3. CASE STUDIES CROSS-CASE ANALYSIS
The final step of data collection for this project involved the design and implementation of an abbreviated case study that built upon what was learned in the preceding literature review and environmental scan. Many of the articles and resources identified through the preceding work focused on the intervention and not necessarily on the linkage itself. Therefore, the case study sought to expand AHRQ's understanding of how linkages are implemented, barriers, facilitators, and lessons learned, as well as to examine key components of the conceptual framework developed to guide this project.
3.1.1 Step 1: Selection Criteria
Upon completion of the literature review and environmental scan, the RTI team worked with AHRQ and the Steering Committee to develop selection criteria that were used to identify potential case study examples. These criteria included key community or program characteristics, which have been categorized according to the framework (Figure 1-1).
Based on the feedback from the Steering Committee and AHRQ, RTI proposed to select cases that maximized variation on key selection criteria, defined in Table 3-1.
Using the selection criteria, RTI reviewed the linkage examples identified through the literature review and environmental scan to generate a short list of 11 potential candidate interventions (or cases). The list of 11 interventions was reviewed by AHRQ and RTI team members and prioritized in terms of the top five potential cases for inclusion and then secondary back-up cases to be contacted if representatives from the first six could not be reached or chose not to be involved in the case studies.
3.1.2 Step 2: Recruitment of Case Study Examples
Interventions selected for participation in the case study were contacted via e-mail to introduce the case study and ask them for additional information about their intervention, including a primary point of contact. Each e-mail was followed by a phone call from an RTI team member to the specified point of contact. During this call, RTI assessed the intervention's eligibility and interest in participating. If an intervention appeared to be a good "fit" with the study priorities and objectives, then they were asked to participate in a 1-day face-to-face site visit during which RTI staff could speak with representatives from their community and clinical partners. From the initial list of 11 cases, a total of five cases were successfully recruited for participation in the case studies.
Table 3-1. Selection Criteria for Case Selection
|Selection Criteria ||Definitions|
|Types of Organizations Involved ||
- At least one case from the following community partners:
- State and/or local government public health agency
- University partner
- Community-based organization
- At least one case from the following clinical partners:
- One or more single practices
- Health care system
- Community health center, clinic, health department
- Additionally, all efforts will be made to select cases that were initiated by the clinical side and examples that were initiated by the community side
|Research vs. Community Effort ||
- At least two cases that are representative of a larger research or funded effort, such as Prescription for Health or Building Community Support
- At least two cases that were initiated independently of a larger research or coordinated effort
|Geography (Rural vs. Urban) ||
- At least two cases that occur in a rural context
- At least two cases that occur in an urban context
|Type of Linkage ||
- At least one case with a linkage other than a referral system
- At least three cases with linkages that are active
3.1.3 Step 3. Collect Data from Key Partners
In collaboration with the Steering Committee and AHRQ, an interview guide was developed that consisted of a series of semi-structured questions aimed at describing the intervention, lessons learned, barriers and facilitators, other characteristics identified as priorities by the Steering Committee and AHRQ, and outcomes of the effort. All protocols and case study procedures were reviewed by the RTI Institutional Review Board (IRB) and were found to be exempt. (Interview protocols are available from RTI upon request.)
Upon agreeing to participate in the case study, an RTI team member worked with four of the cases to schedule interviews with key program stakeholders from both the clinical and community partners. Face-to-face visits were conducted with four cases (Sisters in Action; Strong Kids, Strong Teens; Salud Para Todos; and the North Carolina Prevention Collaborative). A fifth case, the Charlotte REACH 2010 project, was no longer active, and key staff had since moved into other roles in other states; thus, interviews were conducted via phone. Interviews were requested from key staff or individuals for a minimum of one interview with the clinical partner and one interview with the community partner. Each interview lasted approximately 1 hour and, with the interviewee's permission, was digitally recorded to assist with note taking.
3.1.4 Step 4. Data Analysis
Much of the data collected through the case studies were descriptive in nature. Qualitative thematic analyses were conducted to identify characteristics acknowledged as important to the linkages between clinical practices and community/public health interventions. For each case, an RTI team member who participated in the site visit was responsible for analysis of the interview data. Individual case analyses were conducted according to the case study priority questions and, in some cases, the protocol questions. Individual case study summaries were developed for each case. Building upon each individual case analysis, a cross-case analysis was conducted in which critical elements common across cases were identified. The results of the cross-case analyses are presented in the following text.
