes of infant mortality and low birth weight, especially among high risk populations" (Badura, 1999, p. 263). HRSA mandated that at each participating site the health department, nonprofit organization, or other entity serving as the program's grantee agency organize a consortium that included consumers, service providers, public and private community groups, and other stakeholders (HRSA, 1991). Through the consortia, "substantive and informed" community participation was to take place at every stage of the program (HRSA, 1991), with the goals of system change and service integration for women and infants and empowerment of the local community (HRSA, 1996).</p> <p>After nine years as a demonstration program, the Healthy Start Initiative became a permanent program under the Children's Health Act of 2000 (P.L. 106-310). The act's continuation of the mandate that community-based consortia be a central program feature supports the value of in-depth examinations of this unique aspect of Healthy Start and its implications for social workers involved with other community health initiatives.</p> <p>Several studies examined the role of consortia at earlier stages of the Healthy Start Initiative in relation to community empowerment and the phases and forms of consortia development. Plough and Olafson (1994), in a case study of the first two years of one of the original Healthy Start sites (Boston), examined tensions and accomplishments in the development of the consortia from the perspective of community empowerment. They explored the difficulties, and successes, and the power dynamics and conflicts they found to be "inherent in a model that is defined and controlled by the federal government and that simultaneously calls for substantial community participation and control" (p. 232).</p> <p>The staff evaluator for the Cleveland Healthy Start program, herself a social worker, similarly examined that site's early experiences in the assembling and ordering phases of consortia development (Bailey & McNally Koney, 1995), with special attention to how members were recruited and how the site's eight neighborhood consortia tailored the initiative to their own local needs and concerns (Bailey, 1992). The creation of a citywide consortium and of a participatory research team that included community members of the consortia also were described as positive.</p> <p>Finally, in their preliminary examination of community involvement in the 15 original Healthy Start sites, Howell and colleagues (1998) developed a conceptual framework comparing and contrasting a service consortium model, in which the community was involved primarily through a consortium of local providers, and a community empowerment model, which involved a broad range of community stakeholders and strategies. Building "local, neighborhood based consortia that more fully represent the community and consumers" (p. 307) was identified as one of the central features of the latter model, some aspects of-which were reflected in each of the sites examined. The authors found barriers to community participation, among them the greater difficulty in involving community members in the consortia than involving providers, many of whom were subcontractors. Despite such difficulties, however, Howell and colleagues (1998) concluded that most of the 15 original sites had shown a "true commitment" to community involvement through the consortia, town hall meetings, and other means and felt that any improvements in health outcomes could be attributed in part "to the degree to which the community involvement strategies succeed" (p. 312).</p> <p>The present study, conducted in 1999-2000, attempted to complement this earlier work by more closely examining some of the conditions facilitating well-functioning consortia at nine Healthy Start sites.</p> <hd id="AN0011852076-3"> VALUE AND CHALLENGES OF COMMUNITY INVOLVEMENT </hd> <p>The value of involving community members and program participants in collaborative efforts to improve health services has been demonstrated (Fawcett et al., 1997; Kreuter et al., 2000; Plough & Olafson, 1994). Such involvement has been shown to increase a sense of ownership or buy--in by community members; increase the cultural sensitivity with which services are provided; and ensure that the decisions about service delivery reflect genuine community-felt need rather than solely agency concerns. Participation in voluntary organizations and consortia can be empowering for individuals because it helps develop new competencies, confidence, and feelings of helpfulness and responsibility (Wandersman & Florin, 2000; Zimmerman, 2000).</p> <p>Involving diverse individuals, community organizations, and other entities through a range of community involvement mechanisms also can lay important groundwork for intermediate benefits and outcomes, including behavior changes, improved self-esteem, enhanced local infrastructure, and new and modified programs, practices, and policies (Fawcett et al., 1995). These intermediate factors in turn may help build the foundation for achievement of long-term goals (Fawcett et al., 1995; Kreuter et al., 2000), in this case, reducing infant mortality and improving health outcomes. As Kreuter and Lezin (1998) suggested, however, "health status and health systems change are not only difficult to achieve but also relatively difficult to detect--at least in a form that is attributable to any particular intervention" (p. ii). Although a full discussion of the relationship between facilitators, forms, and intermediate and long-term outcomes of community involvement and their measurement difficulties is beyond the scope of this article (see Thompson et al., 2000; Minkler, Thompson, Bell, & Rose, 2001), our study was premised on the belief, supported in a growing body of literature, that community involvement does facilitate intermediate-level outcomes and has the potential for longer-term health outcomes (Fawcett et al., 1997; Kreuter & Lezin; Minkler, 1997; Wandersman & Florin, 2000; Zimmerman, 2000).