Building healthcare-community partnerships: process evaluation of a coalition approach to addressing cancer survivors’ health-related social needs

Abstract

Background

Coalitions involving both healthcare organizations and community organizations, are a way of providing community support to patients. However, the impact of these collaborations and partner satisfaction can be hard to measure without the use of a theoretical framework to guide progress.

Methods

In January 2023 we established the BEAT-C coalition, guided by the Community Coalition Action Theory (CCAT), to improve clinical-community linkages for addressing non-medical needs among individuals affected by cancer in the Washington, D.C. region. To create broad representation, we invited organizations focused on faith, older adults, cancer support, health promotion, healthy food access, and community health to join. The coalition dedicated significant effort at the outset to establish trust, cultivate relationships, and define shared values, mission, goals, and objectives. To assess coalition functioning, we administered a modified version of the Coalition Self-Assessment Survey (CSAS) in December 2023.

Results

Sixteen individuals representing 10 organizations completed the adapted CSAS. Respondents generally responded positively regarding the coalition and made decisions primarily through discussion and agreement (75.0%). Respondents noted respect for leadership (81.3%) and respect for and from fellow coalition members (100.0%). While 56.3% reported meaningful action through the coalition, 31.3% thought there could be more meaningful action. Qualitative feedback mirrored these findings: participants positively regarded the coalition’s responsiveness and noted activities occurring through partnerships developed from the coalition, but some respondents emphasized a desire to act more swiftly.

Conclusion

Our research described facilitators and barriers to early implementation of a theory-driven collaborative coalition to enhance cancer survivor support. Through the continued efforts of the coalition and increased community capacity building, the multi-disciplinary efforts of the coalition have potential to address the needs of cancer survivors.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-025-12883-7.

Background

Convening coalitions is a strategy to address complex community health issues. Coalitions are composed of diverse organizations or constituencies that agree to work together to achieve a common goal [1] and have been used to combat an array of health issues including tobacco use, cancer, and HIV [2–4]. Comprised of various professional and grassroot organizations [5], community coalitions have the potential to promote collective capacity, build social capital among communities, and generate local change through health services and policy [6].

Healthcare organizations may play a key role in advancing health equity due to their role as “economic engines” and networks within communities [7], coupled with documented inequities within the US healthcare system [8, 9]. In light of historical transgressions in clinical research, healthcare organizations have a considerable task to remedy earned mistrust and to strengthen partnerships within communities [10, 11]. However, previous collaborations between local healthcare and non-healthcare organizations have shown limited evidence of improved community health, according to a recent systematic review of the literature [12]. Two factors that may contribute to this include not using a framework to standardize and measure outcomes or failure to address trust and power imbalances within the coalition. The Community Coalition Action Theory (CCAT) [13] was developed by Butterfoss and Kegler to provide a solution to these challenges. CCAT is a theory that can be used to guide shared leadership and decision-making and evaluate effectiveness in establishing trusting interpersonal relationships. It may also provide a framework for developing impactful coalition work as it explains effectiveness across fourteen constructs, ranging from development to increased community capacity and improved social outcomes.

Building trust within a community coalition is a gradual process that requires intentional focus on power dynamics and equitable decision-making. According to Butterfoss and Kegler [13], the process of coalition formation must be approached slowly and thoughtfully, with attention to creating shared leadership and transparent communication. By addressing power imbalances from the start and fostering mutual respect, coalitions can ensure that all members, especially those from historically marginalized communities, have a meaningful role in shaping decisions, which is essential for establishing a foundation of trust and long-term success.

Through focused recruitment, shared development of values and goals, and repeated evaluation, the Building Equal Access Together-Cancer (BEAT-C) coalition followed the theoretical framework of the CCAT to create effective clinical-community linkages. These linkages address both medical and non-medical needs, including social determinants of health, community health, and auxiliary health services, for individuals affected by cancer in the Washington, D.C. region (including D.C., Maryland, and Virginia). Initiated by researchers across multiple cancer centers in the region, this work describes the formation, cultivation, and evaluation of the BEAT-C coalition’s functioning utilizing the CCAT with the aim of improving coordination of local organization efforts, creating more effective referral pathways, and enhancing local support and health outcomes for cancer survivors.

Methods

Study setting and recruitment

The coalition was formed to support a research initiative, funded by the Centers for Disease Control and Prevention (CDC), designed to build the evidence base of community-based interventions to reduce disparities in outcomes including quality of life among cancer survivors of minority racial backgrounds. Historically marginalized populations tend to experience worse cancer outcomes, much of which can be attributed to social needs and structural inequities [14]. The coalition was formed in 2023 in response to a series of interviews with community-based organization that highlighted a need to be able to offer more holistic supports to clients rather than siloed efforts specialized in one area (e.g., food insecurity, mental health). The coalition was intended to improve clinical-community linkages and explore how healthcare systems, community-based organizations (CBOs), and community members can holistically address health related social needs as well as practical and emotional supports for cancer survivors.