The following findings represent cross-case analyses that examine key study questions across all five cases. Five cases were selected for inclusion in the case studies. These are described in Table 3-2.
Table 3-2. Case Study Cases
|Intervention ||Location ||Years of Implementation ||Funders|
|Charlotte REACH 2010 ||Charlotte, North Carolina ||1999–2007 ||Centers for Disease Control and Prevention|
|North Carolina Prevention Collaborative ||Central and Eastern North Carolina ||2007–2009 ||Kate B. Reynolds Charitable Trust|
|Salud Para Todos ||Yuma County, Arizona ||2008–present ||Office of Minority Health|
|Sisters in Action ||Grand Rapids, Michigan ||2006–2009 ||Health Resources and Services Administration|
|Strong Kids, Strong Teens ||Seattle, Washington ||2003–present ||Steps to a HealthierUS|
All interviews were conducted in February and March 2010. Face-to-face interviews were conducted with 26 partners, and telephone interviews were conducted with four partners, yielding a total of 30 stakeholders interviewed across all five cases. Fifteen stakeholders represented community partners, 13 stakeholders represented clinical partners, and two were representatives from "other" stakeholder groups or individuals.
3.2.2 Building Blocks
Organizations Involved in Linkages
Case Study Questions of Interest
- What organizations are involved in these linkages?
- What do these linkages look like?
- Why were the linkages established?
A review of the key partners found that a wide variety of community and clinical partners are engaged in linkages to improve delivery of clinical preventive services (see Table 3-3). Community partners included governmental public health organizations, an Area Health Education Center (AHEC), a community center, YMCAs, and a public university. Clinical partners included two health systems, primary care practices, a community health center, and a hospital.
Table 3-3. Partners Involved in Linkages
|Intervention ||Community Partners ||Clinical Partners|
|Charlotte REACH 2010 ||Community Health Department, YMCA and other organizational partners ||Carolinas Healthcare System|
|North Carolina Prevention Collaborative ||UNC Chapel Hill, NC Department of Health and Human Services, AHEC, and other organizational partners ||Community-based nonprofit primary care practices|
|Salud Para Todos ||Campesinos Sin Fronteras ||Sunset Community Health Center|
|Sisters in Action ||YMCA ||Spectrum Health System|
|Strong Kids, Strong Teens ||Two area YMCAs ||Seattle Children's Hospital|
Types of Linkages Being Implemented
Although there was some variability in how the linkages were implemented across the five cases, referral systems and processes were the most common structure for linking patients with both clinical and community support and resources. Four of the five cases examined in the case study were found to utilize referral systems where patients were referred from a clinical partner to a community partner or from a community partner to a clinical partner.
Within the Strong Kids, Strong Teens program, health care providers were educated about the availability of a YMCA obesity treatment program and then encouraged to refer obese youth to the program so that they could receive information about adopting a healthy lifestyle.
In two examples—Charlotte REACH 2010 and the Salud Para Todos program—referrals were bidirectional with individuals being referred by and to both clinical and community partners. The Charlotte REACH 2010 program included a certified diabetes educator located within a community clinic, who referred eligible patients to the variety of community partner programs. This effort also used lay health advisors who worked within the community and referred residents in need of medical assistance to the participating clinics. The Salud Para Todos program utilized promotoras within each partner organization to create a bidirectional referral process between the partner organizations. The promotoras served as the primary point of contact within each partner organization and referred individuals who were at risk for conditions such as diabetes, pre-diabetes, and hypertension or were in need of services to diagnose and educate about such conditions.
For each of the linkages where referral processes were in place, there was no evidence that any type of feedback loop existed, where the referring organization received an update or information on the individual referred, including diagnosis, enrollment in an intervention, or completion of an activity. Thus, while a bidirectional referral process may be in place, communication after a referral was only unidirectional. It is possible that the Health Insurance Portability and Accountability Act (HIPAA) rules and regulations may have some role in the limited feedback from clinical partners to community partners.
In addition to referral systems, one case focused primarily on provision of information and resources to both patients and providers. The North Carolina Prevention Collaborative developed and utilized a variety of materials and approaches to educate primary care providers about the resources available within the state health system and how to assess patient needs.