</p> <p>Many challenges to initiating and sustaining constructive, high-level community participation have been identified and include lack of transportation and child care; competing individual and community concerns; lack of administrative commitment to more than token levels of participation; inadequate leadership and group process skills; and unresolved tensions related to race and ethnicity, gender, socioeconomic status, and professional hierarchy. (Green, 2000; Gutierrez & Lewis, 1997; Mizrahi & Rosenthal, 1992). Many of these same variables were identified in our study and are discussed elsewhere (Minkler et al., 2001; Thompson et al., 2000). Briefly, they include</p> <p> <bold> • system or environmental variables: </bold> bureaucratic inertia; competing community issues that overshadow program priorities; racial/ ethnic and socioeconomic tensions; and demographic and other shifts in the landscape such as gentrification, welfare reform, managed care; and the rapid growth of new immigrant populations that presented challenges in terms of language and other cultural factors</p> <p> <bold> • leadership and group process variables: </bold> insufficient training for consortia facilitators or consumer members; inconsistent attendance; power struggles and hidden agendas; and interpersonal race and socioeconomic tensions</p> <p> <bold> • resource variables: </bold> insufficient time to achieve ambitious program goals; the labor intensive nature of consortia; budget reductions; and loss of some providers when their funding was eliminated.</p> <p>Many of the factors identified in the present study as contributing to well-functioning consortia appeared to be important because they directly or indirectly addressed one or more of these barriers and challenges.</p> <hd id="AN0011852076-4"> CONCEPTUAL FRAMEWORK </hd> <p>The multilevel construct of empowerment provided a broad theoretical framework for this research. Defined by Rappaport (1984) as an enabling process through which individuals and communities take control over their lives and their environment, empowerment at the organizational level of analysis focuses on "settings which provide individuals with opportunities to exert control and organizational effectiveness in service delivery and the policy process" (Zimmerman, 2000, p. 51). In such settings, four strategies that facilitate the empowerment process and outcomes have been identified: "(<reflink idref="bib1" id="ref1">1</reflink>) enhancing experience and competence, (<reflink idref="bib2" id="ref2">2</reflink>) enhancing group structure and capacity, (<reflink idref="bib3" id="ref3">3</reflink>) removing social and environmental barriers, and (<reflink idref="bib4" id="ref4">4</reflink>) enhancing environmental support and resources" (Fawcett et al., 1995, p. 679).</p> <p>In light of the centrality of multicultural issues to Healthy Start and its mission, we also drew on Gutierrez and Lewis's (1997) emphasis on" education, participation and capacity building" (p. 220) as three critical areas for attention in organizing with women of color, and by extension, communities of color. Gutierrez and Lewis stressed the need to</p> <p>• "recognize and build upon ways in which women of color have worked effectively within their own communities; build upon existing structures</p> <p>• view the situation through the lens or vision of women of color</p> <p>• use the process of praxis to understand the historical, political and social context of the organizing efforts</p> <p>• recognize and embrace the conflict that characterizes cross-cultural work</p> <p>• involve women of color in leadership roles</p> <p>• understand and support the need that women of color may have for their own separate programs and organizations." (p. 220)</p> <p>Finally, we considered Kreuter and colleagues' (2000) characteristics of successful collaborative mechanisms, which include having a well-defined, specific issue on which to direct energies; an agreed on mission or goal; and an emphasis on leadership, rather than a management role. Although an inductive process was used to determine the factors that emerged as major facilitators of well-functioning consortia in the present study, many of the factors we identified are similar to the characteristics and strategies cited by Fawcett and colleagues (1995), Gutierrez and Lewis, and Kreuter and colleagues (2000), as well as to more generalized tenets of empowerment theory (Zimmerman, 2000).