The healthcare systems engaged in this work include three cancer centers in the Washington, D.C. region. The CBOs involved in this work serve the greater Washington, D.C., Virginia, and Maryland communities in various capacities. We designed our outreach strategy with the intent to enhance inclusivity and broaden representation by engaging a diverse mix of community members. We thus intentionally recruited organizations across sectors, inviting cancer-specific support organizations, CBOs not participating in existing coalitions, faith-based groups, organizations focused on older adults, organizations promoting health (e.g., exercise and nutrition services), and an organization providing subsidized fresh food. We also included community health workers employed through the larger parent study who acted as the primary linkage between clinic and community services in the BEAT-C research intervention, and BEAT-C Participant Advisory Board (PAB) members. PAB members are community members with lived experience in cancer treatment or advocacy and strong ties to their community. During coalition formation, we invited members to make suggestions about additional organizations to include. Organizations with a track record of serving historically marginalized communities were prioritized.

Community Coalition Action Theory

CCAT demonstrates the processes of coalitions, offering practical insights into how diverse partners can unite to address community challenges [13]. Key points of CCAT include the importance of inclusivity in coalition membership, the need for shared leadership, and the role of structured decision-making in achieving long-term goals. The three stages of CCAT include (1) Formation, in which a group of organizations are identified, and operating procedures are established; (2) Maintenance, in which the emphasis is on sustaining involvement and implementing action; and (3) Institutionalization, in which coalitions focus on building community capacity and sustainability. In this manuscript we report on CCAT stages 1 and 2 of the BEAT-C coalition. We adapted these principles to our context by striving for broad community representation, fostering collaborative leadership practices, and continuous evaluation. Table 1 illustrates how the 23 propositions of the CCAT were adapted to meet the specific needs of our community and setting, from coalition formation to evaluation.

Table 1.

How Community Coalition Action Theory constructs and propositions were adopted and evaluated specifically for the BEAT-C coalition