Reasons for Establishing Linkages
Each of the five case study cases reported unique goals and objectives for their particular linkage and intervention. In all cases, linkages were formed to provide services and resources to individuals who lived within a particular community or were representative of a population that had previously been found to be facing particular health-related challenges and barriers. In three out of the five case examples, clinical and community partners had a history of working together to address these or other issues in the target community. In one example, Salud Para Todos, the clinical and community partner had maintained a partnership for more than 10 years.
Organizations in three of the case study cases (Salud Para Todos, Sisters in Action, and Charlotte REACH 2010) had worked together on other health-related efforts. These relationships, as well as those formed in the two additional cases, were used as a mechanism to implement a particular intervention that had received external funding to meet the previously identified community health challenge. In most cases, this funding was limited in terms of time (from 2 to 8 or more years) and topic (see Table 3-4).
Case Study Questions of Interest
- What issues are the linkages addressing?
- What is the role of the clinical partner?
- What is the role of the community partner?
- How is information technology used by these linkages?
Each case addressed at least one of the core health behaviors of study. Table 3-4 shows the health behaviors addressed by each of the case study cases. Physical activity and nutrition were addressed by all of the interventions; tobacco was addressed by two. Four of the five case study examples had a focus on a particular target population, defined by race/ethnicity, health condition, gender, and age. Target groups included Hispanic/Latino farm workers, overweight and obese African American women and African American communities more broadly, and overweight and obese youth. In only one case example, the North Carolina Prevention Collaborative, the target population varied significantly due to local-level implementation across six communities; however, all patients were underserved because the clinical partners in all instances were nonprofit community health clinics. Three of the case study interventions were being implemented within urban community settings, one was implemented in a rural community, and one, which had multiple sites, was implemented in both rural and urban communities.
Table 3-4. Health Behaviors Addressed and Target Populations
|Intervention ||Health Behavior Focus ||Geographic Setting ||Target Population|
|Physical Activity ||Nutrition ||Tobacco |
|Charlotte REACH 2010 ||X ||X ||X ||Urban ||Predominantly African American communities|
|North Carolina Prevention Collaborative ||X ||X ||X ||Mix ||Patients served by nonprofit community health clinics|
|Salud Para Todos ||X ||X || ||Rural ||Hispanic/Latino farm workers|
|Sisters in Action ||X ||X || ||Urban ||Overweight and obese African American women|
|Strong Kids, Strong Teens ||X ||X || ||Urban ||Overweight and obese youth|
As described above, a variety of clinical partners were involved in the linkages. Clinical partners included two health systems, primary care practices, a community health center, and a hospital. In three of the five cases, the clinical partner initiated the linkage and intervention. These partners, having led the identification of and application for funding, also served as the fiscal agent for external funding. The role of the clinical partners varied across cases. In all cases, the clinical partner played an active role in the development and/or implementation of the interventions being implemented. Clinical partner activities varied significantly across each of the five cases, but commonly included
- intervention administration (including fiscal oversight and reporting to granting organizations);
- intervention implementation (including hiring staff; developing intervention protocols, procedures, and curricula; recruiting, screening, and referring patients and potential program participants);
- coordination with community partners; and
- evaluation oversight (including development of evaluation protocols, data collection, and analysis).
A variety of clinical staff helped to establish and maintain the linkages and the interventions. Staff consisted of clinicians (e.g., physicians, nurses, health educators) and administrative personnel (e.g., program directors and coordinators). Clinical partners in two cases hired clinical staff to help serve patients recruited for the intervention. This included a certified diabetes educator and a promotora; both were located in community clinics and served intervention participants. Within each of the five cases, each clinical partner had a primary point of contact for the linkage and intervention. However, this individual had different roles in each case. For example, in the Salud Para Todos program, it was a program coordinator for the entire clinic (not just Salud Para Todos); in the Sisters in Action initiative, the point of contact was someone working for the Spectrum Health System Healthier Communities Program (a public health division within the health system); and in two examples—the Charlotte REACH 2010 program and the Strong Kids, Strong Teens initiative—the programs were led by a coalition of community representatives, including clinicians. In addition to having a primary point of contact within each organization, respondents indicated that it was centrally important that their management was supportive of the effort and the time required by staff to coordinate with the community partner and implement the intervention. The meaning of the term "management," however, varied and included departmental leadership (although not necessarily hospital-level management) in the case of Strong Kids, Strong Teens; division-level leadership within Spectrum Health; and the medical director at Sunset Community Health Center for the Salud Para Todos program.