</p> <hd id="AN0011852076-5"> METHOD </hd> <p>We conducted an ethnographic, multisite, case study (Yin, 1994) to examine site-specific and cross-site themes and processes of community involvement. As Miles and Huberman (1995) suggested, examining a range of cases can strengthen the stability and generalizability of findings in qualitative research and enable a deeper understanding of the processes and outcomes. Similarly, use of multiple methods in case study data collection can result in conclusions that are "likely to be much more convincing and accurate" (Yin, p. 92).</p> <p>Using a participatory approach, we established a 15-member advisory board, including several program participants and consortia members from different study sites, to participate in study design, questionnaire construction, and other areas.</p> <p>In consultation with staff at the federal Healthy Start program office and our advisory board, nine sites were chosen for inclusion in the study: Boston; Chicago; Cleveland; Kansas City, Kansas; New Orleans; New York City; Philadelphia; Pee Dee, South Carolina; and Pittsburgh. With the exception of Kansas City, each site was among the original 15 Healthy Start sites, and they represented considerable diversity with respect to geography, nature of grantee organization, health outcomes, and other variables. Site visits were conducted over two days by the project director, a social worker and former director of a nonparticipating Healthy Start site, and one to three other members of the PolicyLink team. The project director made a second visit to most sites for additional data collection. At each site, key informant interviews using a standardized, semistructured questionnaire were conducted with two to five individuals, including the program director and consortium chair and, when possible, committee chairs, former directors, and others whose experience with the program might provide insights. The interviews lasted one to two hours and included questions about consortia history; nature and levels of participation; selection criteria; and factors that impeded or contributed to consortia functioning. Observations of consortia or subcommittee meetings and special programs, project reports and other written materials, and a focus group with five to nine program participants and community members also were included in the data collection.</p> <p>Audiotapes of interviews and focus groups were transcribed and independently reviewed by three members of the research team: the project director, a social welfare doctoral student, and a public health professor--research consultant. Open coding was used by each reviewer to identify patterns and themes in the data, which were noted informally in the margins. Themes that emerged in this process included, for example, attention to community needs, racial/ethnic tensions, limited role in governance and public--private sector partnerships. Each reviewer then examined the themes identified by site to reveal those that emerged for most or all of the sites and generated a final list of 10 to 15 cross-site themes or codes. Each reviewer's cross-site themes then were compared. Ten themes were identified by all three reviewers, with another three identified by two, suggesting a high degree of interreviewer correspondence. Supplemental data from the documents review and on-site observations were used to refine the themes, including those of interest in this article.</p> <hd id="AN0011852076-6"> RESULTS </hd> <hd id="AN0011852076-7"> Conditions That Foster Well-Functioning Consortia </hd> <p>Research has shown that to function well, community-based consortia require effective structures, clear roles, and strong leaders (Bailey & McNally Koney, 1995; McCoy-Thompson, 1994), and an agreed-on mission or goal that in turn reflects a genuine community concern (Kreuter et al., 2000). When consortia are being developed and nurtured in communities of color, additional factors must be attended to that are consistent with Gutierrez and Lewis's (1997) emphasis on "education, participation and capacity building" (p. 220). Building on communities' pre-existing organizations and structures, addressing community-identified needs and concerns, recognizing and addressing cross-cultural conflict, and involving people of color in organizational leadership are critical to consortia success in communities of color.</p> <p>Our examination of nine Healthy Start sites revealed that many of the conditions that appeared to foster well-functioning consortia fit in a framework of five major categories: (<reflink idref="bib1" id="ref5">1</reflink>) flexibility in the development of locally appropriate consortia structures, (<reflink idref="bib2" id="ref6">2</reflink>) broad institutional support, (<reflink idref="bib3" id="ref7">3</reflink>) adequate resource base, (<reflink idref="bib4" id="ref8">4</reflink>) incentives for participation, and (<reflink idref="bib5" id="ref9">5</reflink>) identification with the program and its mission (Table 1).