CCATa Constructs	CCAT Propositions	How the proposition was adopted	Assessment
Stages of Development	1. Coalitions develop in specific stages and recycle through these stages as new members are recruited, plans are renewed, and new issues are added.	Coalition organizers documented stages and transitions and used CSASb results and records to assess and inform transitions into next stages.	CSAS (coalition maturity, readiness, sustainability), records, observations
	2. At each stage, specific factors enhance coalition function and progression to the next stage.	Coalition organizers emphasized the importance of building trust and relationships during the formation stage.	CSAS (trust and relationships), identification and evaluation of stage-specific factors, observation, records
Community Context	3. Coalitions are heavily influenced by contextual factors in the community throughout all stages of coalition development.	Coalition organizers recruited CBOs with varying levels of experience, collaboration history with healthcare systems, and connections with other members. The coalition commonly employed positionality exercises to keep community context at the forefront of activities.	Results from social needs screening of cancer patients; inclusion of CHWsc in the coalition to provide insight into community needs; coalition member insights and data from populations they serve
Lead Agency/Convener Group	4. Coalitions form when a lead agency or convening group responds to an opportunity, threat, or mandate.	Coalition organizers used the Checklist: Is A Community Coalition Right for You [15] to determine if the coalition was a good fit, and attended similar existing groups meetings. The coalition was initiated by a research team in response to the need for better and more coordinated social supports for cancer survivors.	Key informant interviews with community organizations and health care providers.
	5. Coalition formation is more likely when the convening group provides technical assistance, financial or material support, credibility, and valuable networks and contacts.	The study team provided compensation for members as well as technical assistance such as grant writing. Networking was supported by sharing a community event calendar, promoting member events, connecting members with philanthropy, and providing letters of support for grants.	Feedback mechanisms at each meeting for requests for assistance and support.
	6. Coalition formation is more likely to be successful when the convener group enlists community gatekeepers who thoroughly understand the community to help develop credibility and trust with others in the community.	Coalition organizers included patient advocates that are community gatekeepers (e.g., well known and established community members with a track record of organizing and collaboration) to help recruit organizations that are not as widely known in the community and with whom investigators did not have prior working relationships. Organizers also contacted an additional well-connected community advocate for introductions.	CSAS (inclusion, recruitment, membership)
Coalition Membership	7. Coalition formation usually begins by recruiting a core group of people who are committed to resolve the health or social issue.	Coalition organizers intentionally recruited organizations that serve historically marginalized communities and small organizations that are not often included in larger coalitions or groups. Social support organizations that provide broad support not exclusive to cancer patients were included. Buddy recruitment strategies involved current members nominating individuals they felt would be valuable additions to the coalition and leveraging insights to strategically expand the coalition network.	CSAS (inclusion, recruitment, membership)
	8. More effective coalitions result when the core group expands to include a broader constituency of participants who represent diverse interest groups, agencies, organizations, and institutions.
Operations and Processes	9. Open and frequent communication among staff and members helps create a positive climate, ensures that benefits outweigh costs, and makes collaborative synergy more likely.	Coalition communication was supported by monthly meetings, reminder emails and follow up emails, a google website with links to a google drive, a shared calendar, and a listserv.	CSAS (communication), meeting surveys
	10. Shared and formalized decision-making helps create a positive climate, ensures that benefits outweigh costs, and makes collaborative synergy more likely.	Decision-making procedures were discussed in the first 2 meetings until agreement was reached. Decisions made by voting with at least 2/3 of members participating in the vote. Activities pursued were decided via group brainstorm sessions, anonymous ranking, subsequent discussion of the top 3 and voting.	CSAS (decision-making)
	11. Conflict management helps create a positive climate, ensures that benefits outweigh costs, and makes collaborative synergy more likely.	To minimize conflict, organizers spent the first few meetings establishing guiding principles, values, and expectations for all members. Regular surveys after meetings allowed lead agency to address potential conflicts.	CSAS (conflict resolution)
	12. The benefits of participation must outweigh the costs to make collaborative synergy more likely.	Members were compensated for participation, and inclusion in acknowledgments of academic work, if interested. These measures were supported by regular feedback mechanisms for adjustments	CSAS (participation), meeting surveys
	13.Positive relationships among members are likely to create a positive coalition climate.	The coalition fostered positive relationships through structured ice breaker activities, facilitated open communication channels, allocated agenda time for collaborative problem-solving and event sharing, and encouraged social interactions outside of formal meetings.	CSAS (relationships, trust)
Leadership and Staffing	14. Strong leadership improves coalition functioning and makes collaborative synergy more likely.	Leadership was trained in Community Based Participatory Research Methods and CCAT. Following this methodology and theoretical foundation provided a roadmap for recruitment and engagement.	CSAS (leadership, staffing, relationships)
	15. Paid staff who have the interpersonal and organizational skills to facilitate the collaborative process improve coalition functioning and make collaborative synergy more likely.	Leadership was paid with protected time to complete coalition related activities.	CSAS (leadership), research staff have protected time, coalition members compensated
Structures	16. Formalized rules, roles, structures, and procedures make collaborative synergy more likely.	Coalition organizers spent the first few months establishing roles, and procedures including expectations, values, guiding principles, strengths and weaknesses, and short-term and long-term goals. The coalition made decisions centered in shared values. Guiding structures were revisited quarterly.	CSAS (decision-making), shared documents and record keeping
Pooled Member and External Resources	17. The synergistic pooling of member and community resources prompts effective assessment, planning, and implementation of strategies.	Members shared information about community events using a Google Drive and shared calendar. Members contributed to collaborative initiatives by participating in each other’s events and hosting shared events. The pooling of resources helped in the creation of one resource sheet for all members to distribute.	CSAS (participation)
Member Engagement	18. Satisfied and committed members will participate more fully in the work of the coalition.	Coalition organizers interviewed potential members to gauge fit. There was intentional space at every meeting for coalition members to share their work and where they could use assistance. Organizers tried to attend and encouraged others to attend members’ events in the community, provided support and assistance, and promoted events.	CSAS (participation), informal meeting survey
Assessment and Planning	19. Successful implementation of strategies is more likely when comprehensive assessment and planning occur.	Creative brainstorming strategies included in-person sessions with creative warm ups and utilizing Human Centered Design Principles [16] to understand problems (e.g. patient journey mapping of the referral process), 6-3-5 brainwriting [17] for idea generation, and SWOTd analyses.	CSAS (mission, strategies, and action plans)
Implementation of Strategies	20. Coalitions are more likely to create change in community policies, practices, and environment when they direct interventions at multiple levels.	Future directions	Future assessment
Community Change Outcomes	21. Coalitions that are able to change community policies, practices, and environments are more likely to increase capacity and improve health and social outcomes.	Future directions	Future assessment
Health/Social Outcomes	22. The ultimate indicator of coalition effectiveness is the improvement in health and social outcomes.	Future directions	Future assessment
Community Capacity	23. As a result of participating in successful coalitions, community members and organizations develop capacity and build social capital that can be applied to other health and social issues.	By participating in this coalition, members are forging connections that extend beyond meetings. There have also been opportunities to increase social capital through shared grant funding and letters of support. Year two aims to foster new leadership opportunities and skills as we delve deeper into shared ownership of initiatives.	CSAS (relationships), future assessment: new skills, new leadership opportunities, new partnerships, social capital, sense of community

^aCCCT: Community Coalition Action Theory

^bCSAS: Coalition Self-Assessment Survey

^cCHWs: Community Health Workers

^dSWOT: Strengths, Weaknesses, Opportunities, Threats

Compensation and meeting logistics

All non-healthcare institution members were compensated for their time participating in meetings. Each member organization other than the healthcare systems received $500 at the time of joining the coalition, $1000 at the 6-month mark, and $1000 at the one-year mark. Individuals not representing an organization (e.g., patient advisors) received $75 per 60-minute meeting. Lunch was provided for in-person meetings. Healthcare research team members conducted this work as part of their job responsibilities. The research team oversaw coalition administrative responsibilities and meeting organization. Coalition organizers scheduled virtual meetings via Microsoft Teams monthly with bi-annual in-person meetings. This cadence was collaboratively established by coalition members. Consistent emails (e.g., reminder emails, agendas, follow-up notes, collaboration opportunities, upcoming community events) supported ongoing communication.

Aligned with the principles of CCAT, initial efforts were directed towards building trust, cultivating relationships, and defining shared values, missions, goals, and objectives. To better inform coalition progress, brainstorming, and relationship building, coalition organizers utilized engagement platforms designed to foster inclusive participation (such as Ideaboardz, [18]), regularly held brainstorming sessions in which all individuals were invited to share ideas and build from one another, vote on priority areas, and prioritize ideas for action.