Community partners included governmental public health organizations, an AHEC, a community center, YMCAs, and a public university. Of note, four of the five case study cases involved the YMCA in some respect, with respondents from each of those cases indicating that the YMCA provides resources for both implementation of health promotion activities and community outreach.
As with the clinical partners, the role of the community partners varied across each of the cases and was largely dependent on the intervention being implemented. Activities commonly included
- intervention administration;
- intervention implementation (including hiring staff; developing intervention protocols, procedures, and curricula, teaching classes or intervention components; recruiting and referring patients and potential program participants; providing intervention support activities, including transportation and childcare; and providing space for interventions to be implemented);
- coordination with clinical partners; and
- support for evaluation activities by collecting data from participants.
Community partners were less involved with fiscal oversight of the intervention, as in most of the case study examples the funding was awarded to the clinical partners and played primarily a supporting role in the evaluation of the interventions. Community partners tended to play a more significant role in the administration of the intervention, including leading or hiring staff to lead education and behavior change activities as well as providing support services, such as transportation and childcare.
A wide variety of staff within the community partners were involved with the development and implementation of the intervention. As mentioned previously, the YMCA was found to be a critical community partner engaged in these linkages. A variety of staff from the YMCA were involved, including individuals hired to serve as program coordinators, dieticians, and exercise coordinators. YMCA support staff, including front desk support, and childcare staff also played an important role. Within the Salud Para Todos program, promotoras were hired by both the clinical and the community partners, which helped facilitate coordination.
Use of Information Technology (IT) to Implement the Intervention
The literature review showed that some linkages used IT (e.g., Web sites and handheld devices) as part of the interventions. Staff within each of the case study cases were asked about the role of IT in the implementation of their linkage or intervention. Among these five cases, IT played a very limited role. Staff with the North Carolina Prevention Collaborative developed a Web site where clinical practice teams could submit their data, track progress, and find resources that met the needs identified through their quality improvement audit, although program staff viewed it as time consuming and challenging. Consequently, the Web site was underutilized. Although not a part of the design of the Sisters in Action effort, the coordinators found that one of the groups of women enrolled started their own social networking group where they could e-mail each other and share victories, healthy restaurant recommendations, and coupons for healthy foods. This group was not facilitated by the partner organizations; however, partners indicated that the support offered by other women enrolled in the intervention was particularly important to their success.
3.2.4 Predisposing, Enabling, and Reinforcing Factors
Within the aforementioned framework (Figure 1-1), a hypothesized set of predisposing, enabling, and reinforcing characteristics are presented. This categorization is useful as it helps one to better understand the characteristics and conditions that affect why and how an organization may engage in a linkage with a clinical or community partner and in particular interventions.
In this section, we present our findings on predisposing, enabling, and reinforcing factors as organized by the original program framework, although with the categories slightly altered based on what has been learned through this work. We use the headings of Community Context; Organizational Characteristics, which includes Organizational Capacity and Interactional Characteristics (building upon the work of Dr. Ruth Martin-Misener and Dr. Ruta Valaitis from McMaster University) (Martin-Misener & Valaitis, 2009), and Intervention/Innovation Characteristics. In addition to adding Interactional Characteristics, we included Provider Characteristics in the category of Organizational Characteristics because the organizational structure within which providers operate has a significant influence on their behaviors and delivery of services. We also note that the term "provider" should be expanded conceptually to include all individuals who provide services to individuals through a community or clinical organization and that the term not be limited to a health care provider or physician.
With this understanding, a variety of predisposing, enabling, and reinforcing factors that affect successful linkages were identified through the case study and are presented below. In most cases, the findings are described in a "positive" or facilitative manner where their presence will help facilitate the development and implementation of linkages and health promotion initiative. It can be assumed in most cases that the absence of these same factors will serve to challenge or act as a barrier to development and implementation of these efforts.
Case Study Questions of Interest
- What community conditions supported or challenged the linkages and their interventions?
- What role does policy play in the development and implementation of these linkages?
- What motivated providers to become involved?