</p> <p> <bold> Flexibility in Developing Locally Relevant Consortia Structures. </bold> Although each Healthy Start program was required by legislative mandate to create a consortium, there was considerable flexibility in how the consortia should be structured and how they would operate. (McCoy-Thompson, 1994). Consistent with Gutierrez and Lewis's (1997) admonition to build on existing structures in communities of color, this flexibility enabled several sites to develop regional consortia that supplemented and complemented pre-existing neighborhood entities. For example, Cleveland was able to build on its communities' largely black-run tenant associations and New York City on its settlement houses (Table 2). In New York City, where borough identification is strong, the ability to develop separate regional consortia in Harlem, the Bronx, and Brooklyn was a critical ingredient to success. Boston, Chicago, and Philadelphia maintained strong unitary consortia informed by a well-developed subcommittee structure. Finally, in rural Pee Dee, South Carolina, the development of separate provider and consumer consortia reflected in part Gutierrez and Lewis's (1997) reminder to "understand and support the need that women of color may have for their own separate programs and organizations" (p. 220). It should be noted, however, that this arrangement also reflected based on race, socioeconomic class, and professional hierarchy between the largely African American community members and the predominantly white providers. By subsequently attempting to link these two groups through an overarching consortium, this Healthy Start program illustrated another of Gutierrez and Lewis's concerns, recognizing and addressing conflict that typically characterizes cross-cultural work (Table 2).</p> <p> <bold> Broad Institutional Support. </bold> Obtaining and sustaining support from local organizations and institutions is critical in the initiation and sustenance of well-functioning consortia and increasing environmental supports and resources for community involvement (Fawcett et al., 1995, McCoy-Thompson, 1994). Our study findings suggest that community involvement was best fostered if a strong and positive relationship existed between the grantee agency and the community. In Boston and Pittsburgh, for example, strong and constructive links with the health department led to the development of other partnerships with public and private agencies. Pittsburgh Healthy Start had on its board representatives of a community health center and the Port Authority.</p> <p>Environmental supports and resources were also enhanced through contact with respected political leaders and local media, which helped to create awareness of Healthy Start's role in improving the health and welfare of targeted communities. At most of the sites examined, the media were invited to participate in special events and, conversely, Healthy Start responded when called on by reporters to consult on issues related to infant mortality, low birthweight, and teenage pregnancy. Furthermore, consortia at all sites sought and maintained contacts with key political leaders, creating opportunities to move their agendas forward and obtain key endorsements for Healthy Start. In Cleveland and New Orleans, the mayors were strong partners in their cities' Healthy Start programs. Kansas City Healthy Start had strong political ties in both states where its programs are located (Kansas and Missouri), and their consortium's legislative committee was successful in convening consistent meetings reflective of this high level of participation.</p> <p> <bold> Adequate Resource Base. </bold> As numerous observers have pointed out, adequate fiscal and personnel resources are important ingredients in effective functioning of collaborative partnerships (Brown, 1984; Kaye & Wolff, 1995; Wandersman, Goodman, & Butterfoss, 1997). For Healthy Start substantial resources were required to support day-to-day consortia maintenance and consortia activities such as health fairs, leadership training workshops, and ongoing community programs. Although some consortia activities were not directly related to infant mortality reduction, they provided critical avenues for community involvement, awareness, and support, all of which fostered an environmental context in which empowerment could take place (Fawcett et al., 1995). Consortia activities also provided opportunities for health promotion, health education, and primary prevention, which can improve knowledge about prenatal care and help lay the groundwork for improved health outcomes. Such activities can help participants understand the psychosocial aspects of health and prenatal care from a public health perspective. Focused, well-planned, and consistent outreach activities targeting program participants and community members also contributed to the recruitment of new members and effective consortia functioning.</p> <p>Although consortia activities constituted significant budget line items, project directors viewed the investment as critical to their mission; as Philadelphia's director noted, "expensive, but worth it in the long run." Staff at three of the nine programs commented that although initial consortia costs were high, they paid off in building strong consortia, which were better positioned to maintain critical activities with decreased support. During the late 1990s, for example, when the Healthy Start program expansion forced the redistribution of Healthy Start funds across more sites, substantial reductions in consortia staffing and funding occurred. Faced with budget cuts, many Healthy Start sites showed creativity in obtaining resources for consortia and other key program elements. New York City Healthy Start began including in its leadership training program training in how to write small grant proposals and other ways to work toward sustainability. Similarly, when the Boston program