Brainstorming activities were a central component of our decision-making process. Through these activities, members were encouraged to generate ideas for coalition involvement collectively, leveraging the diverse expertise and perspectives present within the coalition. In-person sessions included warm-up activities designed to stimulate creativity and encourage participation, brainstorming strategies grounded in human-centered design principles, and positionality exercises aimed at fostering awareness of individual perspectives, backgrounds, and experiences within the group. By fostering an environment of open dialogue and idea sharing, organizers harnessed the collective knowledge of the group to address the health-related social needs of cancer survivors.

Measurement

Process evaluation and quality improvement

To ensure continuous improvement and reflect on the coalition’s progress, detailed process records were maintained, including meeting notes shared with all members. Researchers documented observations on group dynamics, meeting flow, and the strengths and challenges of leading the coalition. Weekly discussions among researchers were held to address these observations. Additionally, a feedback survey was distributed to all participants after each meeting to gather input on meeting satisfaction, feedback, and the relevance of the content to members. These records and feedback mechanisms informed ongoing quality improvement efforts within the coalition [18].

Coalition Self-Assessment Survey (CSAS)

The CSAS was modified by the research team to evaluate and enhance coalition functioning across key process metrics, including perceptions of leadership, communication, member engagement, resource utilization, and alignment with CCAT [19]. The CSAS is comprised of over 140 questions and sub-questions across the following domains: 1). Coalition role; 2). Inclusion, recruitment, membership; 3). Decision-making, conflict resolution; 4). Leadership, staffing, relationships; 5). Trust; 6). Mission strategies and action plans; 7). Participation; 8). Communication; and 9). Coalition maturity, readiness, sustainability. Three open-ended questions were also added to obtain feedback on the facilitators and barriers associated with coalition operations.

Survey findings were used to monitor progress, identify areas for improvement, and track effectiveness of coalition functioning over time. Surveys were administered in December 2023, approximately one year after the coalition had started, and were delivered electronically via REDCap (Research Electronic Data Capture), a secure, web-based software platform designed to support data capture for research studies [20].

Ethics

This research was approved by the Georgetown University Institutional Review Board (STUDY00004397) through expedited review. Informed consent was obtained from all participants in REDCap prior to completing the CSAS.

Data analysis

We conducted descriptive analyses for means and frequencies and conducted thematic analysis for open-ended responses. Analyses were conducted using SAS Version 9.4 (SAS Institute, Inc., Cary, NC) for survey data. Organizational characteristics of the involved CBOs were captured based on organization web presence. Qualitative responses were analyzed by two researchers (SW and LS) using thematic analysis in Microsoft Excel. All responses were analyzed by both researchers, and conflicts were resolved through discussion with a senior researcher (HA). Researchers reviewed all open-ended responses to the survey and developed initial codes through an emergent approach [21], prior to independently coding participant responses. The researchers compared results and identified common themes.

Results

Process evaluation outcomes

Monthly meeting outputs included establishing coalition principles, values, mission, and the development of both long-term goals and short-term objectives. Over the first 9 months, the coalition spent substantial time establishing coalition processes and goals, relationship building internal and external to the coalition, and brainstorming how to operationalize coalition objectives. Outputs included a collaborative grant application, development of a resource sheet, and the implementation of a group calendar for shared scheduling and event participation. We conducted an assessment to understand the landscape of potential referral partners and to pinpoint gaps and barriers in achieving effective, closed-loop referrals. Strengths and challenges of the coalition were discussed during coalition meetings to refine goals and activities. Currently, the coalition exists in the maintenance stage, in which the coalition has the capacity to take on greater challenges, its visibility within the community increases, and the primary strategy is to expand and diversify. This stage involves sustaining achievements, reinforcing partnerships, adapting to changes, continuous evaluation, and maintaining high levels of member and community engagement to ensure lasting impact [22].

Survey outcomes

Individual demographics

Sixteen individuals completed the adapted CSAS. Three (18.8%) of the individuals held a role as a PAB member for the BEAT-C research project. Three (18.8%) individuals were CHWs serving three health systems. All individual coalition members completed the survey except for one, who was not able to complete the survey in time due to a temporary leave of absence.

Organization demographics

The 16 individuals represented 10 organizations. The average and median number of coalition members who completed the CSAS per organization were 1.3 and 1, respectively. The 10 participating organizations were involved in a variety of services ranging from food distribution to health education, and organizations primarily served families and communities (n = 5, 50%) or cancer patients (n = 4, 40%), with the remaining organization acting as a faith-based organization (n = 1, 10%). Eight of the organizations (80%) had been established for over ten years. More than half of the organizations served the greater Washington, D.C. region.

CSAS findings by domain

Some categories will not equal 100% due to responses indicating “Don’t Know” or “N/A.” Findings by CSAS domain are reported in Table 2. Results represent responses from individual participants, opposed to organizations.

Table 2.