Within the five case study cases, community context plays an important role in the types of interventions and linkages that are implemented. Community context is conceptualized as factors that are either characteristic of the community or external to the partner organizations that serve as predisposing, enabling, or reinforcing factors to the linkages and interventions. The following are several key factors within the community context:
- funding for linkages and interventions,
- understanding of community members' health needs,
- understanding of community resources,
- trust between communities and organizations implementing programs, and
Funding for linkages and interventions: Funding played a critical role in the implementation of all of the interventions implemented, and the presence or absence of funding serves as an important enabling factor. All five cases indicated that without funding the interventions would not have occurred and, in four of the five cases, the linkages between partners would not have been developed as fully. In some cases, relationships between the clinical and community partners were already established. External funding further solidified these relationships and contributed to the development of a more formal linkage with the purpose of implementing a particular intervention. For organizations without preexisting relationships, the presence of new external funding to implement a particular intervention was often a motivation to identify and establish new relationships and linkages. For example, for the Strong Kids, Strong Teens initiative, Seattle Children's Hospital had the expertise to develop an evidence-based program, but they needed better reach within the community to market the program and reach the target population. To do this, they identified and recruited the YMCA as a partner. "Given the Y's broad presence and the similarity in our missions, it looked like they were the logical choice. … Our challenge with trying to do it ourselves was that we weren't able to meet kids where they were" (clinical partner).
Respondents from all cases reported that without the external funding these linkages and interventions would not have been implemented. Similarly, although funding helped to establish these linkages, respondents from four of the five cases commented that looking forward, long-term relationships had been established through these efforts and will be used in future health promotion efforts. For instance, the partnering organizations for the Salud Para Todos program have worked together for 10 years on various health promotion efforts; each of these efforts was supported by external funders, such as the Office of Minority Health and RWJF.
Understanding of community members' health needs: Two of the five case study cases had previously conducted or been involved with a community-level health needs assessment. Staff with the Grand Rapids YMCA collected health information (e.g., height, weight, BMI) from the African American community; from that needs assessment, they discovered high rates of overweight and obesity among this population. Similarly, one case example used chart audits as part of a quality improvement effort to assess the health needs of patients receiving services from participating practices. These needs assessments served as important predisposing factors that helped the organizations to identify important health issues and prompted them to develop linkages and interventions to target those issues.
Understanding of community resources: According to case study respondents from two cases, having a solid understanding of community resources enables organizations to develop and offer relevant programs that meet the needs of community members. In one case, the absence of available programs to which providers could refer youth indicated a community need for such a program. Other respondents indicated that understanding resources that may contribute to interventions, such as transportation needs, can have a significant influence on who to involve in a linkage, infrastructure needed for implementation, and the nature of the intervention itself.
Trust between the communities and organizations implementing programs: Trust between the communities being served by programs and the organizations seeking to provide programs was a critical issue in several of the case study cases. This was particularly true for the Charlotte REACH 2010 case where there was as history of distrust between the community and the hospital. The Charlotte REACH 2010 effort was one way to try to build this trust, as was establishing a health clinic within the community. "[It] took lots of years of coalition squabbles to get people to a place of trust where community could benefit from this relationship with the hospital" (clinical partner). If trust does not already exist between the community and the partner organizations, it is important to take the process slowly and build that trust through open and honest engagement of the community in planning and implementation. For Charlotte REACH 2010, one way of doing this was through the leadership of a coalition with diverse community and organizational membership.
Policies: Staff from each of the cases were asked about community, state, or national policies that would impact the development of linkages to deliver preventive health services. Respondents consistently reported that they had never thought about the role of policy in establishing or maintaining linkages or in the delivery of preventive health services. We suggest that this is an area that needs further examination.
Case Study Questions of Interest
- What motivated the partners to become and remain involved in these linkages?
- What needs were addressed through these linkages?
- What resources need to be in place to facilitate these linkages and their interventions?
- What other organizational factors facilitated or challenged the development and implementation of the interventions?
In all five case study cases, the capacity of an organization to address key community needs was important to establishing successful linkages and implementing interventions. Capacity refers to the ability of an organization to take action or meet organizational goals and objectives. It may include organizational infrastructure, support, and commitment to work with other organizations. Respondents identified three key characteristics related to the capacity of organizations to create linkages with partner organizations and implement health promotion interventions:
Leadership and management support: Respondents within each of the case study cases indicated that having the support of organizational management was critical to the success of their linkages and interventions. As an enabling factor across the cases, management support included the commitment of staff who could develop and oversee the organizational relationships and interventions; commitment of resources, often in-kind to support the intervention; and organizational commitment to addressing the health and wellness needs of the communities within which they operate. In two cases, evaluation data from previous efforts helped program staff to garner management support. For example, when the medical director of the Sunset Community Health Center saw data indicating that patients who worked with promotoras reduced their hemoglobin A1c, he became convinced that the clinic should also adopt and integrate the promotora model. As a result, he advocated for the promotora model and continued to work with Campesinos Sin Fronteras.