was faced with budget cuts, it hired a consultant to help 20 of its community-based organization subcontractors arrange for alternative funding to help ensure their viability. Many of the Healthy Start programs drew on other environmental supports and resources, including the continued involvement of churches and other local partners. Finally, using consumer consortia members for outreach was cited as a resource for conducting consortia business in the face of fewer staff. As one New York City participant suggested, "You've got some devoted clients. Ask us to help...we can do a little follow-up, send [consortia members] a note saying 'we missed you at the meeting'...We can do a little bit more." In short, an adequate fiscal and personnel resource base early on resulted in both consortia and community readiness to carry on and find creative alternative resources when budget cuts occurred.</p> <p> <bold> Incentives for Participation. </bold> Gutierrez and Lewis's (1997) admonitions to "view the situation through the lens or vision of women of color" and "give on the community's terms" (pp. 220, 223) have special relevance in the context of learning about the daily lives of program participants and other community members. Through such understanding, program staff can better identify incentives to increase community members' participation in the consortia and other Healthy Start activities.</p> <p>For many Healthy Start participants and other community members, provision of transportation and child care helped remove two major barriers to consortia participation and was therefore a critical incentive to participation. Meals, raffle tickets, and other tangible inducements also were useful, although as several focus group participants pointed out, of greater importance were the receipt of education and training, the development of new skills, "feeling listened to," and having a direct role in setting the program or meeting agenda. Each of these approaches also was an important means of enhancing individual and group skills (Fawcett et al., 1995) and capacity building (Gutierrez & Lewis, 1997), which are critical to the empowerment process in communities of color.</p> <p>For Healthy Start's community contractors, many of whom were local organizations and people of color, a key incentive for participation was sometimes the possibility of funding through the program. Yet, for many the opportunities for constructive input in the consortia and for networking with other organizations and perhaps expanding their base of support were also important incentives.</p> <p> <bold> Identification with the Program and Its Mission. </bold> As Kreuter and his colleagues (2000) suggested, having a "well defined, specific issue on which to focus energies," "having an adversary" (for example, a health problem), and "having an agreed upon vision and goal" are characteristics of successful, collaborative mechanisms (p. 55). In our study, providers' and community members' belief in the importance of Healthy Start's goal of reducing infant mortality was a major factor contributing to consortia involvement.</p> <p>In Boston, to make connections between the program's mission and community health outcomes, regular presentations at consortium meetings included providing participants with statistics on infant deaths, women lacking access to prenatal care, and other variables related to the health of women and children in their community. At Pee Dee, linking infant mortality with issues of more immediate concern to residents (for example, housing, substance abuse, and poverty) was part of "doing whatever it takes" to get infant mortality "on the radar screen" and creating critical awareness of some of the root causes of health problems (Zimmerman, 2000). This process also was important in helping' place infant mortality in a broader social, historical, and political context, thereby increasing its perceived relevance to the lives of community members (Gutierrez & Lewis, 1997). As a result of such efforts, according to Pee Dee's project director, there was "a tremendous amount of interest" in Healthy Start and a real change in the community's orientation to health outcomes.</p> <p>The ability of program staff to elicit support and community ownership of Healthy Start and its goal of infant mortality reduction also was described at many sites as a major contributor to community involvement and well-functioning consortia. In Boston and New Orleans, participants complimented program staff for soliciting ideas from the consortia and translating them into programs. A New York City focus group member similarly reported how proud she was on reading a story in the New York Times about their Brooklyn site and recent reductions in New York City's infant mortality rates, saying, "It makes me proud to know that what we are doing is working."