Select findings across all seven CSAS domains from the first yearly evaluation of the BEAT-C coalition (N = 16)

Donecision-Making, Conflict Resoluti
How are decisions usually made regarding coalition priorities, policies and actions? Please indicate the main way(s) you think decisions are usually made. (Choose no more than two)
Coalition members vote, with majority rule				4 (25%)
Coalition members discuss the issue and come to consensus				12 (75%)
The lead agency for the project makes the decisions				2 (12.5%)
Don’t know				1 (6.3%)
Please indicate how comfortable you are overall with the coalition decision-making process.
Not at all comfortable				0 (0%)
Somewhat comfortable				2 (12.5%)
Very comfortable				14 (87.5%)
Indicate the response that represents the amount of conflict in your coalition.
More conflict than I expected				0 (0%)
Less conflict than I expected				11 (73.3%)
About as much conflict as I expected				4 (26.7%)
Indicate your opinion of how much conflict within the coalition was caused by each of the following factors.
		None	Some	A Lot		Don’t Know
Differences in opinion about coalition mission and goals		10 (62.5%)	4 (25%)	0 (0%)		2 (12.5%)
Differences in opinion about the best strategies to achieve coalition goals and objectives		9 (56.3%)	6 (37.5%)	0 (0%)		1 (6.3%)
Please indicate how much you agree or disagree with the following statements.
		Strongly Disagree	Disagree	Agree	Strongly Agree	Don’t Know
The coalition has clear and explicit procedures for making important decisions		0 (0%)	1 (6.3%)	9 (56.3%)	6 (37.5%)	0 (0%)
The decision-making process used by the coalition is fair		0 (0%)	0 (0%)	7 (43.8%)	8 (50.0%)	1 (6.3%)
The decision-making process used by the coalition is timely		0 (0%)	2 (12.5%)	7 (43.8%)	7 (43.8%)	0 (0%)
The coalition makes good decisions		0 (0%)	0 (0%)	9 (56.3%)	4 (25.0%)	3 (18.8%)
Leadership, Staffing, Relationships
Who do you think is most significant in providing leadership for the coalition?
Research Staff				13 (81.3%)
Community Organizations				1 (6.3%)
Participant Advisory Board Members				1 (6.3%)
Don’t Know				1 (6.3%)
With respect to the leadership you just identified, please indicate how much you agree or disagree with the following statements. The leadership of our coalition:
		Strongly Disagree	Disagree	Agree	Strongly Agree	Don’t Know
Has a clear vision for the coalition		1 (6.3%)	2 (12.5%)	10 (62.5%)	2 (12.5%)	1 (6.3%)
Is respected in the community		1 (6.3%)	0 (0%)	8 (50.0%)	4 (25.0%)	3 (18.8%)
Is respected in the coalition		1 (6.3%)	0 (0%)	6 (37.5%)	7 (43.8%)	2 (12.5%)
Builds consensus on key decisions		1 (6.3%)	0 (0%)	9 (56.3%)	4 (25%)	2 (12.5%)
Trust
Please indicate how much you agree or disagree with the following statements
		Strongly Disagree	Disagree	Agree	Strongly Agree	Don’t Know
I am comfortable requesting assistance from the other coalition members when I feel their input could be of value		0 (0%)	0 (0%)	10 (62.5%)	5 (31.3%)	1 (6.3%)
I can talk openly and honestly at the coalition meetings		0 (0%)	1 (6.3%)	9 (56.3%)	6 (37.5%)	0 (0%)
Coalition members respect each other’s points of view even if they might disagree		0 (0%)	0 (0%)	9 (56.3%)	7 (43.8%)	0 (0%)
My opinion is listened to and considered by other members		0 (0%)	0 (0%)	10 (62.5%)	6 (37.5%)	0 (0%)
Participation
Please indicate how much you agree or disagree with the following statements
	Strongly Disagree	Disagree	Agree	Strongly Agree	Don’t Know	Missing
I feel that I have a voice in what the coalition decides	0 (0%)	3 (20.0%)	9 (60.0%)	3 (20.0%)	0 (0%)	1 (6.3%)
I feel a strong sense of “loyalty” to the coalition	0 (0%)	1 (6.7%)	11 (73.3%)	2 (13.3%)	1 (6.7%)	1 (6.3%)
Please indicate to what extent each of the following have been problems for your participation or your organization’s participation in the coalition.
			No problem	Minor problem	Major problem	N/A
Coalition activities do not reach my primary constituency			9 (56.3%)	5 (31.3%)	0 (0%)	2 (12.5%)
My skills and time are not well-used			12 (75.0%)	4 (25.0%)	0 (0%)	0 (0%)
Communication
Please indicate how much you agree or disagree with the following statements.
		Strongly Disagree	Disagree	Agree	Strongly Agree	Don’t Know
The current method for communication between coalition staff/leadership and its members is effective		0 (0%)	0 (0%)	10 (62.5%)	6 (37.5%)	0 (0%)
Members can communicate between themselves as necessary or desired		0 (0%)	1 (6.3%)	8 (50.0%)	7 (43.8%)	0 (0%)
Mission Strategies and Action Plans
Please indicate how much you agree or disagree with the following statements.
		Strongly Disagree	Disagree	Agree	Strongly Agree	Don’t Know
Our coalition has a clear and shared understanding of the problems we are trying to address		0 (0%)	1 (6.3%)	12 (75.0%)	3 (18.8%)	0 (0%)
There is a general agreement with respect to the mission of the coalition		0 (0%)	1 (6.3%)	9 (56.3%)	5 (31.3%)	1 (6.3%)
Our action plan defines well the roles, responsibilities and timelines for conducting the activities that work towards achieving the stated mission of the coalition		0 (0%)	4 (25.0%)	8 (50.0%)	4 (25.0%)	0 (0%)
Coalition Maturity, Readiness, Sustainability
Please indicate how much you agree or disagree with the following statements.
		Strongly Disagree	Disagree	Agree	Strongly Agree	Don’t Know
In general, I am satisfied with the coalition		0 (0%)	1 (6.3%)	10 (62.5%)	4 (25.0%)	1 (6.3%)
Has the coalition been responsible for activities or programs that otherwise would not have occurred?
Yes				9 (56.3%)
No				2 (12.5%)
Don’t Know				5 (31.3%)