Knowledge and skills of staff: Ranging from an understanding of the clinical needs of patients, or how to implement support groups and health education programming, each organization brought with it a core set of knowledge and skills that facilitated their ability to implement the intervention and establish a successful linkage. Such knowledge and skills serve as an important enabling factor. Each organization also recognized that, although their organization could have provided some services, there existed resource gaps that could not be addressed without assistance from other partners. Creating a linkage allowed multiple organizations to use their strengths more effectively to deliver services and create opportunities and resources to meet needs that neither partner could fill alone.
Organizational policies and values: Representatives from all five case study cases reported that the organizations involved in these efforts had a strong organizational commitment to the communities they serve. In some ways, these policies and values serve as predisposing, enabling, and reinforcing factors at different times. One community partner reported, "We are always working with little or no money. [We] truly believe in the work that [the founder of the organization] did. [We] need community programs to service the need of the people who are invisible." Another community partner reported, "Without the [clinical partner's] support, this would never have happened. They leveraged the grant writing team, they were committed to serving the population and social responsibility." These values encouraged respondents to work through challenges, continue seeking funds, and look for additional opportunities for collaboration. It is also important to note that timing plays an important role in whether an organization seeks to address a particular topic or issue. Organizational policies and foci may change over time, and this will impact if and how an organization becomes engaged in a particular issue and whether that support is sustained.
As with any partnership or relationship that involves more than one organization, how those organizations interact and relate to each other is of critical importance to how successful this relationship is and what it is able to accomplish. Three core characteristics were reported as having an influence on these linkages:
- history of collaboration between partner organizations,
- shared mission/vision/purpose between partner organizations, and
- communication between partner organizations.
History of collaboration between partner organizations: Serving as both a predisposing and enabling factor, many of the organizations and/or staff involved in the case study cases had a history of working together on previous efforts. Some of the organizations had formal partnerships in the past, but others had only become familiar with each other through a variety of other efforts, coalitions, and workgroups. Capitalizing on these previous relationships, they could build linkages and implement health promotion efforts. Existing linkages and relationships also enabled them to bring in new partners. In one example, Salud Para Todos, the clinical and community partners had worked collaboratively for more than a decade and had identified opportunities and funding both internally and externally to support their collaboration. With the Charlotte REACH 2010 initiative, the hospital system and local health department had shared staff and developed a relationship through that partnership.
Shared mission/vision/purpose between partner organizations: Many partners reported that their organization became engaged in these linkages because the goals of the effort were in line with their organizational mission, vision, and purpose, indicating that having shared mission, vision, and purpose serves as an important predisposing factor in our model. While each organization may be working toward these objectives independently, these linkages provided an opportunity for organizations to work collaboratively with other community partners who have a common purpose. One clinical partner reported, "Given the YMCA's broad presence and the similarity in our missions (nonprofit, kids, and families being the focus), it looked like they were the logical choice to be our partner in this initiative."
Communication between partner organizations: Respondents from each of the five programs reported that open and regular communication was critical and enabled the relationships to be developed and the interventions to be implemented. According to one respondent, having a primary point of contact available to troubleshoot issues contributed to the ability of the partners to respond thoughtfully and in a timely manner to issues. One community partner reported, "We have to deal with communication and avoiding duplication of effort. [That is a] major challenge that [the] partnership faces. [Partnerships] need a key contact person to make sure that they will be communicating and addressing community challenges." Communicating frequently was also helpful with respondents from one case indicating that they communicate weekly at a minimum and another having bimonthly meetings and monthly reporting.
Providers include both clinical and community partners who deliver health promotion services to patients and individuals in a community. They include, but are not limited to, physicians, nurses, physician assistants, dieticians, exercise leaders, and public health professionals.