</p> <p>Finally, the creation of nonprofit agencies at several of the Healthy Start sites (Table 2) was a reflection of and a contributor to identification with the program and its mission. By "enhancing group structure and capacity" (Fawcett et al., 1995) and by creating "settings which provided individuals opportunities to exert control" (Zimmerman, 2000, p. 51), these agencies appeared to facilitate empowerment and contribute to community capacity. New Orleans's Healthy Start program used its new autonomy to manage alternative funding streams and hire outreach workers. Pee Dee Healthy Start's formation of a separate 501(c) (<reflink idref="bib3" id="ref10">3</reflink>) resulted in a strong African American-led organization that reflected Gutierrez and Lewis's (1997) reminder of "the need that women and people of color may have for their own separate programs and organizations." (p. 220). And in Pittsburgh, the Healthy Start nonprofit gave its consortium a policy decision-making role, including input on budget and personnel decisions, which in turn resulted in strong feelings of community ownership.</p> <p>The five factors described were the key conditions for well-functioning Healthy Start consortia. Each of these factors also related in part to strategies for facilitating empowerment processes and outcomes with people of color.</p> <hd id="AN0011852076-8"> Limitation of the Study </hd> <p>Limitations of this study include the small number of participating sites (nine of 94 Healthy Start programs), the relatively brief time available for site visits, and the cross-sectional nature of the study. The latter factor prevented us from examining consortia growth and development over time using models that have demonstrated utility in such analyses (Bailey & McNally Koney, 1995; Fawcett et al., 1997; Kreuter et al., 2000). Finally, although the diversity of the sites allowed us to examine a broad range of consortia and their program settings, it was difficult to design a data-gathering instrument that was relevant to each site. Despite these limitations the data helped us illuminate many aspects of community involvement in Healthy Start and its community-based consortia.</p> <hd id="AN0011852076-9"> IMPLICATIONS FOR SOCIAL WORK PRACTICE </hd> <p>Forming and sustaining community-based consortia and other collaborative partnerships is labor and time intensive and can sometimes slow progress toward program goals (Green, 2000). Yet, as numerous social workers and health professionals have pointed out, well-functioning consortia can be critical for individual, organizational, and community empowerment and capacity building, which may serve as important intermediate variables to the achievement of health and health system-change outcomes (Bailey & McNally Koney, 1995; Fawcett et al., 1995; Howell et al., 1998; Kreuter et al., 2000; Mizrahi & Rosenthal, 1992).</p> <p>Our study suggested a variety of conditions and strategies that provided fertile ground for well-functioning consortia, in part by addressing some of the challenges and barriers confronted. Consistent with Fawcett et al. (1995) and Gutierrez and Lewis's (1997) criteria, several of these conditions and strategies can be used by social workers to facilitate empowerment by contributing to the "reciprocal processes of education, participation, and capacity building" (p. 219). On the macro level, forging strong links with health departments, political leaders, the mass media, and a host of public and private sector agencies can enhance environmental support and resources. Similarly, providing consumer training and opportunities for diverse roles and responsibilities in programs like Healthy Start can work on the micro level to enhance individual experience and competence and on a broader level strengthen group or organizational structure and capacity. Finally, the provision of incentives such as transportation and child care and addressing issues such as housing, welfare reform, and racial/ethnic tensions can work on multiple levels simultaneously to help overcome social, psychosocial, and environmental barriers to participation. The provision of incentives further represented an important means through which social services staff could "view the situation through the eyes of women of color" and their families and communities (Gutierrez & Lewis, p. 220). Without minimizing the profound and continuing roles of poverty, racism, and related factors in the lives of participants, programs such as Healthy Start can help build individual and community capacity.</p> <p>Social workers can play an important role in increasing the level of client participation in consortia in the early stages of development. And consistent with the field's emphasis on strengths-based practice (Saleebey, 1997), even before the emergence of the formal consortium, client voices can be encouraged through focus groups and other less formal convenings.</p> <p>Our study results also suggest that social workers have a critical role in helping ensure that community-based consortia have specific roles, including strategic planning to engage community members in identifying their shared concerns and working to address these; identification and recruitment of community institutions to partner in implementation; and ongoing outreach, monitoring, program development, and evaluation. Social workers in administrative capacities who are planning for or establishing consortia can help ensure that adequate support is provided for these collaborative mechanisms. Such support should include high-level administrative personnel to enable effective consortia operation; clear guidance and technical assistance in the development, governance structure, functioning, and sustaining of the consortia; and ongoing training for consortia members and leaders in governance, leadership, and advocacy skills.