Decision-making, conflict resolution

A majority of members agreed or strongly agreed the decision-making process was clear (93.8%), fair (93.8%), and timely (87.5%). Most respondents (81.3%) agreed or strongly agreed that the coalition makes good decisions. Most members (73.3%) reported less conflict than expected, with the remaining proportion reporting about as much as expected. Respondents felt that decisions were generally made through discussion and consensus (75%) and felt comfortable with the decision-making process (87.5%) including having open debates around opposing viewpoints (62.5%). 62.5% of respondents indicated there were no differences in opinion on mission and goals and 25% indicated “Some” differences. Further analysis showed less synergy on the best way to achieve these objectives, where 56.3% agreed there were no differences in opinion on best strategies, and 37.5% responded there were some differences in opinion.

Leadership, staffing, relationships

When asked which organization or individuals were most significant in providing leadership for the coalition, 81.3% indicated the research staff. The remaining responses were split across community organizations, PAB members, and “Don’t Know” (6.3%, respectively). When asked about leadership, 75% agreed or strongly agreed there was a clear vision for the coalition, with the remaining individuals indicating they strongly disagreed (6.3%) or disagreed (12.5%). 81.3% agreed or strongly agreed that leadership built agreement on key decisions, while 6.3% strongly disagreed. 81.3% of respondents agreed or strongly agreed leadership was respected in the coalition while 6.3% strongly disagreed. Similarly, 75.0% indicated they agreed or strongly agreed that coalition leadership was respected in the community while 6.3% strongly disagreed.

Trust

Respondents reported high levels of comfort within the coalition, where 93.8% of respondents agreed or strongly agreed they felt comfortable in requesting assistance, as well as trusting they could talk openly and honestly at meetings. Only 6.3% of participants disagreed with the latter. All respondents agreed or strongly agreed their opinion was listened to and considered by other coalition members, and coalition members respected each other’s points of view even if they disagreed.

Participation

A majority of respondents agreed or strongly agreed they had a voice in decisions (80%), while 20% disagreed. Respondents generally felt a strong sense of “loyalty” to the coalition (86.7%), while 6.3% disagreed. When asked the extent to which there were ‘problems’ around the coalition is reaching their primary constituency, 56.3% responded “no problem,” 31.3% indicated “a minor problem,” and 0% reported “a major problem.” 25% of respondents suggested a minor problem in that their skills and time were not well-used, while the remaining 75% reported no problem.

Communication

All individuals (100%) agreed or strongly agreed that communication between coalition leadership and its members is effective. Most members (93.8%,) agreed or strongly agreed on their ability to communicate as necessary or desired, 6.3% disagreed.

Mission strategies and action plans

Most (93.8%) individuals agreed or strongly agreed that the coalition had a clear and shared understanding of the problems they are trying to address, while 6.3% disagreed. Similarly, most respondents agreed or strongly agreed that there was general agreement with respect to the priorities of the coalition (81.3%) while 12.5% of people disagreed. Responses to the statement “Our action plan defined well the roles, responsibilities, and timelines for conducting the activities that work towards achieving the stated mission of the coalition” showed the most variation, where 75% agreed or strongly agreed and 25% disagreed.

Coalition maturity, readiness, sustainability

More than half of the participants (56.3%) indicated that the coalition had been responsible for activities that would not have occurred otherwise. 87.5% of respondents agreed or strongly agreed they were satisfied with the coalition, and 6.3% disagreed.

Strengths and challenges

Table 3 summarizes strengths and challenges faced by the coalition. A significant strength was the meeting structure, which combined virtual meetings with bi-annual in-person gatherings, ensured robust participant engagement, and facilitated relationship-building. In-person meetings fostered collaboration and enhanced problem-solving. Structured exercises, such as warm-ups, positionality exercises, and shared visioning activities were employed to increase engagement. These exercises also guided discussions, shaped decision-making processes, and improved collaboration. Meeting facilitators periodically revisited the values, guiding principles, and goals to ensure continued alignment and focus. Strengths indicated through the CSAS evaluation included collaborative nature of meetings, effective decision-making processes, and minimal conflict.

Table 3.