Provider characteristics serve as key enabling factors within the proposed model. Staffing was perhaps the most important component of organizational capacity to establish and maintain successful linkages and interventions. Respondents from all of the cases indicated that having the right people involved was critical. When asked about what makes someone the "right" person, characteristics included individuals who
- represent and/or are familiar with the target population or culture being served;
- are passionate about the community and the issue being addressed;
- understand the clinical and the community perspectives and can "wear both hats" when making decisions;
- are credible to the community, the general public, and policymakers; and
- have key skills and knowledge related to health promotion and program implementation (e.g., grant writing).
In addition to the characteristics above, respondents from one case emphasized the importance of having staff who believe in and are willing to take action to promote good health behaviors as a mechanism for disease prevention. Since the traditional medical model tends to focus on disease treatment and not necessarily health promotion, it is of critical importance to engage staff—both clinical and community—who are willing to take the time to work with individuals and patients who may be at risk for chronic disease.
Case Study Questions of Interest
- What additional organizational factors were facilitators of the development or implementation of the intervention?
Alignment with existing organizational and community priorities and needs: For most of the cases, the topics addressed through the linkages were in line with organizational or public health priorities and thus were more easily adopted by partner organizations. In one case, the YMCA had recently adopted their Activate America initiative, which is one of the initiatives the YMCA has developed to address health promotion and disease prevention. This initiative was in line with the goals and objectives of the Strong Kids, Strong Teens program, and thus, when approached to become involved, the YMCA was a willing partner. "Activate America … also has an external focus, which is working with community partners. (Active America) has some outcomes regarding large and extensive change so we are perceived as a prevention organization, as well as embracing what the communities need now" (community partner). Another YMCA partner from a different case reported, "It [the program] has to connect with our mission. I have to say no to many things because it does not connect with our mission." Thus, it is beneficial to seek out partners who are also looking to address a particular issue or topic when developing an intervention and linkage. In both of these cases, the YMCA has clearly adopted the role as an organization that has a focus on health promotion and disease prevention.
In addition to aligning with organizational priorities related to health, some cases also appeared to address the organizational priorities to gain research funding in order to implement and evaluate evidence-based programs. The North Carolina Prevention Collaborative and the Strong Kids, Strong Teens program both appeared to align with the research priorities of their respective institutions.
Many linkages and interventions funded were in line with existing national public health priorities. Two cases—Charlotte REACH 2010 and Strong Kids, Strong Teens—were funded because they sought to affect health issues that were aligned with CDC priorities. In part because these local efforts addressed national priorities, they were able to successfully secure funding for program development and implementation.
Cultural competency: The interventions developed were all tailored to be culturally competent and address the unique needs of the target populations and groups. Stakeholders worked hard to ensure that intervention activities were culturally relevant and sensitive. In one case, this included hiring an African American dietician and exercise leader to ensure that the women were comfortable with the program staff leading the instructional sessions. Two other cases that involved lay health leaders and promotoras used this structure to ensure that they had individuals engaging with the community members who were familiar with the community and understood the unique challenges and needs of the community members; this was important in part because many of the health care providers were not from the community or representative of the target population.
Case Study Questions of Interest
- What did the linkages accomplish?
- What outcomes are being measured?
- What are the data sources?
All five of the case study cases conducted some form of evaluation to examine key outcomes of interest. At the time of the case study data collection, two cases were still ongoing but had some preliminary evaluation results (Strong Kids, Strong Teens and Salud Para Todos), and two ended within a year of the case study data collection and were still finishing analyses but were able to share some preliminary findings (North Carolina Prevention Collaborative and Sisters in Action). Only one case (Charlotte REACH 2010) had completed its evaluation and subsequent write-ups of results and findings.
A review of the evaluation information from each case indicates that most of the evaluations were designed to examine key short-term/process and intermediate outcome questions of interest. Process outcomes included participant satisfaction, attendance at program activities and training sessions, and enrollment of the target population in the intervention. Intermediate outcomes included changes in knowledge and behaviors related to improved diet, physical activity, and smoking. Evaluation designs consisted primarily of pre-post data collection from participants with no long-term follow-up or longitudinal data collection to assess long-term program outcomes. Data collection consisted primarily of patient surveys of health behaviors and knowledge. Some cases also included collection of biometrics (clinical outcomes), such as blood pressure, weight, blood sugar, and waist circumference. Other data collection methods utilized, although not by more than one case, included a community-level survey, focus groups, interviews, a patient survey, and chart audits of participating clinical practices.