</p> <p>As social workers grapple with complex health problems such as infant mortality, HIV/AIDS, substance abuse, and violence, community-based consortia represent important vehicles for engaging multiple partners, including consumers and other community members, in working collaboratively for change. The present study suggests that such consortia can help identify and implement creative approaches to addressing such problems and, in the process, help create stronger, more empowered organizations and communities. By helping overcome barriers and challenges to well-functioning consortia and by helping identify and facilitate the conditions in which consortia can grow and thrive, social workers can help these collaborative partnerships reach their full potential.</p> <p>Original manuscript received August 11, 2000 Final revision received February 21,2001 Accepted October 4, 2001</p> <p>The authors gratefully acknowledge the contributions of other members of the PolicyLink project team: Zita Allen, Janet Dewart Bell, Angela Grover Blackwell, Modupe Carpenter, and Heather Bent Tamir.</p> <hd id="AN0011852076-10">Table 1. Contributors to Well-Functioning Consortia</hd> <p>Flexibility in the development of locally appropriate consortia structures</p> <p>• Building on pre-existing organizations and structures</p> <p>• Respecting local boundaries and identifications</p> <p>Broad institutional support</p> <p>• Constructive links with health departments, leading to other partnerships</p> <p>• Strong links with diverse public and private agencies</p> <p>• Support from local political leaders and the mass media</p> <p>Incentives for participation</p> <p>Incentives for consumers</p> <p>• Provision of enabling services (for example, transportation and child care)</p> <p>• Opportunity for education and training and development of new skills</p> <p>• Active engagement of churches and other respected community institutions</p> <p>• Provision of incentives (for example, meals, raffles, and so forth) which may enhance attendance</p> <p>• Generalized belief that reducing infant mortality is an important goal</p> <p>• Feeling "listened to" and knowing that community issues are taken seriously</p> <p>Incentives for community partners</p> <p>• Possibility of funding for potential subcontractors</p> <p>• Networking opportunities</p> <p>• Perceived means for churches and other partners to expand their own base of support</p> <p>• Committee structure enabling participants to work on issues of special interest</p> <p>Identification with the Program and its mission</p> <p>• Belief in Healthy Start's goal by residents, CBOs, and potential partners</p> <p>• Program staff able to elicit feelings of community buy-in and ownership</p> <p>• Connecting of infant mortality to issues of greater immediate concern to residents</p> <p>• Creation of nonprofit agencies</p> <p>Note: CBO = community-based organization.</p> <hd id="AN0011852076-11">Table 2. Healthy Start Site Profiles and Sample Consortia Facilitators</hd> <ct id="AN0011852076-12"> Legend for Chart: A - SITE B - FISCAL AGENT C - CONSORTIA STRUCTURE D - CONSORTIA'S ROLE IN GOVERANCE E - SAMPLE CONSORTIA FACILIATORS A B C D E BOSTON Boston Public Health Commission Very strong consumer participation model with seven committees Policy decisions on type and level of services Influence on outreach strategies and marketing tools Strong links with health department leading to other institutional partnerships CHICAGO State of Illinois, Department of Human Services Very strong consumer participation model with three committees Policy decisions on type and level of services Annual consumer conference on topics identified by participants in consortia subcommittee CLEVELAND Cleveland Department of Public Health Eight sites serving 15 neighborhoods Executive Council and Administrative Management Group make policy decisions Consortia built in part on pre-existing tenant organizations Active mayoral participation in consortium KANSAS CITY Heart of America United Way Strong provider representation with three committees No involvement in governance Strong ties with political leaders and mass media Cultural competence workshop for consumer and provider members NEW ORLEANS City of New Orleans, Mayors Office receives funds; passes through to Great Expectations Foundation, a 501(c)(3) 10 Service Area Advisory Councils represented on Consortia Steering Committee 4 Leadership council members and 3 consumer representatives make policy decisions on Great Expectations Board of Directors Consortia Steering Committee makes recommendations on service delivery models, identifies community needs and partnerships Some input on budget and personnel decisions Consortia built in part on pre-existing settlement houses Training for selected consortia members and their subsequent inclusion on governing board NEW YORK Medical and Health Research Association of NYC, INC (grantee) Regional model with five citywide committees and 3 Harlem local area committees Local consortia representatives are members of citywide consortium that makes governance-level decisions Community consortia members trained in public speaking, board involvement, and resource development strategies PEE DEE Private, non-profit Separate consortia for providers and consumers, now working more closely together Agency's board of directors makes