Researcher-identified strengths and challenges of BEAT-C coalition operations and functioning as identified through meeting surveys and CSAS feedback

Strengths and Challenges of Coalition
Strengths	Challenges
• Collaborative nature of meetings including intentionally seeking and utilizing skills of all coalition members • Decision making processes and coalition operations • Little to no conflict • Synergy on coalition mission, goals, and objectives • Limited personality conflicts, power struggles, or member dominance in meetings • Coalition leadership respected with clear vision and “gets things done” • Effective, timely, and useful communication methods • Benefits to participants: Relationship building, reaching new populations, giving and getting referrals for clients, increasing professional skills, sharing resources, and staying well informed. • Highly motivated and committed individuals • Trust between members and with coalition leadership • Responsiveness to member needs and flexible to pivot directions as appropriate • Coalition size and diversity of membership	• Developing partnered and actionable short-term initiatives as steps toward achieving long-term goals • Shared decision making across and between organizations • Shared responsibility and ownership • Less synergy on strategies and best practices to achieve coalition goals and objectives • Maintaining member interests, particularly during planning phase • Complex nature of problem • Identifying and utilizing individual member strengths • Presence in community: Community members do not know the coalition and may only recognize and trust specific affiliated names or organizations, creating challenges for shared messaging. • Sharing resources as everyone uses different systems, and/or use their own curated list of trusted referral sources. Creation of shared space poses challenges such as requiring separate logins or subscriptions.

The coalition also faced several challenges, ranging from administrative (e.g., all coalition members relied on different trusted software, and many shared platforms exist behind a paywall) to creating networks (e.g., developing a trusted presence in the local community). Other primary barriers that emerged in the first year centered around fostering relationships within and between coalition members. These included challenges recognizing and utilizing the unique strengths, talents, and skills individual members had (these emerged after a candid “icebreaker” conversation), and challenges reaching shared decision-making and responsibility within members.

Three open-ended questions were posed to respondents as a part of the CSAS. When prompted about difficulties the coalition faced and opportunities for improvement, respondents indicated a need for increasing participation and action, both within and outside of the coalition. Some participants remarked on the need to involve other agencies and improve internal communication and connections. Conversely, some members expressed the need to define expectations, identify strengths of individual members, and create measurable goals to guide coalition action. One participant wrote, “…We have spent enough time establishing a firm foundation… Now we need to engage in concrete action.” Respondents were asked to remark on what has gone well and should be continued. Coalition members commented primarily on the connections that formed through their involvement, with one member noted that the connections led to off-site collaboration. A few members mentioned pursuing funding to meet goals, and two participants spoke of continuing to develop resources and resource guides. The final open question gauged respondents’ feelings towards the responsiveness of the coalition. Responses were largely positive. As one participant wrote, “…They are doing a good job of raising issues and seeking input from the members of the coalition.”

Discussion

Coalitions have been commonly used to address community health needs [23], though measuring the functioning of a coalition can sometimes be difficult when lacking a guiding theory or framework. Our work used an adapted version of the CSAS to assess functioning of the BEAT-C coalition assembled to inform our efforts to address the health-related social needs of cancer survivors in Washington, D.C. Results suggested a high level of satisfaction with functioning, communication, and decision-making [22].

A notable theme from this work is the reported synergy, trust, and comfort among participants in the BEAT-C coalition. Trust, especially, is a critical element to ensure smooth functioning in coalition operations [24]. Previous work examining the dose-response of researcher involvement in a given coalition found that leadership, staffing, and trust among engaged coalitions were closely associated with engagement beyond funding, as well as improved decision-making, capacity, and conflict resolution [25]. Similarly, within community-based participatory research, a high level of trust within organizations has the potential to lead to sustained partnerships, generate spin-off work, and eventually catalyze systemic change [26]. In the present work, over half of the respondents noted the coalition was responsible for activities that would not have otherwise occurred, and one participant stated the coalition led to off-site collaborations. These breakout collaborations formed between involved organizations reflect some of the benefits of participation in the coalition, catalyzing partnerships that may otherwise not naturally emerged.

To build the foundation of trust within the BEAT-C coalition, members engaged in a year’s worth of relationship development, goal setting, and evaluation. Our qualitative findings showed that members were split on how to best move forward, with some respondents indicating a need for continued recruitment and connection building, and others expressing their desire to move forward with external action. Our finding that members conflicted in opinions on how and when to move forward suggest that there is no one-size-fits-all approach to moving through coalition work. These findings align with Butterfoss and Kegler’s theory that coalitions exist iteratively, evolving through stages as they grow [13]. This pertains specifically to our coalition work on an individual participant level, in which evolution may be an iterative process depending on members’ readiness to progress.

Coalition facilitators should, therefore, be mindful of navigating evolving priorities of coalition members, taking care to establish clear decision-making structures [24]. In the Nine Habits of Successful Comprehensive Cancer Control Coalitions, having “clear roles and accountability,” “empowering leadership,” and “shared decision-making” are emphasized to ensure equitable coalition partnership [27]. Interestingly, when participants were asked, “Who do you think is most significant in providing leadership for the coalition?” there was not 100% agreement. While this may be a positive sign of curating a culture of shared decision-making and leadership, this also may be a result of ambiguous roles. Furthermore, perceptions around leadership were generally positive but occasionally mixed. Work examining aspects of model coalition functioning within stages demonstrated the importance of leadership, where higher levels of coalition leadership were more likely to achieve model fidelity, together with strong team cohesion [28]. Kegler et al. [29] similarly observed that team cohesion and effective communication facilitates program delivery within the implementation stage.