In three of the five cases, evaluation activities were conducted by staff from one or more of the clinical or community partners. One case contracted with a university partner for evaluation, and one clinical partner engaged an evaluation partner within their health system to conduct the evaluation activities.
The outcomes of interest for the case study cases varied and were dependent on the intervention and linkage focus and topic. Evaluations in all five cases were focused on the intervention implementation and not necessarily on the linkage between the clinical and community partner or how the linkage facilitated or improved service delivery to patients. Similarly, few cases included assessment of any organizational outcomes; however, one case, Salud Para Todos, examined outreach and access to patients, screening for cardiovascular disease risk factors by program staff, education provided by the program staff, and cultural competency of staff.
As mentioned above, because four of the five cases had not completed their evaluations, availability of final evaluation results was limited.
Preliminary behavioral outcomes reported by cases with some evaluation data—Charlotte REACH 2010; Strong Kids, Strong Teens; Sisters in Action; and Salud Para Todos—included increases in physical activity (duration and intensity) and fruit and vegetable consumption and a decrease in caloric intake. Clinical outcomes included a decrease in blood pressure, weight, and BMI. Organizational outcomes were not examined as frequently as individual-level changes and appeared to be more of an afterthought for most cases. Examples reported included changes in how the YMCA defined family for the purpose of providing a free "family" membership to those women enrolled in the Sisters in Action program. Respondents from the Salud Para Todos program also noted that they would be able to sustain promotoras in both the clinical and community partner organizations once Office of Minority Health funding ends.
Anecdotally, respondents within each of the case study cases indicated that they believe their linkages have been a successful way to provide preventive health services and that that the interventions have been a success in reaching the intended target population. While it is difficult to say whether these interventions have truly resulted in improved patient health outcomes, it is possible to conclude that in each of these case examples, the linkages resulted in the development and implementation of programs, services, and resources that were not available to individuals in these target communities prior to these efforts. Therefore, they were successful in improving delivery of preventive health services to individuals who otherwise would not have received any services or support.
Although sustainability is often challenging, it is generally a goal of most programs and interventions. Although one case (the North Carolina Prevention Collaborative) was designed as a 1-year pilot effort, sustaining programs and linkages appears to have been an objective of the other four case study cases. Two of these cases (Charlotte REACH 2010 and Sisters in Action) were unable to identify ongoing funding to continue to implement their interventions as originally designed and implemented. However, partners in the Charlotte REACH 2010 program were able to sustain small subcomponents of their effort (a farmers market and the ongoing presence of a certified diabetes educator at the community health center). Despite a waiting list of 250 persons, Spectrum Health and the YMCA of Grand Rapids were unable to identify funding for Sisters in Action and could not absorb the costs themselves.
Two other programs (Strong Kids, Strong Teens and the Salud Para Todos) have been sustained by their partner organizations. The Salud Para Todos program, which utilized promotoras in both the clinical and community partner organizations, has been sustained by additional external funding obtained by Campesinos Sin Fronteras. The Strong Kids, Strong Teens program has been sustained largely through fundraising efforts at the local YMCA level and through in-kind contributions of the YMCA and Seattle Children's Hospital Children's Obesity Action Team (COAT) members.
Although most of these efforts may not have been sustained in their original form and design, many of the cases were able to sustain subcomponents of their efforts or were able to be adapted in some way to obtain additional funding. For example, the YMCA and Spectrum Health System were able to obtain funding for a similar program for Latino women and are hopeful that they will eventually identify funding to reinitiate the Sisters in Action program. This adaption or "morphing" of programs from one into another appears to be an alternative for programs that cannot identify new external or internal funding.
Although the interventions may not have been sustained, interviewees' responses indicate that the linkages formed through these efforts have been significantly valuable to both clinical and community organizations alike and that those relationships will continue in the future as new opportunities for collaboration are examined and sought out. One representative from the Charlotte REACH 2010 project reported, "Some of the projects have to end but the benefits live on. The health care system in Charlotte is much more engaged with the community. Community and professional people are more skilled and capable in going and doing community work elsewhere. Not a sustainability plan that worked, but sometimes the view is too shallow. May not benefit that particular community but there will be benefit in other similar communities." Thus, while the interventions may not be sustained, the linkages and relationships between partners continue.