governance decisions Creation of van transportation system to facilitate participation PHILADELPHIA Philadelphia Department of Public Health, MCH Additional consortia focused on males Policy decisions on type and level of services Separate community consortium and development of nonprofit in part in response to felt need for separate African American-led organizations PITTSBURGH Allegheny County Health Department; passes funds through to Healthy Start nonprofit. Very strong consumer participation model with six committees Regional model with one consortium in each of six target areas Policy decisions on type and level of services Input on budget and personnel decisions Daylong event to build trust between consortia providers and community members Strong, active involvement of the county health department since project's inception</ct> <ref id="AN0011852076-13"> <title> REFERENCES </title> <blist> <bibl id="bib1" idref="ref1" type="bt"></bibl> <bibtext>Badura, M. (1999). The Healthy Start Program: Mobilizing to reduce infant mortality and morbidity. Journal of Pediatric Nursing, 14, 263-265.</bibtext> </blist> <blist> <bibl id="bib2" idref="ref2" type="bt"></bibl> <bibtext>Bailey, D. (1992). Using participatory research in community consortia development and evaluation: Lessons from the beginning of a story. 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Minkler (Ed.), Community organizing and community building for health (pp. 3-19). New Brunswick, NJ: Rutgers University Press.</bibtext> </blist> <blist> <bibl id="bib22" type="bt"></bibl> <bibtext>Minkler, M., Thompson, M., Bell, J., & Rose, K. (2001). Contributions of community involvement to organizational level empowerment: The federal Healthy Start experience. Health Education and Behavior, 28, 783-807.</bibtext> </blist> <blist> <bibl id="bib23" type="bt"></bibl> <bibtext>Mizrahi, T., & Rosenthal, B. (1992). Managing dynamic tensions in social change coalitions. In T. Mizrahi & J. D. Morrison (Eds.), Community organization and social administration: Advances, trends and emerging principles (pp. 1-33). New York: Haworth Press.</bibtext> </blist> <blist> <bibl id="bib24" type="bt"></bibl> <bibtext>Plough, A., & Olafson, F. (1994). Implementing the Boston Healthy Start initiative: A case study of community empowerment and public health. 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Hyattsville, MD: Author.</bibtext> </blist> <blist> <bibl id="bib29" type="bt"></bibl> <bibtext>Wandersman, A., & Florin, P. (2000). Citizen participation and community organizations. In J. Rappaport, & E. Seidman (Eds.), Handbook of community psychology (pp. 247-272). New York: Kluwer Academic/Plenum.</bibtext> </blist> <blist> <bibl id="bib30" type="bt"></bibl> <bibtext>Wandersman, A., Goodman, R. M., & Butterfoss, F. D. (1997). Understanding coalitions and how they operate: An "Open Systems" organization framework. In M. Minkler (Ed.), Community organizing and community building for health (pp. 261-277). New Brunswick, NJ: Rutgers University Press.</bibtext> </blist> <blist> <bibl id="bib31" type="bt"></bibl> <bibtext>Yin, R. K. (1994). Case study research design methods (2nd ed.). Newbury Park, CA: Sage Publications.</bibtext> </blist> <blist> <bibl id="bib32" type="bt"></bibl> <bibtext>Zimmerman, M. A. (2000). Empowerment theory: Psychological, organizational and community levels of analysis. In J. Rappaport & E. Seidman (Eds.), Handbook of community psychology (pp. 43-63). New York: Kluwer Academic/Plenum.</bibtext> </blist> </ref> <aug> <p>By Mildred Thompson; Meredith Minkler; Judith Bell; Kalima Rose and Lisa Butler</p> <p></p> <p>Mildred Thompson, MSW, is senior policy fellow, PolicyLink, 101 Broadway, Oakland, CA 94607: e-mail: Mildred@policylink.org.</p> <p>Meredith Minkler, DPH, is professor, School of Public Health, University of California, Berkeley.</p> <p>Judith Bell, MPA, is vice president, PolicyLink, Oakland.</p> <p>Kalima Rose, BA, former senior associate, PolicyLink, Oakland.</p> <p>Lisa Butler, PhD, is a doctoral candidate, School of Public Health, University of California, Berkeley.</p> </aug>
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  Data: Facilitators of Well-Functioning Consortia: National Healthy Start Program Lessons.
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  Data: <searchLink fieldCode="DE" term="%22Community+Involvement%22">Community Involvement</searchLink><br /><searchLink fieldCode="DE" term="%22Consortia%22">Consortia</searchLink><br /><searchLink fieldCode="DE" term="%22Empowerment%22">Empowerment</searchLink><br /><searchLink fieldCode="DE" term="%22Infant+Mortality%22">Infant Mortality</searchLink><br /><searchLink fieldCode="DE" term="%22Program+Effectiveness%22">Program Effectiveness</searchLink><br /><searchLink fieldCode="DE" term="%22Social+Work%22">Social Work</searchLink>
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  Data: Presents findings from a multisite case study of consortia in the federal Healthy Start Initiative to reduce infant mortality in high-risk communities. Examines the facilitators of well- functioning consortia in a framework of empowerment theory and community organizing with women of color. Implications for social work practice and for policy are provided. (Contains 32 references and 2 tables.) (GCP)
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