Still, coalition organizers were attuned to challenges with virtual engagement of coalition members, particularly early in the formation process. Engaging participants in virtual meetings can be more challenging than in-person gatherings due to reduced verbal interaction, potential multi-tasking, and less engaged participation [30]. Virtual engagement platforms are helpful, but selecting an accessible virtual engagement tool posed a challenge. Some tools are complex or require logins and subscription plans, making it difficult to find options that were both free and user-friendly. Despite this, providing options for participants to contribute through virtual sticky notes, chat, or verbal communication, with a designated note-taker and with team support, proved to be an effective strategy. Developing actionable short-term initiatives as steps toward achieving long-term goals was another challenge, requiring careful planning and consideration to ensure feasibility and alignment with overall objectives as indicated by members on the free text portion of the CSAS and coalition staff. Lastly, coalition staff noted that achieving quick wins and recognizing productivity and accomplishments (e.g., submitting a grant together) helped sustain engagement and momentum while pursuing longer-term initiatives. These wins built confidence and motivation among participants.

There are several limitations to this work. First, the size of the coalition was small; thus, collective impact may be more limited than with larger coalitions due to fewer resources and limited outreach capabilities. However, the coalition was intentionally formed to include only 1–2 organizations providing similar services to facilitate a “hub and spoke” model. This approach allows each organization to share valuable insights about their specific service areas (e.g., food insecurity, older adult wellness, cancer support) while playing a critical role in networking with other organizations that provide similar supports. Additionally, the sample of organizations participating in this coalition may introduce a level of bias into the results. Organizations that possess institutional buy-in, sufficient staffing, and economic resources may be more likely to participate, potentially skewing the findings toward the experiences and perspectives of these organizations. This bias may limit the generalizability of the results to other settings or organizations with different capacities and resources. Future research should aim to include a broader range of organizations to enhance the diversity and applicability of findings.

Still, this work has several strengths. First, an existing research initiative was able to provide financial compensation to community partners for their time, which can be hard to find with competing priorities. Findings suggest that participation strengthened connections between healthcare settings and community organizations. This work is also guided by theory, providing structure, a consistent means of assessment and comparison, and comparable data to contribute to a growing body of coalition development research. It also therefore contains implications for other coalition work, including those at the local level as the focus is on multi-disciplinary collaboration built and evaluated through theory. Future work will look to progress the coalition’s aims and expand the coalition, broadening the reach of involved organizations to ensure better representation and a wider scope to address many more health-related social needs commonly seen in the Washington, D.C. area.

Sustainability and future directions

After one year of coalition activity, we assessed future directions and sustainability through a collaborative decision-making process that involved open discussion and voting by all members. Based on responses, we transitioned away from a compensation model, recognizing that this change would not impact members’ ability or interest in participating while allowing for the inclusion of more community members and organizations. Additionally, the coalition adopted a co-leadership structure, introducing a rotating coalition co-chair to assist the research team and share leadership responsibilities. To streamline operations and maintain engagement, members also voted to move to an every-other-month meeting schedule, supplemented by monthly email updates. These changes reflect the coalition’s commitment to transparency, shared governance, and adaptability as we move forward.

Conclusion

Our findings suggest that theory-based approaches in measuring engagement, functioning and satisfaction within a coalition can help coalitions document impact, illuminate weaknesses, and understand member’s readiness for next steps. With ongoing examination of coalition operations and functioning through data collection and documentation of coalition outcomes, collective impact to address persistent disparities in access to health-related social needs among cancer survivors can be improved.

Abbreviations

BEAT-C

Building Equal Access Together in Cancer

CCAT

Community Coalition Action Theory

CSAS

Coalition Self-Assessment Survey

CDC

Centers for Disease Control and Prevention

CBOs

Community-Based Organizations

PAB

Participant Advisory Board

Authors'contributions

Conceptualization: HA, KS, SW. Data Curation: SW, MS. Formal Analysis: SW, LS. Funding Acquisition, MPC, HA. Investigation: SW, HA, MS, JRR, MPC, KS. Methodology: SW, HA, MPC, KS. Project Administration: MS. Resources: HA, MPC. Supervision: HA, MPC. Visualization: LS, SW. Writing– Original Draft: SW, LS. Writing– Review & Editing: SW, LS, MPC, MS, JRR, KS, JLS, SS, ER, HA

Funding

This project is supported by the Centers for Disease Control and Prevention of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award (U01DP006639). The findings and conclusions in this report are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Data availability

Data is provided within the manuscript or supplementary information files.

Declarations

Ethics approval and consent to participate

This research was approved by the Georgetown University Institutional Review Board (STUDY00004397) through expedited review. Informed consent was obtained from all participants prior to survey completion.

Consent for publication

No copyrighted material, surveys, instruments, or tools were used in the research described in this article.

Competing interests

The authors declare no competing interests.